Hypnotic

Signs of Hypnosis

The responses of a subject to induction suggestions are what we collectively refer to as a trance. These responses are a function of what suggestions are made and the subject's own preconceptions of what a hypnotic state is like.

These suggestions and preconceptions in turn are usually similar enough, even in nominally different methods of hypnosis, the produce common reactions in different subjects, which are usually taken as evidence of hypnotic induction. Indeed, hypnotic induction proceedings are often stereotyped enough so that what is really remarkable is not the similarity of the reactions among different subjects but the fact that there is so much variability.

With respect to an individual subject, the initial induction is a very important event. Although little has been written on this topic, it appears likely that the reactions obtained in this sessions will determine the subject's personal expectations concerning the hypnotic state and will tend to reappear in all subsequent sessions. Thus, individual reactions to hypnotic inductions tend to remain similar from session to session unless specific suggestions are made to vary them.

The signs of hypnotic induction can be divided into objective signs that the hypnotist can observe directly and subjective signs that the subject must be asked to describe. Some of the more common objective signs of hypnosis are the following:

1. Initial eyelid fluttering followed by eye closure.

2. Deep relaxation as evidenced by limpness of the limbs, lack of facial expression, and marked disinclination to move of talk spontaneously.

3. Literalness in the understanding and following of suggestions. Often hypnotic subjects behave as though their understanding of language is more primitive; metaphoric expressions or idioms may be given their literal meanings. A subject told to raise his hand, for example, may simply raise the hand alone while leaving the arm unmoved, or a subject told to write their name, may literally write "Your name."

4. In some subjects, there may be excessive salivation and swallowing or excessive tearing of the eyes during hypnosis.

5. A characteristic of a hypnotized subject that some would call a defining feature of hypnosis is the tolerance of the subject for inconsistencies or anomalies in experience or perception, that is, trance logic.

The signs of hypnosis, while common, are all high individual. One subject may display most of these responses and be only in a very shallow state, as measured by his responsiveness to suggestions.

Another may not show and of these signs and yet be in a very deep hypnotic state. After working with an individual subject often enough, the hypnotist will be able to gauge this subject's trance depth from his objective responses.

The subjective feeling accompanying hypnotic induction are even more variable. They often include one or more of the following:

1. Feelings of deep relaxation and disinclination to expend any kind of effort during hypnosis.

2. Feelings of bodily heaviness, more likely in the limbs during hypnosis.

3. Feelings of numbness, tingling, or dullness in the limbs and/or hands during hypnosis.

4. A feeling of floating.

A common phenomenon in hypnotic sessions is the development of what is usually called rapport between the subject and the operator. This means that the subject reacts only to suggestions made by the hypnotist and treats suggestions made by anyone else as part of the background stimuli or noise, which he ignores.

Some operators believe that this is an essential aspect of hypnosis, but, like all other characteristics of a trance, it probably results from either an explicit or an implicit suggestion. For example, if the hypnotist tells the patient, "Attend only to the sound of my voice," as is commonly done during induction, he or she is in effect specifically telling the subject in a literal manner not to respond to suggestions from any other person.

In experimental work, the subject's doubt that hypnosis occurred is usually irrelevant to the study. If it is important to convince a patient of the reality of trance induction and the preceding steps leave him unconvinced, then hypnosis should be re induced and the subject given some posthypnotic suggestions to perform, such as developing an amnesia for the number 6.

Self-Hypnosis

Self-hypnosis or autohypnosis is a procedure in which the subject both induces the hypnotic state and makes suggestions to himself. When self-hypnosis is to be employed as part of a therapeutic regimen, it is necessary for the therapist to train the patient in its use. Often training is done under heterohypnosis, and the initial self-inductions are aided by a posthypnotic signal to into the hypnotic state. There is some experiemental evidence that inexperienced subjects can hypnotize themselves about as well as they can by hypnotized by another person.

There is ambiguity, however, concerning the nature of the self-hypnosis procedures typoically employed in such studies, involving, as they do, an experimenter giving a subject either initial verbal instructions or a booklet of directions on hypnotizing one's self, as well as a set of suggestions. There may be elements of both self-hypnosis anad heterohypnosis present in such a procedure. The main value of heterohypnosis in training a subject to induce autohypnosis is not providing him with a posthypnotic signal for induction but in letting him experience the subjective feelings of the hypnotic state that he must seek to attain self-induction.

The view is often expressed that all hypnosis is self-hypnosis because it is the subject's imagination that produces all of the effects in heterohypnosis. On the other hand, it could be argued that all hypnosis is basically heterohypnosis, and self-hypnotic effects resulty from posthypnotic suggestions given while training subjects in self-hypnosis. As early as 1928, Young researched this issue. He had hypnotic subhjects instruct themselves prior to hypnosis to modify specific aspects of rapport behavior and posthypnotic amnesia. He found that subjects could do this successfully and concluded that ther was no sine qua non of hypnosis. Posthypnotic amnesia was dependant on the subjects set of expectancy, and hypnotic behavior could be modified in many ways without affecting its depth. He concluded that the essential element in heterohypnosis was the autosuggestion of the subject.

Ruch (1975) also supports the notion that active self-hypnosis is the primary phenomenon and that heterohypnosis is, in effect, a case of guided self-hypnosis. He found that initial self-hypnosis facilitated subsequent heterohypnosis but that conventional heterohypnosis (of a passive subject by an active hypnotist) inhibited later attempts at self-hypnosis. This inhibitory effect was eliminated when "first-person instructions" were used in heterohypnosis. That is, instead of saying to the subject, "I am going to give you suggestions to help you to relax," the experimenter would say, "I am going to give myself instructions to help me relax." Thus the subject was able to regard the hypnotist's voice as his own, making suggestions to himself.

Ruch's view of the primacy of self-hypnosis is contrary to the conventional idea that heterohypnosis is an aid in training a person in self-hypnosis. It is premature to say whether the foregoing results are generalizable or are limited to the particular induction procedures tested. However, it seems questionable to label the procedure used as self-hypnosis, since, in the initial instructions, the experimenter made suggestions concerning the sequence of events that were to occur and then left the subject to count to himself and experience hem. This is similar to the Flower method of heterohypnosis in which all instructions to the subject are massed at the beginning of the induction. For an induction to qualify as an example of true autohypnosis, the subject should be responsible for all elements of the induction, and the hypnotist should make no suggestions of any kind beyond requesting the subject to commence the procedure.

Johnson (1981) notes that any study of self-hypnosis must be contaminated to some degree by heterohypnotic influence unless the study is limited to spontaneously developed trance states. Gardner (1981) proposed making a distinction between self-hypnosis (which she used to indicate self-hypnosis preceded or aided by heterohypnosis) and autohypnosis (which referred to spontaneous autohypnosis with no prior heterohypnosis). However, since these two terms are generally used interchangeably, such a distinction will probably prove as futile as the distinction between susceptibility and hypnotizability made in this book. If such distinctions are to be made (and they probably should be), then perhaps it will be necessary to coin new terms.

Most researchers have found few, if any, differences in success in inducing self-hypnosis as a function of previous heterohypnotic experience (Johnson, 1979; Kroger, 1977a; LeCron, 1964; Sacerdote, 1981; Shor and Easton, 1973). Sacerdote (1981) points out that with the modern trend toward more permissive inductions, the distinction between heterohypnosis and self-hypnosis is becoming vaguer.

Fromm (1975) notes that until recently, most of the serious research in hypnosis was in heterohypnosis; the literature of self-hypnosis was often the product of "quacks and laymen." She questioned on theoretical grounds the common assumption that heterohypnosis and self-hypnosis are basically the same and undertook to investigate the similarities and differences between the two. She conceptualizes hypnosis as an ego-splitting process. In heterohypnosis, the ego splits into two parts: the experimenter (participating ego) and the observer (observing ego). In autohypnosis, the ego splits into three parts: the experimenter and observer plus a director who gives the hypnotic instructions and suggestions. She found that in some subjects, a third or fourth aspect of the ego, a skeptic, was also present.

In a preliminary study, Fromm gave 18 males and 18 females one session each of heterohypnotic and autohypnotic experiences using a counterbal-anced order of presentation. The 12 least susceptible subjects described both experiences as essentially the same, but the 24 most-susceptible subjects de-scribed subjective differences between the experiences. Idiosyncratic fantasy and visual imagery arose spontaneously with a much higher frequency In autohypnosis. There was also more rational, cognitive activity going on In thes condition, and subjects were unanimous in reporting the greater number of ego splits predicted. Autohypnosis was found, as predicted, to require more effort on the part of the subjects.

Some subjects were able to reach a deeper state under heterohypnosis, while others went deeper under autohypnosis. Fromm accounts for this difference in terms of differences between subjects with respect to their need for surrender versus their need for autonomy and control. In a second study, three males and three females were instructed to practice self-hypnosis once a day for a month. Subjects were required to keep a daily diary of their experiences and were interviewed by telephone every few days. They were also subjected to two interviews plus a follow-up group discussion one month after the study.

Fromm found that with practice, self-inductions were easier to achieve. Eventually subjects began to employ methods of induction exclusively of their own design. Some used dissociative methods, such as producing an arm levitation by forgetting about the arm or commanding it to rise. Others simply "let go" and developed a passive-receptive ego state. After 2 or 3 weeks, most subjects who did not incorporate self-hypnosis into their life-style became bored with the procedure and had to be coaxed to continue the experiment. One of the causes of this problem was thought to be the tendency of prolonged self-hypnosis to reduce the transference with the experimenter. It was found that imagery was stimulated to a much greater extent in self-hypnosis but that some effects, such as positive hallucinations, profound ego regression, and role playing, were easier to produce in heterohypnosis.

The major advantage claimed for self-hypnosis in this study was that the subject was always attuned to his own responses during induction, and hence suggestions could be optimally timed. An outside hypnotist can at best make an educated guess as to the subject's subjective state. Johnson and Weight (1976), using factor analysis, found that behavioral and subjective experiences of subjects under heterohypnosis and self-hypnosis were generally similar. However, heterohypnosis invoked more feelings of unawareness of the environment, passivity, and loss of control, while autohypnosis was associated with more feelings of time distortion, disorientation, active control, and variations of trance depth.

In a later longitudinal study, Fromm and her associates (1981) essentially confirmed her earlier results. They concluded that "expansive free-floating attention" and ego receptivity to internal stimuli were state-specific for self-hypnosis, while concentrated attention and receptivity to a single external source of stimuli were state-specific for heterohypnosis. Again imagery was found to be much richer in self-hypnosis, while suggestions of age regression or positive and negative hallucinations were markedly more effective in heterohypnosis.

Psychological Problems Concerning Hypnosis Continued

Kleinhauz and Beran (1981, 1984) present six cases of severe and/or chronic reactions to hypnosis, five Involving either Inadequate dehypnotlzlng of the subject by a lay or stage hypnotist and one Involving a dentist ex ceeding his area of competence by treating a patient for smoking without consideration of the dynamic value of the symptom to the patient. One of the patients was reported to be a member of the audience at a stage dem onstration, and another claimed to have stolen a pistol as a result of the misinterpretation of a remark by a stage hypnotist that he should act like a cowboy and crack shot. The present author is skeptical of this latter case since the claim was raised as a defense in a criminal prosecution. The authors con clude that all therapists should inquire about prior hypnotic experiences to discover such influence in the genesis of the patient's condition so that they can provide adequate treatment. They also advocate the outlawing of stage hypnosis and criticize the "contamination" of the relationship with the subject by the hypnotist by using it not for the benefit of the patient but to make him an instrument for the purpose of entertaining an audience.

On the other hand, they do not object to experimental hypnosis because, while the researcher seeks to accomplish research goals rather than help the subject, the latter is aware of this, and the procedures are carefully designed and monitored. This position seems to present a problem in logical consis tency. The subject in stage hypnosis is also aware of the purposes of the hypnotist (often to a greater extent than in experimental hypnosis), and there is usually little concern with the subject in most experimental work but rather a focus on some hypnotic phenomenon. Often researchers are not clinically experienced, and little follow-up work on possible sequelae is undertaken. It is possible that the unstated reason for the belief of the authors that experi mental hypnosis is acceptable while stage hypnosis is not is that the value of the former justifies whatever risks may be involved.

Other reactions to hypnosis reported to have occurred in the course of psychotherapy include a spontaneous 72-hour atypical paranoid reaction, a spontaneous cataleptic reaction, and a spontaneous age regression (Hall, 1984; Kornfeld, 1985a; J. Miller, 1983; D.Spiegel and Rosenfeld, 1984). Although such reactions would be a disaster to a lay hypnotist, when they occur in the course of therapy and are properly managed, they may con tribute to a dynamic understanding of the patient. Certainly anyone under taking to do hypnotherapy needs to be prepared for such atypical reactions. Orne (1965a) suggests that some of the severe anxiety reactions that may occur in therapeutic inductions result from the fact that the patient expects permanent changes in his personality and that he is ambivalent about these changes. This ambivalence is demonstrated by the fact that the anxiety re actions can often be controlled by assuring the patient that the induction is intended simply to test his ability as a subject and that no therapeutic sug gestions will be made during the session. Also, transference and counter-transference issues may contribute to this anxiety. Orne believes that these issues should be dealt with under hypnosis, for if the therapist awakens the patient, the latter may interpret this as meaning that the therapist is unable to deal with the anxiety reaction.

J. Hilgard also reported on the incidence of sequelae in laboratory hypnosis and agrees with Orne's conclusion that most reported cases of serious difficulties with hypnosis arise in clinical rather than laboratory settings (Hil gard, Hilgard, and Newman, 1961; J. Hilgard, 1974). Hilgard concludes that most of the fears expressed concerning reactions to hypnosis are groundless and are based on inaccurate preconceptions of the hypnotist having undue influence over a subject. Untoward reactions obtained from subjects experi encing experimental hypnosis, although theoretically interesting, are not se vere. The 1974 study was undertaken because of a change in the charac teristics of the student body available for research since the study of 1961. It was found that of the 120 university students studied, 15% had some kind of reaction to the hypnotic experience (SHSS, form C) that lasted an hour or longer. This figure rose to 31% if short-term reactions (lasting from 5 min utes to an hour) were included. Thus, she warns against the premature dis missal of hypnotic subjects.

Some of the reactions (e.g., headache, confusion, or anxiety) began dur ing hypnosis and either terminated with it or persisted for a while after the session. The chief short-term aftereffects reported were drowsiness and con fusion (16 of 19 sequelae). Hilgard suggests that these may be regarded as a continuation of the hypnotic state rather than a reaction to it. It is similar to the experience of many people who require a period of readjustment after awakening in the morning.

Longer sequelae were experienced by 18 of 120 subjects in the 1974 study as opposed to only 7 of 220 subjects in the 1961 study. The much higher percentage in the later study may be due to the fact that form A of the SHSS was used in the earlier study, and form C, which includes age regression and dream induction, was used in the later one. Half of the long-term reactions (9 of 18) were a continuation of drowsiness and confusion, but more complex ones were also reported. One delayed response reported involved nocturnal dreaming about hypnosis, but it is not clear whether this response should be considered a sequelae or the hypnosis simply regarded as a day residue that appeared in the dream. Headaches were also reported that lasted from 1.5 to 2 hours but disappeared following sleep. Headaches were interpreted as representing a conflict between the desire to be hypnotized and anxiety con cerning the experience or a desire to avoid it. Little, if any, relationship was lound between hypnotic susceptibility and sequelae. There was, however, a positive relationship between pleasant aftereffects (which were not considered sequelae, such as feelings of relaxation, calm, and well-being) and suscep­tibility. Although these reactions were always suggested at the termination of hypnosis, only about 60% of the subjects reported experiencing them. It was found that there were wide individual differences in how subjects react fol lowing a hypnotic experience, but, in an experimental setting at least, thert were no alarming sequelae. In the 1961 study, a significant relationship was found between sequelae and adverse childhood experience with anesthesia, the patients was reported to be a member of the audience at a stage dem onstration, and another claimed to have stolen a pistol as a result of the misinterpretation of a remark by a stage hypnotist that he should act like a cowboy and crack shot. The present author is skeptical of this latter case since the claim was raised as a defense in a criminal prosecution. The authors con clude that all therapists should inquire about prior hypnotic experiences to discover such influence in the genesis of the patient's condition so that they can provide adequate treatment. They also advocate the outlawing of stage hypnosis and criticize the "contamination" of the relationship with the subject by the hypnotist by using it not for the benefit of the patient but to make him an instrument for the purpose of entertaining an audience.

On the other hand, they do not object to experimental hypnosis because, while the researcher seeks to accomplish research goals rather than help the subject, the latter is aware of this, and the procedures are carefully designed and monitored. This position seems to present a problem in logical consis tency. The subject in stage hypnosis is also aware of the purposes of the hypnotist (often to a greater extent than in experimental hypnosis), and there is usually little concern with the subject in most experimental work but rather a focus on some hypnotic phenomenon. Often researchers are not clinically experienced, and little follow-up work on possible sequelae is undertaken. It is possible that the unstated reason for the belief of the authors that experi mental hypnosis is acceptable while stage hypnosis is not is that the value of the former justifies whatever risks may be involved.

Other reactions to hypnosis reported to have occurred in the course of psychotherapy include a spontaneous 72-hour atypical paranoid reaction, a spontaneous cataleptic reaction, and a spontaneous age regression (Hall, 1984; Kornfeld, 1985a; J. Miller, 1983; D.Spiegel and Rosenfeld, 1984). Although such reactions would be a disaster to a lay hypnotist, when they occur in the course of therapy and are properly managed, they may con tribute to a dynamic understanding of the patient. Certainly anyone under taking to do hypnotherapy needs to be prepared for such atypical reactions.

Orne (1965a) suggests that some of the severe anxiety reactions that may occur in therapeutic inductions result from the fact that the patient expects permanent changes in his personality and that he is ambivalent about these changes. This ambivalence is demonstrated by the fact that the anxiety re actions can often be controlled by assuring the patient that the induction is intended simply to test his ability as a subject and that no therapeutic sug gestions will be made during the session. Also, transference and counter-transference issues may contribute to this anxiety. Orne believes that these issues should be dealt with under hypnosis, for if the therapist awakens the patient, the latter may interpret this as meaning that the therapist is unable to deal with the anxiety reaction.

J. Hilgard also reported on the incidence of sequelae in laboratory hypnosis and agrees with Orne's conclusion that most reported cases of serious difficulties with hypnosis arise in clinical rather than laboratory settings (Hil gard, Hilgard, and Newman, 1961; J. Hilgard, 1974). Hilgard concludes that most of the fears expressed concerning reactions to hypnosis are groundless and are based on inaccurate preconceptions of the hypnotist having undue influence over a subject. Untoward reactions obtained from subjects experi encing experimental hypnosis, although theoretically interesting, are not se vere. The 1974 study was undertaken because of a change in the charac teristics of the student body available for research since the study of 1961. It was found that of the 120 university students studied, 15% had some kind of reaction to the hypnotic experience (SHSS, form C) that lasted an hour or longer. This figure rose to 31% if short-term reactions (lasting from 5 min utes to an hour) were included. Thus, she warns against the premature dis missal of hypnotic subjects.

Some of the reactions (e.g., headache, confusion, or anxiety) began dur ing hypnosis and either terminated with it or persisted for a while after the session. The chief short-term aftereffects reported were drowsiness and con fusion (16 of 19 sequelae). Hilgard suggests that these may be regarded as a continuation of the hypnotic state rather than a reaction to it. It is similar to the experience of many people who require a period of readjustment after awakening in the morning.

Longer sequelae were experienced by 18 of 120 subjects in the 1974 study as opposed to only 7 of 220 subjects in the 1961 study. The much higher percentage in the later study may be due to the fact that form A of the SHSS was used in the earlier study, and form C, which includes age regression and dream induction, was used in the later one. Half of the long-term reactions (9 of 18) were a continuation of drowsiness and confusion, but more complex ones were also reported. One delayed response reported involved nocturnal dreaming about hypnosis, but it is not clear whether this response should be considered a sequelae or the hypnosis simply regarded as a day residue that appeared in the dream. Headaches were also reported that lasted from 1.5 to 2 hours but disappeared following sleep. Headaches were interpreted as representing a conflict between the desire to be hypnotized and anxiety con cerning the experience or a desire to avoid it. Little, if any, relationship was lound between hypnotic susceptibility and sequelae. There was, however, a positive relationship between pleasant aftereffects (which were not considered sequelae, such as feelings of relaxation, calm, and well-being) and susceptibility. Although these reactions were always suggested at the termination of hypnosis, only about 60% of the subjects reported experiencing them. It was found that there were wide individual differences in how subjects react following a hypnotic experience, but, in an experimental setting at least, thert were no alarming sequelae.

Psychological Problems Concerning Hypnosis

Minor problems with result from carelessness on the part of the hypnotist and can usually be prevented by the use of proper technique. They include delayed effects of posthypnotic or uncancelled hypnotic suggestions, misunderstanding by the subject of the suggestions made, and the rare difficulties encoun tered in the termination of hypnosis.

All hypnotic suggestions given during a session that are not intended to affect posthypnotic behavior should be cancelled prior to terminating hypnosis, even if the subject did not appear to accept them. Subjects should be tested in the waking state prior to being dismissed to ensure that these sug gestions have in fact been cancelled. The evidence is that in most cases the subject himself will cancel these suggestions, but it is better not to rely on his implicit understanding that the suggestions were not meant to outlast the ses sion.

Because of the literalness with which most hypnotic subjects react to sug gestions, hypnotists should always avoid the use of idiomatic expressions that, if taken literally, would produce results different from those sought. (For example, a patient told to "Let her hair down" and describe how she really feels about something may actually undo her hair arrangement.) Particular care is required when making suggestions to subjects with limited ability in English who are foreign born, uneducated, or of low intelligence. Precautions must also be taken to ensure that a child patient understands the suggestions clearly. Often very bright children give the hypnotist the illusion that he or she is dealing with a small adult; but even bright children may not understand some words in a suggestion.

Orne (1965a) notes that amateurs are the hypnotists most likely to have difficulty with subjects refusing to terminate a hypnotic state, probably because such a reaction is an ideal passive-aggressive response on the part of a subject who has become angry at the hypnotist. The reason that profes sionals using hypnosis rarely get such reactions is that they fail to reinforce them by getting upset, as does a suddenly frightened and terrified amateur hypnotist.

The possibility of problems with symptom substitution has also been pre viously discussed. It should be noted that this is not properly considered a problem of hypnosis but is a problem of any type of psychotherapy that seeks to directly remove a symptom having a dynamic value to the patient. Some symptoms may have such value; many do not. There is no general agree ment as to what percentage of symptoms fall into either category. The sig nificance of a particular symptom in an individual patient is always a matter of clinical judgment on the part of the therapist.

The remaining psychological problems to be considered here are those reactions that occur either during or immediately after hypnosis and are usually discussed under the rubric of sequelae.

Orne (1965a) finds both qualitative and quantitative differences in the types of hypnotic sequelae seen in the laboratory and in therapeutic settings. If the hypnosis is perceived by the subject as episodic and he has no expectation of permanent change, there are very few sequelae, and any that do occur of a minor nature. This is the case in laboratory research, where the emphasis is impersonal and on the phenomena studied, not the subject, or in dental treatment where effects are also perceived by the subject as temporary.

In experimental work with thousands of "normal college students," in a setting specifically de'ined as experimental and with subjects told that no treatment, however minor, would be given, Orne reports virtually no serious reactions to hypnosis. Anxiety reactions, symptom formations, depressions, or decompensations, which have occasionally been reported in clinical con texts did not occur. The complications that did appear were such minor dis-turbances as an occasional mild and transient headache, drowsiness, nausea, or dizziness. If these complications occur, they typically do so on the first induction and are easily suggested away. The incidence of such reactions was reported by Orne to be from 2% to 3%, which is in close agreement with J. Hilgard's (1965) findings. Orne points out that due to the superficial screening of his subjects and the large numbers of them, it is quite likely that some of them may have had serious psychopathology. Since these results were in an experimental context, they are more likely to reflect the effects of hypnosis per se than the effects of either a therapeutic relationship or therapeutic sug gestion, and these results suggest that hypnosis itself is a safe procedure.

Orne further notes that although minor problems experienced by amateur hypnotists might be concealed, it would be hard for them to hide major problems. Although major problems can occur, they are quite rare, in spite of the incompetence and irresponsibility of the hypnotist. This scarcity of untoward reactions is probably due to the episodic and nontherapeutic nature of the hypnotic session.

The low incidence of serious aversive reactions in experimental work is in contrast to their relatively high incidence in the reports of experienced clini cians. Levitt and Hershman (1961, 1963) surveyed 866 hypnotherapists and found that about 27% of the 301 respondents reported observing major or minor untoward reactions to hypnosis, including anxiety, panic, depression, headache, crying, vomiting, fainting, dizziness, excessive dependency, and eight cases of sexual difficulties and psychotic behavior. Forty-three percent of the psychologists (as compared to 27% of the other respondents) reported these difficulties. J. Hilgard (1974) notes that often the more experienced hypnotists reported the most problems.

Orne (1965a) and Conn(1972) interpret this finding quite differently. Conn believes the prevalence of sequelae reflects an incompetence on the part of the hypnotist, who failed either to dehypnotize subjects properly or to screen them adequately prior to hypnosis. Orne, on the other hand, suggests that only the better-trained therapists adequately observed and recorded sequelae.

Wineburg and Straker (1973) report an acute, self-limiting depersonali zation reaction in a 26-year-old female paraprofessional hospital worker. This woman was used as a demonstration subject in a hospital training course in hypnosis and was given weight reduction suggestions. They believe that the adverse reaction was due to the subject's misconceptions about hypnosis and the fear that it could weaken superego controls over her sexual fantasies. The authors recommend that to prevent reactions such as this, all patients should be observed after hypnotic treatment. Moreover, the patients' beliefs and ex pectations concerning hypnosis should be investigated beforehand, at which time they should be given an explanation of the true nature of hypnosis. This type of reaction, although certainly a risk in hypnotherapy, seems clearly to be the result not of hypnosis but of the patient's fears and inrrapersonal dy namics. It should be preventable by an adequate consideration of these fac tors prior to and during hypnosis. Straker (1973) presents two other cases in which patients developed emotional upsets during a therapeutic induction because of intrapersonal dynamic reasons. In one instance, the induction re sulted in a rapid regression and enhanced transference that flooded the pa tient with childhood memories of early fears and recurrent nightmares. In the other instance, a hypnotic induction took on the significance of a sexual at tack to a 36-year-old female patient because of her previous beliefs about hypnosis. This resonated with earlier rape fantasies, greatly upsetting her. These types of reactions are not different from those obtained in ordinary psychotherapy, but the fostering of regression and transference by hypnosis can make them occur more rapidly and dramatically and give the illusion that they are caused primarily by hypnosis.

Sometimes the unusual nature of the hypnotic state causes even an ex perienced therapist to forget that a hypnotic induction does not cause all of the usual principles of human behavior and interaction to cease to operate. As an illustration, Orne (1965a) cites the case of a dentist whose wife was constantly asking him to hypnotize her for weight reduction suggestions, which he steadfastly refused to do. Instead, he insisted that she see a physician to get diet recommendations. The dentist finally relented and hypnotized his wife, but, instead of making weight loss suggestions, he made the suggestion that she would see her doctor. This suggestion was unsuccessful and resulted In the formation of a minor symptom. The idea of consulting a doctor was unacceptable to this woman in the waking state, and it was equally unacceptable under hypnosis.

Rosen (1960a) cited clinical examples of what he considered to be very serious dangers of hypnosis. These included the development of psychoses and a suicide following the hypnotic removal of phantom limb or low back pain and pruritus. He believes that pain that persists for emotional reasons may be a depressive equivalent and hold a severe depression in check. He is quite critical of weekend hypnotic courses touting hypnosis as an uncov- ering device and believes that neither uncovering techniques nor regressions are safe in the hands of persons ignorant of psychodynamics. Although it is hard to disagree with his contention that no one should treat a patient under hypnosis beyond his competence to treat him while awake, it is equally hard to agree with his view concerning the dangers of hypnosis. The cases he cited are clinical examples and as such cannot establish the causal agency of either the hypnosis or the symptom removal in producing the sequelae claimed. The fact that a psychosis follows hypnosis does not logically demonstrate that II was caused by the hypnosis. Conn (1972), after 30 years of practicing hypnotherapy on over 3,000 patients, denies ever seeing a psychosis pre cipitated by hypnosis. Also, even if such causality could be established, It Hems clear that the cause of adverse reactions reported is less likely to be the hypnosis than the method of psychotherapy. These cases really relate to the issue of symptom substitution, not hypnosis, and the weight of the lit-erature does not support the view that symptom substitution involving new, psychotic, or life threatening symptoms is a high-risk phenomenon.

Posthypnotic Amnesia

Posthypnotic amnesia is a condition that occurs when, with or withoutexplicit or implicit suggestions to do so, a subject is unable to remember some or all of the events that occurred in the hypnotic state when he is subsequently awakened. Typically these unavailable memories can be restored suddenly and without any intervening opportunity for relearning by means of a prear- ranged release signal. These memories are also freely retrievable in a sub- sequent hypnotic session. It is this property of reversibility or retrievability that differentiates true posthypnotic amnesia from some types of pseudo-amnesia, which may be caused by simple forgetting or by the failure to attend to or learn material while in the hypnotic state. The material lost as a result of this kind of pseudo-amnesia is not recoverable posthypnotically; the loss is per- manent. The phenomenon of reversibility also demonstrates that posthyp- notic amnesia is not caused by a failure to record material in the hypnotic state but by an interference with the normal retrieval or playback mechanism for gaining access to material in memory (Kihistrom, 1977; Kihisrrom and Evans, 1976; Nace, Orne, and Hammer, 1974; Orne, 1966b; Spanos and Bodorik, 1977). This conflicts with Hilgard's hypothesis that posthypnotic amnesia occurs because subjects under hypnosis suffer from a reduced ability to retain memories just as sleeping subjects do. This is particularly so in view of the findings of Nace, Orne, and Hammer (1974) that there were no sig- nificant differences between high- and low-susceptibility subjects in total recall of events experienced under hypnosis. Furthermore, Orne (1966b) dem- onstrated that the suggestion made to subjects in stage 1 sleep that their noses would itch when a cue word was spoken elicited scratching behavior in sub- sequent stage 1 sleep. This suggestion was also effective on the following night, even though the subjects were amnesic for the suggestion during the waking interval between the two laboratory sessions. This suggests that even sleeping subjects may have more capacity to retain memories than is gen- erally indicated (by studies showing that nocturnal dreams are usually for- gotten if a subject is not awakened within 10 minutes of the REM period during which the dream occurred). Perhaps it was the active response of the subject to the suggestion that enabled the memory trace to be recorded. While spontaneous posthypnotic amnesia is commonly regarded as a sign of somnambulism and is thought by some to be one of the signs of a deep hypnotic state, the experimental literature is in agreement that this phenom- enon rarely occurs in the laboratory (Barber and Calverley, 1966c; Kihistrom, 1977; Kihistrom and Evans, 1977).

Kihistrom and Twersky (1978) found that not only is posthypnotic am- nesia not caused by poor waking memory but subjects displaying marked posthypnotic amnesia actually had superior long-term retention of intention- ally learned material in the waking state.

Young and Cooper (1972) demonstrated the effect of implicit suggestion on the development of posthypnotic amnesia in subjects whose expectancies concerning the development of amnesia following hypnosis were manipu- lated. Half of their subjects were exposed to a prehypnotic lecture on hyp- nosis stating that posthypnotic amnesia invariably follows hypnosis, and the other half were told that it never occurs spontaneously. A significantly greater number of subjects expecting to develop posthypnotic amnesia developed it spontaneously.

In a study involving suggested rather that spontaneous posthypnotic am- nesia, Ashford and Hammer (1978) found a nonsignificant relationship be- tween inferred subject expectancies of posthypnotic amnesia and its subse- quent development following its suggestion on the HGSHS'.A. Simon and Salzberg (1985) also found that manipulating subjects' expectations had no effect on the occurrence of posthypnotic amnesia on the SHSS form A but hypnotic suggestion did. Hypnotic subjects given no specific suggestion for amnesia had less memory than nonhypnotized control groups, which sug- gests the possibility of self-suggestion. Perhaps the reason for the apparent conflict between this study and the findings of Young and Cooper was that in the present study subjects' expectancies were manipulated by having some of them read a paragraph denying the spontaneous occurrence of posthyp- notic amnesia. None was cued to expect this phenomenon, and since the initial expectancy of posthypnotic amnesia in these subjects seemed to have been low to begin with, this "manipulation" may not have produced two groups differing in expectancies. Orne (1966b), on the other hand, cites the cross-cultural occurrence of spontaneously developed posthypnotic amnesia, particularly in hypnotic-like religious and mystic experiences. He believes that this phenomenon deserves more attention than a glib dismissal of it as being due to implicit suggestion. Orne further notes that emotionally charged ma- terial relived by patients during hypnosis is usually forgotten spontaneously on awakening. This material is often related in language appropriate to an earlier stage of life, and he suggests that part of the difficulty in memory may involve the need to translate this material into adult patterns of thought. He reports that patients have difficulty in integrating this type of material into present consciousness even after they have the opportunity to listen to a tape recording of their hypnotic session while awake. Kline (1966) also notes that amnesia is more common following hypnotherapy than other types of hyp- nosis, and its extent seems to be related more to the material brought up under hypnosis than to the depth of the trance.

As in many other areas of controversy in hypnosis, perhaps both sides in this conflict are right. Although the development of spontaneous amnesia is rare in the laboratory, typical hypnotic research does not deal with affect- laden events, and there is no dynamic need for subjects to display an un- suggested amnesia. In clinical practice, however, where affect-laden material is routinely dealt with under hypnosis, spontaneous amnesia may be more common. Indeed, under these circumstances, the amnesia may be caused by the same dynamic factors that produced the original repression rather than by any special properties of the hypnotic state. Thus, as Orne suggests, there may be two different mechanisms involved in the production of posthypnotic amnesia: one based on suggestions in experimental work and one based on repression in clinical phenomena. His idea that dissociation may result from essential differences between the hypnotic and waking thought processes is more difficult to square with the apparent lack of spontaneous amnesia in experimental work, unless it is realized that clinical investigations typically deal with personal memories as opposed to material learned under hypnosis. Suggested posthypnotic amnesia has many subclassifications. Generally it is not an all-or-none phenomenon and can vary in degree from complete to slight. This is indeed fortunate, for the occurrence of partial posthypnotic amnesia makes it possible to study the effects of hypnotic suggestions on the mechanisms of memory retrieval. This would not be possible if amnesia were complete (Evans and Kilhstrom, 1973).

Suggested posthypnotic amnesia can be general—all memories of the hyp- notic experience are interfered with—or specific—only certain memories (either acquired under hypnosis or previous to it) are inhibited. In the former case, the subject may develop pseudo-memories and fill in the gaps with confabulations, as sometimes b . with patients having organic memory defects (Orne, 1966b). If a specific amnesia is suggested for a familiar name or a number, there will be marked differences in both the subjective experi- ence and objective behaviors of subjects responding to such a suggestion. Some subjects will report totally forgetting the name or number, while others will report remembering it but be unable to pronounce it when challenged to do so. It is quite common for such a suggestion made to a group of subjects to be interpreted differently by individual subjects. Hence these differences in responses are not due merely to the wording of the suggestions but also to the individual interpretations of these words made by each subject (and possibly to individual differences in hypnotic depth and the resulting literal- ness of understanding).

There was a time when it was widely believed that in order for a post- hypnotic suggestion to be effective it was necessary at the time of making the suggestion also to suggest a specific posthypnotic amnesia for it. Although this is no longer regarded as essential, Orne (1966b) believes that posthyp- notic suggestions made with suggestions of amnesia tend to last longer. In any event, subjects carrying out posthypnotic suggestions without awareness of the source of their behavior tend to justify their seemingly odd conduct with rationalizations. Subjects aware of the cause of their behavior tend to experience a compulsion to carry out the suggested actions (Estabrooks, 1957; Orne,1966b).

Posthypnotic amnesia may be divided into source amnesia or content am- nesia. Source amnesia is commonly produced when a hypnotized subject is given some obscure bit of information that he would have been unlikely to be aware of prior to hypnosis. Following a suggestion for a general posthyp- notic amnesia, it is found that he is immediately aware of this information on waking but is unaware of its source. This reaction, like most other hypnotic alterations of memory, is similar to the normal waking characteristics of mem- ory. Most people retain factual information of the type learned in school in isolation from the context in which it was learned. Thus the average adult will be unable to tell the circumstances under whic** ''" '"arned the date of the discovery of America or the Pythagorean theorem, source amnesia can be a source of torment for an author who remembers an appropriate quo- tation but cannot remember who said it. Memory that includes the contextual situation surrounding the information recalled is referred to as redintegration. It usually is related to personal experiences rather than factual or theoretical data. Unlike content amnesia, source amnesia is not often suggested explicitly under hypnosis and usually occurs spontaneously (Kilhstrom, 1977; Nace Orne, and Hammer, 1974; Orne, 1966b; Thorne, 1969).

Evans (1979) found that source amnesia occurred in 31% and 33% 29 and 12 deeply hypnotized subjects, respectively, who displayed a total recall amnesia for all other events under hypnosis, but it did not occur in 15 simulating subjects. Hence he concluded that it resulted from a dissociative phenomenon rather than the demand characteristics of the hypnotic situation or subtle cues given concerning the expectations of the experimenter (who was blind as to the hypnotic or simulating status of the subject).

Like all other posthypnotic phenomena, a posthypnotic amnesia can last for a variable period of time following termination of hypnosis. In some sub- jects, this period can be quite lengthy. A posthypnotic suggestion that a sub- ject will not develop a posthypnotic amnesia or that one developed will ter- minate is usually effective in preventing any spontaneous amnesia. Besides being terminated suddenly by a posthypnotic release cue or the reinduction of hypnosis with suggestions that the subject will now be able to regain all memories from the previous hypnotic experience, hypnotic amnesia can be permitted to dissipate with the passage of time.

A 1949 ftim, Unconscious Motiuation, was designed to demonstrate the effect of ui ous ideation on behavior. A male and a female college stu- dent were given the suggestion under hypnosis that as children they had failed to return a pocketbook they had found containing two coins and had used the coins to buy candy. The subjects were given a suggestion of post- hypnotic amnesia for this fantasy, and it was found to produce an unpleasant affective state in them, although they were unable to assign a reason for their feelings. In spite of their lack of conscious awareness of this ideation, it af- fected their responses on TAT-like and Rorschach-like tests, as well as word association responses. The amnesia was broken down without a prearranged release signal by the kinds of associations used in psychotherapy. Often in- complete memories obtainable under conditions of posthypnotic amnesia can be used as a starting point for associations to break the amnesia, and some- times total recall can be obtained soon after the first breakthrough is attained.

Orne (1966b) believes that memories retained during a suggested post- hypnotic amnesia relate to events during relatively light periods of the trance. Thus, he believes that the effectiveness of a suggestion for posthypnotic am- nesia is determined not by the overall depth of the trance but by its depth immediately preceding the suggestion of amnesia. A subject's failure to re- spond to suggestions early in the trance may not interfere with the devel- opment of the suggested amnesia, provided that he is given suggestions that he can respond to just prior to the suggestion for amnesia. The converse is also true; failed suggestions just prior to suggesting amnesia may interfere with its being developed in spite of previous successful tests of trance depth. This was demonstrated by giving the Harvard Group Scale of Hypnotic Sus- ceptibility (HGSHS) to two groups of subjects. Test items were given to one group in ascending order of difficulty and to the other in descending order of difficulty.

Miscellaneous Applications of Hypnosis

Hypnosis has been used in education as a learning aid, and as a methodof dealing with examination anxiety, and for self-improvement suggestions (e.g., of greater self-confidence) in social and business situations (Boutin, 1978; Cohen, 1979; Hebert, 1984; Porter, 1978; Spies, 1979; Wollman, 1978). Cole (1979) found that hypnosis was no more effective in improving the academic performance of 31 students in a college preparation course (who were exposed to a 40-minute induction and deepening tape plus four sub- sequent 15-minute hypnotic tapes making suggestions of enhanced academic performance) than exposing students to control tapes making the same sug- gestions without hypnosis or lectures. These results are not particularly sur- prising. Hypnosis would not be expected to improve academic performance unless poor performance was caused by psychological factors (other than a low level of ability) and these factors were identified and addressed by the hypnotic technique used. Van Pelt (1975a, 1975b) suggested the use of hyp- nosis in business as a method of coping with interpersonal problems and in space travel to deal with boredom, nervous strain, and problems produced by weightlessness, interruption of sleep cycles, and space sickness. Christie (1982) discusses a variety of industrial uses of hypnosis, such as attitude change, performance facilitation, vocational counseling, advertising, and consumer research, both with and without formal trance induction.

Hypnotic phenomena play an indirect role in entertainment. Most mem- bers of a movie audience resemble people in a hypnotic trance. The movie itself probably functions similarly to the word picture painted by a hypnotist in a cognitive induction and detaches the audience members from their im- mediate surroundings. Good subjects trained in self-hypnosis can probably use this skill to enhance the vividness of the private fantasies in which all people engage. It is likely that creative people like authors or playwrights can use hypnotic fantasy productively to generate new ideas for their work. Rob- ert Louis Stevenson got the idea for Dr. Jekyll and Mr. Hyde from a nocturnal dream (Dement, 1974). Hypnotic suggestions have not only been used to help actors assume a character but also to generate appropriate facial expres- sions in photographers' models (Kondreck, 1963).

Hypnosis even comes into play in modern religious life. Many people have had the experience of being so entranced by the charismatic style of a tele- vision evangelist that they listened captivated for an entire sermon without having had prior interest in the message being conveyed. Indeed, the ability to attract and hold the attention of an audience is much like a hypnotist's getting a subject to concentrate on a fixation object or instructing him to "at- tend only to the sound of my voice."

Matheson (1979b) points out the similarities between religious experiences and healing and hypnotic phenomena. Tappeiner (1977), a theologian who notes the operation of hypnotic factors in several varieties of religious ex- perience, argues that the fact that religious phenomena can be explained in terms of hypnotic principles does not negate their spiritual validity, that is, God works through natural mechanisms.

The present author would agree that noticing the hypnotic qualities and techniques of an evangelist commits the observer to nothing regarding the spiritual validity of his message.

Walker (1984) notes the common factor of what he calls "inadequate re- ligious attitudes," which can complicate psychotherapy, and suggests a role both for hypnosis and ministers of religion in an effort to correct these and facilitate therapy. This thought-provoking article suggests that perhaps psy- chotherapists, as part of their training, should be exposed to the major tenets of the various religious denominations, for guilt is commonly seen in patients with overly strict religious beliefs, and psychotherapists are often reluctant to address such issues. Perhaps if they were more knowledgeable concerning the beliefs of the major religious denominations, they might recognize when their patient's beliefs were idiosyncratic or "inappropriate" and when a con- sultation with a clergyman might prove helpful in correcting them (just as therapists are trained to recognize when a medical consultation is necessary).

The diverse applications of hypnosis discussed tend to ob- scure the fact that hypnosis is basically a phenomenon rather than a tech- nique. It would be strange indeed if a natural phenomenon like hypnosis did not occur often in daily life, but when it does occur naturally in such prosaic settings as the movies or while watching television, we usually fail to recognize a spontaneous trance for what it is. Sometimes naturally occurring trances can have unfortunate consequences, as in the case of highway hypnosis. Recognizing that effects of this nature can occur makes it possible for engi- neers to design cars and highways to minimize or eliminate such risks.

Training in self-hypnosis opens the door for the employment of hypnosis in many minor applications, such as the control of normal levels of anxiety before giving a speech or prior to an important business interview, where it would normally not be practical to incur the expense of a professional con- sultation.

While this chapter has considered some of the major applications of hyp- nosis, it is not possible to consider all of its potential uses, for these extend to any situation that requires relaxation; the stimulation of imagery, emotion or motivation; or the enhancement of the ability to concentrate on something and become detached from the environment.

Hypnotic Susceptibility

Hypnotic susceptibility or trance capacity refers to the ability of a subject to achieve a given level of hypnotic trance. This in turn makes two assumptions:

1. There is such a phenomenon as a trance state.

2. This state can be meaningfully measured along a depth scale from shallow (hypnoidal) to deep (somnambulistic).

With respect to the first issue, Sutcliffe (1961) has oriented theoretical views about the nature of hypnosis on a scale ranging from "credulous" to "skeptical." At the credulous end of the scale are the "hypnotic state" theorists, who regard a trance state as a phenomenon that enhances the suggestibility of a hypnotized subject. At the skeptical end of the scale are theorists like Barber, who take the view that a hypnotic state is neither a necessary nor sufficient condition to produce the classic effects of hypnosis, or Gibbons, who refers to the notion of a trance state as a "shared delusion."

Barber points out that well-motivated subjects who have not been hypnotized can produce all of these phenomena, while some subjects in a deep trance cannot.

Implicit in the idea of measuring hypnotic susceptibility is the notion that it is a stable personality characteristic as opposed to a situational variable. If susceptibility is, in fact, a stable characteristic of a person, questions arise about what factors cause some people to develop a markedly greater capacity for hypnosis than others and how readily this capacity can be modified.

Does repeated experience with hypnosis improve a subject's ability to achieve a deeper state, in the sense of being able to do things under hypnosis that he formerly was incapable of achieving?

In order to be hypnotized a subject not only has to have the trance capacity, but must also want to be hypnotized and must actively cooperate in the process. It is conceivable that a person with a lot of ability as a hypnotic subject may be afraid of being hypnotized, react negatively to the hypnotist, or be suffering from some physical or mental distraction at the time of an original attempt at hypnosis. The subject will thus appear to be a poor subject.

If after repeated hypnotic sessions these fears abate, the subject's rapport with the hypnotist improves, or his motivation to be hypnotized increases, he may achieve a much deeper trance. This result may give the illusion that the practice has improved the subject's basic trance capacity when in fact it has not. It is clear that the best subject cannot be hypnotized unless he wants to be.

Thus, tests of hypnotic susceptibility are valid only when the tester is certain that the subject is will motivated and doing his best.

To avoid semantic confusion the term hypnotic susceptibility or trance capacity will be used when referring to the stable or long-term ability of a subject to be hypnotized, and the term hypnotizability will denote the net effect of susceptibility plus any operative situational factors affecting the hypnotic ability of a subject at a given time.

Unfortunately, this distinction is not generally made in the literature, and usually the terms susceptibility and hypnotizability are used interchangeably, resulting in a great deal of confusion in research dealing with the issue of whether susceptibility is modifiable.

It is a common experience that subject exposed to repeated hypnotic sessions tend to enter the trance state more rapidly on successive sessions and often appear to develop greater depth. It is for this reason a good idea not to give up therapeutic efforts on what may seem like a poor subject without at least a few trials. (Fortunately many therapeutic applications do not require a very deep trance.)