By Dr. Alfred Barrios, PhD in Clinical Psychology from the University of California
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 related to hypnosis in the last three years (1966 to 1968), with approximately forty percent of these pertaining to its use in therapy.
During the same period, we found 899 articles on psychoanalytic therapy and 355 on behavioral therapy.
Contrary to popular opinion that hypnosis is only effective in certain specific cases for symptom removal, a wide range of diagnostic categories have been successfully treated through hypnotherapy. This includes anxiety reactions, obsessive-compulsive neurosis, hysterical reactions, and sociopathic disorders (Hussain, 1964), as well as epilepsy (Stein, 1963), alcoholism (Chong Tong Mun, 1966), frigidity (Richardson, 1963), stuttering and homosexuality (Alexander, 1965), various psychosomatic disorders including asthma, spontaneous abortions, dysmenorrhea, allergic rhinitis, ulcers, dermatitis, infertility, and hypertension (Chong Tong, 1964, 1966). Additionally, in recent years, a growing number of reports indicate that psychoses are well treatable with hypnotherapy (Abrams, 1963, 1964; Biddle, 1967).
Three Large-Scale Studies
Three large-scale studies in the last five years have yielded fundamental results.
Richardson’s study (1963) dealt with seventy-six cases of frigidity. He reported that 94.7% of the patients improved. The average number of sessions required was 1.53. The criterion for judging improvement was an increase in the percentage of orgasms. The percentage of orgasms increased from an average pre-treatment rate of 24% to an average post-treatment rate of 84%. Follow-ups (exact time period not reported) showed that only two patients were unable to maintain the same level of climax as when treatment ended. Richardson’s treatment method was a combination of direct symptom removal, exposure, and the removal of underlying causes, as he found that direct symptom removal alone was not always sufficient. He reported no failures in hypnotic induction.
Chong Tong Mun’s study (1964, 1966) covered 108 patients suffering from asthma, insomnia, alcoholism, dysmenorrhea, dermatitis, anxiety states, and impotence. The percentage of patients reported to have improved was 90%. The average number of sessions was five. The criterion for judging improvement was symptom removal or improvement. The average follow-up period was nine months. Chong Tong Mun’s treatment approach was threefold. With some patients, he worked on re-educating the patient regarding behavior patterns immediately underlying the symptoms. With others, he first regressed the patient back to the original inception of the symptom. After regressing, he re-educated the patient that the original cause was no longer operative. Additionally, he typically used additional suggestions for direct symptom removal.
Hussain’s study (1964) reports on 105 patients suffering from alcoholism, sexual promiscuity, impotence, frigidity, sociopathic personality disorders, hysterical reactions, behavior disorders, school-age child disorders, speech disorders, and various other psychosomatic illnesses. The percentage of patients reported as having improved was 95.2%. The number of sessions required ranged from four to sixteen. The criterion for judging improvement was complete or nearly complete symptom removal. In follow-ups ranging from six months to two years, no cases of relapse or symptom substitution were noted.
Hussain’s approach is illustrated by the case of a 35-year-old woman who exhibited the following symptoms: anxiety, alcoholism, depression with suicidal tendencies, sexual promiscuity, insomnia, and an inability to make decisions or plans for the future.
Before treatment, Hussain located the various fears and negative attitudes that he believed were underlying the symptoms—for example, the patient feeling despised and unwanted in her marriage, feelings of inadequacy as a mother, fear of her own mother, fear of responsibility and decision-making, and guilt over her sexual promiscuity.
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-inducing situation, reconditioning her with suggestions that she would feel calm and relaxed in that situation. This particular approach is used quite frequently today in one form or another. Abrams (1963) refers to this technique as an “imagined situation” technique. Through hypnosis, the patient is able to experience her new attitudes in an “imagined situation,” a situation in her mind. This differs from Wolpe’s approach in two ways. First, Wolpe does not frequently use hypnosis. Second, Wolpe has the patient go through a hierarchy of “imagined situations,” ranging from the easiest to deal with to the most difficult. (There is no reason, however, not to incorporate this approach into hypnotherapy).
With the above patient, Hussain also used direct symptom removal suggestions. For example, “an aversion to the thought and sight of alcohol was also established 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.”
Current Method of Using Hypnosis
As seen in the studies above—and this may come as a surprise to most patients and many therapists—the primary use of hypnosis is not a means of direct symptom removal. Nor is its primary use a method of discovery. The current trend is to use hypnosis to remove negative attitudes, fears, maladaptive behavior patterns, and negative self-images underlying symptoms. The discovery of causes and direct symptom removal are still used to some extent but generally in conjunction with this new primary function.
In the past, so much emphasis was placed on symptoms and pathological processes that some of us felt guilty for forgetting the person in the body. It is our duty (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 leading physicians in the field, shares with all other forms of modern psychiatric treatment the concern not only for the presented symptoms but primarily for the dynamic impasse in which the patient finds themselves and their character structure (Alexander, 1965).
The objection that the results of symptom removal will rarely be permanent is certainly not valid. This may have been the case in the past when only removal was practiced and nothing was done to strengthen the patient’s ability to cope with their difficulty or to encourage them to stand “on their own feet” (Hartland, 1965).
This shift is emphasized in this present work because part of its purpose is to fit hypnotherapy into the “general context.” Many therapists rejected hypnosis because its past direct approach to symptoms clashed violently with their dynamic approach. Now we see that such conflict no longer needs to exist.
The Non-Historical Approach vs. The Historical Approach in Therapy
Some hypnotherapists partly use a historical approach, regressing the patient back to their childhood and changing their attitudes toward the causes of these patterns (Fromm, 1965; Abrams, 1963; Chong Tong Mun, 1964, 1966). However, for the most part, hypnotherapy is non-historical and seemingly faster. If we wanted to change the course of a river, it would be much easier to work on the main current directly (once located) than to go upstream, identifying all the tributaries, and redirecting each one in a new direction.
A Comment on the Dangers Attributed to Hypnosis
In the past, certain dangers were attributed to hypnosis, such as the risk of a psychotic crisis or the substitution of more harmful symptoms. According to various researchers (Kroger, 1963; Abrams, 1964), these dangers were excessively exaggerated. However, any dangers that did exist have been virtually eliminated by this new approach. The few accidents that occurred in the past resulted from (1) the inappropriate use of hypnosis as a tool for revelation or (2) its inappropriate use as a means of directly removing symptoms. The first type of inappropriate use was produced by therapists who allowed or forced the patient to become aware of repressed information without being strong enough to face it. The second type of inappropriate use occurred when therapists removed a symptom that the patient used as a crutch before the patient was strong enough to stand on their own.
Hypnotizability of Patients
Freud abandoned hypnosis due to the “small number of people who could be placed in a deep state of hypnosis” at the time, and because in the cathartic approach, symptoms disappeared first but reappeared later if the patient-therapist relationship was disturbed (Freud, 1955, p. 237). In the studies above, the only induction failures were reported by Chong Tong Mun (eight failures out of 108 patients). This could mean one of two things: hypnotic induction procedures have improved since Freud’s time, 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.
While many thought that hypnotic susceptibility was a set of personality traits, several studies now seem to indicate that this is not the case, and responsiveness can be increased by certain changes in hypnotic induction procedures (Pascal and Salzberg, 1959; Sachs and Anderson, 1967; Baykushev, 1969), as well as through an introductory conversation (pre-talk) aimed at ensuring a positive attitude, appropriate expectations, and high motivation for hypnosis (Dorcus, 1963; Barber, 1969; Barrios, 1969).
Regarding the depth of hypnosis required for the reconditioning approach to work, there are several therapists who feel that only a light state of hypnosis is necessary (Van Pelt, 1958; Kline, 1958; Kroger, 1963). A study by Barrios (1969) lends some support to this argument: it was found that an increase in salivary response could be produced almost as effectively by lighter levels of hypnosis as by deeper levels.
The last statement makes us wonder if hypnotic induction is in any way necessary for the reconditioning approach to function. Judging by the work of Wolpe (1958), it seems that hypnosis is not an absolute requirement. This idea would also be supported by the work of Barber (1961, 1965), who found that hypnotic phenomena can be produced without prior hypnotic induction. However, the real question to be answered is not whether hypnotic induction is absolutely necessary but whether it can, in addition, simplify the conditioning process. Wolpe himself agrees that hypnosis apparently simplifies conditioning:
“Patients who cannot relax will not make headway with this method. Those who can or cannot be hypnotized but can relax will make progress, though apparently more slowly than when hypnosis is used”
(Wolpe, 1958, p. 141.)
Furthermore, although Barrios’ study (1969) indicated that conditioning could be enhanced during lighter levels of hypnosis, it was also found that there was no increase in conditioning for those individuals who did not respond to hypnotic induction.
As observed in theory (Barrios, 1969), hypnotic and waking suggestion are on the same spectrum, and hypnotic induction should be considered as a procedure through which we can increase the likelihood of obtaining a more positive response to suggestion. The next question to be decided now is not whether hypnotic induction procedures increase responsiveness (this is widely accepted – for example, Barber, 1969), but which variables in hypnotic induction are acting as key factors and what can be done to strengthen the effectiveness of these factors.
Comparison with Psychoanalysis and Behavior Therapy
In Wolpe’s comparison of psychoanalysis and his own approach (Wolpe, Salter, and Reyna, 1964), the following results were found: based on all psycho-neurotic patients analyzed, the number of patients cured or greatly improved through psychoanalysis was 45% in one study involving 534 patients and 31% in another study involving 595 patients (the only two large-scale studies in the literature on psychoanalysis). The average treatment duration for improved patients (reported only in the first study) was three to four years with an average of three to four sessions per week, or an average of approximately 600 sessions per patient. In Wolpe’s approach, based on all patients analyzed, the recovery rate was 65% in his own study involving 295 patients (generally reported as 90% of 210 patients) and 78% in a study by Lazarus involving 408 patients. The treatment duration for improved patients averaged thirty sessions in the first study and fourteen in the second.
Calculating the above statistics, we can conclude that with psychoanalysis, we can expect an incidence of improvement of 38% after approximately 600 sessions. With Wolpe’s therapy (also known as “behavioral therapy”), we can expect an incidence of improvement of 72% after an average of 22 sessions, and with hypnotherapy, we can expect an incidence of improvement of 93% after an average of 6 sessions.
It is interesting to note the negative correlation between the number of sessions and the percentage of improvement incidence. At first glance, this may seem paradoxical. However, if a form of therapy is truly effective, it should not only increase the incidence of improvement but also shorten the number of sessions required (as well as expand the range of treatable cases).
The Need for a Rational Explanation
Despite all the encouraging reports, there is still considerable hesitation among psychotherapists to use hypnosis. Hypnosis is still viewed as an “unknown” by most therapists. They are not yet aware of any rational explanation for hypnotic phenomena that would satisfy them, an explanation that would place these phenomena on the level of observable facts and laws. As long as hypnosis continues to emit an air of mysticism and charlatanism, it will be rejected by many, no matter how great the claims made on its behalf.
An Explanation Based on the Principles of Conditioning
Experienced therapists should not be surprised by the effectiveness of hypnosis in streamlining therapy. Hypnotic induction can be seen as a technique for establishing a very intense rapport, creating greater trust, and instilling a stronger belief in the therapist, making their words much more effective. As Sundberg and Tyler (1962) observed, one common feature 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 accumulates, come to place much more emphasis on this variable.” (pp. 293-294).
The question that remains, however, is this: what exactly is the process by which “mere words” can produce enormous changes in personality?
As Barrios’ theory of hypnosis (1969) suggests, the capacity of words to produce changes is not really difficult to understand if we are familiar with the principles of higher-order conditioning.
First, we know that words can act as conditioned stimuli.
Pavlov recognized this fact:
“For humans, speech obviously provides conditioned stimuli that are as real as any other stimulus…
Speech, considering the entire preceding life of the adult, is linked to all the internal and external stimuli that can reach the cortex, signaling all of them and replacing all of them, and thus, it can bring forth all those reactions of the organism that are normally determined by the actual stimuli.”(Pavlov,1960, p. 407)
Of course, we know that under normal circumstances, suggestions are not always accepted (and therefore, conditioning does not always occur when an appropriate suggestion is given). Why does this happen? Osgood (1963) believes that a suggestion will tend to be rejected if it is incongruent with the individual’s prior beliefs and attitudes or their current perceptions. It seems then that if there were ways to eliminate these, we would be able to have a more readily acceptable suggestion, thus simplifying higher-order conditioning. Hypnosis is one of these means.
So, we arrive at the reason why hypnosis is so effective in simplifying therapy: dissonant perceptions, beliefs, and attitudes abstain from interfering with the suggestion (and thus with conditioning).
As Pavlov said:
“The hypnotist’s command, in correspondence with the general law, focuses excitement in the individual (who is in a condition of partial inhibition) on some clearly and distinctly narrow region, simultaneously intensifying (through negative induction) the inhibition of the rest of the cortex, thereby abolishing all conflicting effects of contemporary stimuli (current perceptions) and signals left by those previously received (prior beliefs and attitudes). This explains the great and unsurpassed influence of suggestions as a stimulus during hypnosis, as well as shortly afterward”.
(Pavlov, 1960, p 407.)
As an example, let’s consider that we want to change a patient’s self-image from that of an incompetent person to a more self-confident one. Under common circumstances, if we were to suggest that they no longer feel incompetent, this would likely have little success. This is because the patient’s negative self-image, typically ever-present and entirely dominant, would quickly suppress any positive image suggested, or at the very least, prevent it from being very vivid or real. But in the highly suggestible hypnotic state, the conditions are different. The patient’s negative self-image is more easily inhibited and, therefore, should be less likely to interfere when we evoke the positive self-image through suggestion. As a result, conditioning can occur, and new associations can be established. The person can genuinely envision themselves feeling self-confident in various situations, and these newly conditioned associations, in turn, can lead to new behavior. This new attitude can now become permanent through self-reinforcement, much like their old negative attitude was maintained by self-reinforcement. While the patient holds negative attitudes, these are self-reinforced. They make them feel tense, act inappropriately, and make many mistakes. Furthermore, they probably would not believe in any compliments or positive occurrences if they happen. However, if this negative self-image has been replaced by a positive one, the opposite cycle can result. By being more confident and relaxed, they will naturally tend to be more accepted. Additionally, they will now be more open to believing and accepting compliments and positive outcomes.
References
ABRAMS, S. “Short-term hypnotherapy of a schizophrenic patient”, American Journal of Clinical Hypnosis, 5 (1963), pp. 237-247.
ABRAMS, S. “The use of hypnotic techniques with psychotics. A critical review”, American Journal of Psychotherapy (1964), pp. 79-94.
ALEXANDER, L. “Clinical experiences with hypnosis in psychiatric therapy”, American Journal of Clinical Hypnosis, 7 (1965), pp. 190-206.
ALEXANDER, L. “Conditioned effects of ‘hypnosis’”, American Society of Psycho-somatic Dentistry and Medicine, 13 (1966), pp. 35-53.
BARBER, T.X. “Physiological effects of ‘hypnosis’”, Psychological Bulletin, 58 (1961), pp. 390-419.
BARBER, T.X. “Physiological effects of ‘hypnotic suggestion’”, Psychological Bulletin, 63 (1965), pp. 201-222.
BARBER, T.X. “An empirically-based formulation of hypnotism”, American Journal of Clinical Hypnosis, 12 (1969).
BARRIOS, A.A. “Toward understanding the effectiveness of hypnotherapy: A Combined clinical, theoretical and experimental approach”, Doctoral dissertation, University of California, Los Angeles, 1969.
BAYKUSHEV, S.V. “Hyperventilation as an accelerated hypnotic induction technique”, International Journal of Clinical and Experimental Hypnosis, 17 (1969), pp. 20-24.
BIDDLE, W.E. Hypnosis in the psychoses. Springfield, Ill.: Charles C. Thomas, 1967.
Chong Tong Mun. “Hypnosis in general medical practice in Singapore”, American Journal of Clinical Hypnosis, 6 (1964), pp. 340-344.
Chong Tong Mun. “Psychosomatic medicine and hypnosis”, American Journal of Clinical Hypnosis, 8 (1966), pp. 173-177.
DORCUS, R.M. “Fallacies in predictions of susceptibility to hypnosis based on Personality characteristics”, American Journal Of Clinical Hypnosis, 5 (1963), pp. 163-170.
FREUD, S. The complete psychological works of Sigmund Freud. Volume 18. London: Hogarth Press, 1955.
FROMM, E. “Hypnoanalysis: Theory and two case excerpts”, Psychotherapy, 2 (1965), pp. 127-133.
HARTLAND, J. “The value of ‘ego-strengthening’ procedures prior to direct symptom removal under hypnosis”, American Journal of Clinical Hypnosis, 8 (1966), pp. 89-93.
HOSKOVEC, J., & SVORAD, D. “Recent literature on hypnosis from the European Socialist countries”, American Journal of Clinical Hypnosis, 8 (1966), pp. 210-225.
HUSSAIN, A. “Behavior therapy using hypnosis”, The Conditioning Therapies. New York: Holt, Rinehart & Winston, (1965), pp. 5-20.
JACOBS, L. “Emotional and behavioral problems in clinical pediatrics”, American Society of Psychosomatic Dentistry and Medicine, 11 (1965), pp. 40-56.
KLINE, M.V. Freud and Hypnosis. New York: Julian Press, 1958.
KROGER, W.S. “An analysis of valid and invalid objections to hypnotherapy”, American Journal of Clinical Hypnosis, 6 (1964), pp. 120-131.
KROGER, W.S. Clinical and Experimental Hypnosis. Philadelphia: Lippincott, 1963.
MANN, H. “Hypnosis comes of age”, American Journal of Clinical Hypnosis, 5 (1963), pp. 159-162.
MOWRER, O.H. Learning Theory and the Symbolic Process. New York: John Wiley and Sons, 1960.
OSGOOD, C.E. “On understanding and creating sentences”, American Psychologist, 18 (1963), pp. 735-751.
PASCAL, C.R., & SALZBERG, M.C. “A systematic approach to inducing hypnotic behavior”, International Journal of Clinical and Experimental Hypnosis, 7 (1959), pp. 161-167.
PAVLOV, I.P. Conditioned Reflexes. New York: Dover, 1960.
RICHARDSON, T.A. “Hypnotherapy in frigidity”, American Journal of Clinical Hypnosis, 5 (1963), pp. 194-199.
SACHS, L.D., & ANDERSON, W.L. “Modification of hypnotic susceptibility”, International Journal of Clinical and Experimental Hypnosis, 15 (1967), pp. 172-180.
STEIN, C. “The clenched fist technique as a hypnotic procedure in clinical psychotherapy”, American Journal of Clinical Hypnosis, 6 (1963), pp. 113-119.
SUNDBERG, N.D., & TYLER, L.E. Clinical Psychology. New York: Appleton-Century-Crofts, 1962.
VAN PELT, S.J. Secrets of Hypnotism. Los Angeles, Wilshire Book Company, 1958.
WOLPE, J. Psychotherapy by Reciprocal Inhibition. Palo Alto, Calif.: Stanford University Press, 1958.
WOLPE, J., SALTER, A., & REYNA, L.J. The Conditioning Therapies. New York: Holt, Rinehart & Winston, 1964.