Several therapeutic techniques other than those already reviewed in this task force report appear to be useful adjuncts in the treatment of anxiety and panic disorders.' These techniques include relaxation, meditation, hypnosis, self-hypnosis, autogenic training, and biofeedback (Benson and Klipper 1976; Brown 1977; Kroger 1977; Luthe 1969; Townsend et al. 1975). Such procedures are considered adjunctive because they are used in an overall therapeutic program and are rarely, if ever, appropriate for the treatment of anxiety or panic disorders outside of such a larger context.
Although the techniques vary considerably, they can all be characterized as facilitating relaxation and calm, both in psychological and physiologic terms, while simultaneously conveying therapeutic suggestions, implied or explicit. Generally, the achievement of physiologic resting levels is associated with a sense of ease, and vice versa. The techniques for the most part depend on cognitive and behavioral procedures that are intended to provide the patient with coping strategies that he or she may draw upon in future life situations outside the therapeutic context. In addition to the relaxation that results, patients gain reassurance and not infrequently a sense of mastery and control over symptoms and fears that previously were disruptive and threatening.
The techniques typically encourage patients to narrow the focus of their attention. An important consequence of biofeedback, meditation, or hypnosis seems to be a shift of one's appreciation of reality, of who and where one is, to the periphery of awareness and to disconnect it from the major focus of the moment (Shor 1959).
Biofeedback involves providing an external signal of internal events that makes it easier for the patient to become aware of physiological events, typically by means of electronic sensors and visual or auditory displays. In the treatment of anxiety disorders, frontalis muscle feedback using electromyographic (EMG) signals has been
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employed most often. From feedback of muscle tension, the patient can learn to decrease it and presumably thereby decrease the level of anxiety.
In meditation, attention is directed toward a specific thought, object, or physical activity. The meditator is required to maintain his or her focus and to ignore both irrelevant internal and external stimuli, one consequence of which is the decrease of anxiety.
In hypnosis, the generalized reality orientation and critical judgment are partially suspended, facilitating dissociation (Hilgard 1977). With suggestibility increased, patients can become responsive to suggestions to experience altered perceptions, memory, and mood (Orne 1977). Hypnosis may also facilitate the patients' bringing forth affect-laden associations and memories. The whole sequence is generally initiated in a relaxed context and occurs to varying degrees, depending on the aptitude of the patient for such voluntary dissociation.
It is often useful for the patient, especially early in therapy, to have available specific procedures to use at home and to use them in anxiety-inducing situations outside the therapeutic context. For example, self-hypnosis as taught by a therapist after or during the administration of an induction of heterohypnosis is used widely in clinical practice (Fromm et al. 1981). Among patients who are taught self-hypnosis and who are directed to practice it at home to control anxiety between therapy sessions, many appear to achieve some symptom relief on their own (Soskis 1986).
Autogenic training is a variant of self-hypnosis that involves a series of graded mental exercises that the patient is required to practice between office visits. Over time, the patient becomes able to master the more difficult procedures that permit him or her to control the level of tension and anxiety (see Luthe 1969).
Progressive relaxation is a related technique based on the premise that it is not possible to be anxious if one is physically relaxed. Described by Jacobson in 1938, the procedure involves much feedback based on observations concerning when the patient relaxes, where areas of bodily tension persist, and the like. It also uses the technique of asking patients to tense muscle groups to become aware of the difference between relaxation and tension.
Treating Generalized Anxiety
Many clinical reports attest to the effectiveness of each of these techniques in the treatment of anxiety. (For the most part these patients would now be classified as having general anxiety disorder.) There are few systematic studies available; however, in virtually all case reports and studies of groups, significant improvement occurs in patients following any of these interventions when patients are compared before and after treatment. The area where the most systematic outcome studies have been carried out involves EMG biofeedback. Typically, improvement is evaluated both in terms of the patient's success in decreasing muscle tension as indexed by the frontalis EMG and some kind of self-report anxiety change score.
Probably because biofeedback was initially conceptualized as a form of conditioning by some investigators, there was considerable interest in and controversy about whether or not conditioning could explain the therapeutic effects of EMG feedback.
In a number of studies, frontalis EMG biofeedback was compared with other techniques. For example, one study compared chronically anxious patients treated either with EMG biofeedback or group psychotherapy. Significant decreases in EMG
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levels and in subjectively rated anxiety were observed in the biofeedback group, with no such changes seen in the psychotherapy group (Townsend et al. 1975).
In another study, 28 anxiety neurotics, half of which received EMG biofeedback and the other half Jacobson's relaxation training, were compared. Both groups reported significant improvement. However, 12 of those treated with biofeedback as opposed to only seven of those with relaxation training reported improvement. Even greater outcome differences were noted in therapists' reports. Most interesting, investigators found the level of the EMG decrease was significantly correlated with reported improvement (Canter et al. 1975).
In contrast to the findings of these two clinical studies, which suggest that EMG biofeedback is the specific agent responsible for improvement, are the findings of a number of other studies. For example, 40 students with severe test anxiety were given one of the following four treatments: EMG feedback, relaxation, attention-placebo relaxation, and a no-treatment control. Compared to the no-treatment control, all three groups showed improvement, but there were no differences between these groups (Beiman et al. 1978).
Another study compared EMG feedback with progressive relaxation and selfrelaxation for dental phobic patients. EMG feedback and progressive relaxation both were more effective in relieving dental state anxiety than self-relaxation, but there was no difference between them (Miller et al. 1978).
Similar results were obtained in comparing three groups of anxiety disorder patients. The first group received EMG feedback, the second muscle relaxation training, and the third transcendental meditation. Forty percent of the patients demonstrated significant decreases in anxiety, but there were no differences between the three groups in terms of effectiveness (Raskin et al. 1980).
One study that directly addressed the question of mechanism involved 12 students who reported anxiety and difficulty in managing everyday stress. Half of these received EMG biofeedback and the other half (yoked controls) received feedback not contingent upon changes in muscle tension. The group receiving true EMG feedback showed significant reduction in muscle tension during a stress task when compared to individuals who did not receive contingent feedback. Nonetheless, analogous to observations reported in other studies, there were no differences between the groups on measures of subjective anxiety (Gatchel et al. 1978).
Though it is clear that EMG biofeedback has been therapeutically useful, the theoretical rationale upon which it was based-that is, that anxiety will be reduced by teaching patients to decrease the tonic level of frontalis muscle tension-has not been justified by subsequent research. Thus, in later studies there was generally no relationship found between anxiety relief and the ability to learn relaxation as indexed by the frontalis EMG. Similarly, the relief of tension headaches, for which one would expect frontalis EMG to be a specific factor, is also unrelated to an individual's ability to learn frontalis muscle relaxation-though the procedure itself is quite effective in providing symptomatic relief (Orne 1980). In summarizing work in this area, Gatchel (1982) states ". . . that this procedure may be clinically effective with patients suffering primarily from anxiety. However ... methods such as progressive relaxation training are at least equally effective" (pp. 392-393).
Regarding the other techniques discussed in this section, the question of whether they are specific therapeutic agents has not been addressed as cogently as in the biofeedback literature. It should be clear, however, that the failure to find differences between muscle relaxation training and EMG biofeedback challenges the specificity of relaxation training as much as that of EMG training. Indeed, both of these procedures are challenged by the fact that curarized individuals are by no means without
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anxiety. Again the fact that studies have shown no differences between EMG feedback, relaxation training, and meditation raises questions about the specific effect of each of these procedures. The failure to document differences in outcome between meditation and self-hypnosis in the treatment of anxiety does not help support the view that either have specific therapeutic effects (Benson et al 1978).
The insights offered by Frank (1961) seem particularly relevant. He points to a number of characteristics common to all treatments. Thus, the therapist is a culturally sanctioned expert, with relevant special training. Both the patient and the healer need to have faith in the curative power of the treatment. It is carried out in a place designated for this purpose. All treatments have some rationale that makes sense within the culture-but are not necessarily correct from our current scientific perspective.
Whatever the intervention, it must make it possible for the patient to attribute his improvement to the treatment. The relationship between therapist and the patient is of considerable importance, and the person of the therapist and his or her attributes greatly affect the outcome. Finally, if the procedure requires much of the patienthard work, discomfort, great cost, dramatic affects-the likelihood of cure is enhanced.
These nonspecific factors, which in psychopharmacology are in part subsumed under placebo effects, are remarkably powerful. They are therefore often difficult to disentangle from specific effects that may be swamped by the placebo components of a dramatic treatment. Conversely, a specific drug effect may be negated in the absence of the necessary nonspecific components of treatment (see Rickels 1968).
The importance of the interpersonal relationship in the biofeedback situation is, for example, illustrated by Beiman et al. (1978) who found that live relaxation was superior to taped progressive relaxation and self-relaxation. Similarly, among those patients who are helped by these techniques, the meditators, for example, report far more success at least initially when meditating with their teacher than by themselves. Similarly, the majority of patients practicing self-hypnosis report that the experience is not as rich as when hypnotized during their therapy hour. This does not appear to be a matter of the patient's ability to respond, but rather it is likely to reflect the central importance of the relationship between the patient and the therapist. It would seem that motivation or talent is of itself likely to be insufficient unless allowed to function within the context of a therapeutic relationship and its many levels of meaning.
Treating Phobias, Panic, and PTSD
While the techniques aimed at relaxation often work quite well in the alleviation of generalized anxiety, they offer limited help in the treatment of obsessive-compulsive rituals. When used to treat phobias, panic, and posttraumatic stress disorders, they become effective only when they are specifically adapted to the particular patient's needs.
The literature contains many examples of the adjunctive use of hypnosis in the treatment of phobic symptoms (McGuiness 1984). It may well be relevant that individuals who suffer from simple and social phobias tend to be more highly hypnotizable than other patients (Frankel and Orne 1976).2 Such patients can be helped to overcome simple and social phobias either by the encouragement of ego-strengthening techniques (Hartland 1982), by uncovering emotionally traumatic material (Frankel 1976),
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or by blending behavior modification methods such as imaginal desensitization or implosion with the hypnosis (Kroger and Fezler 1976).
Although there is an extensive history and literature on the use of each of these techniques in the treatment of anxiety, neither the clinical reports nor the available studies are adequate to determine what is specific to the success of the treatment.
This lack is perhaps less problematic than it might seem, because, as we have discussed, these procedures are primarily adjunctive components in the treatment of anxiety and panic disorders. Neither biofeedback, hypnosis, meditation, nor relaxation procedures are seen here as treatments in their own right. They are techniques that are useful when woven into the fabric of a treatment plan; they facilitate and enrich the therapy by adding dimensions to it that would otherwise be wanting. For these reasons, it may be most useful to illustrate how these procedures can be applied as adjunctive techniques within the broader therapeutic context. The ultimate purpose here is to show how they can contribute to the therapeutically desired change in the patient's experience of anxiety or panic.
Case Histories
In the following case vignettes, we will try to determine the predominant therapeutic themes elicited or purposefully shaped by the use of the adjunctive techniques.
Case 13
A 29-year-old bachelor engineer presented with marked insomnia and general tension. His treatment plan consisted of individual and group psychotherapy as well as relaxation training with electromyograph feedback.
He was described in the initial interviews as if carved of wood. His movements were restricted and he showed little or no affect. Of note in his family history are psychotic parents, a father functioning as a therapist, and a mother confined to an institution for the mentally ill.
He responded in part well to two months of biofeedback training, learning to relax his muscles. However, his anxiety and insomnia increased to a point at which the biofeedback was discontinued, and the thrust of the treatment concentrated on the psychotherapy. It was here that he was able to focus on his watchfulness at night, which kept him from sleeping, and his anxiety. Recognizing that he could now relax his body and was yet unable to relax his mind, he was led to a memory of a bizarre sexualized threat made repeatedly by his father as he was growing up: "Some day you and I are going to tangle backsides." He had repressed a memory that reappeared now in a flood of fearful affect and an awareness of the need to remain vigilant throughout the night. This was followed by an improvement in the insomnia and the anxiety.
Over a period of seven months, he became more emotionally expressive and found new freedom socially and elsewhere. Later in the therapy he recalled a long repressed memory that his father had indeed raped him at the age of nine years. Within two weeks of the recall and the start of working through the feelings associated with this memory, the patient had his first successful sexual experience with a woman.
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Case 2
A 45-year-old man sought assistance for impotence of recent onset. He had been in the throes of a crumbling marriage over the previous six months, with a final decision by his wife that she wanted a divorce. At the time of his first visit, they were negotiating the settlement in an atmosphere of anger and counter-accusation.
It was during this period that he met a woman roughly his age similarly struggling with the breakup of her marriage. They dated a few times, felt a great fondness for each other, and after a few weeks of increasing mutual interest moved toward intercourse.
Although he had been greatly aroused during the courting, he found he could not sustain an erection after penetration. The repeated failure on three subsequent occasions prompted him to seek help. His partner had been constantly supportive and encouraging throughout.
He was the youngest of four siblings in an upwardly mobile family, encountering few problems as he grew up other than the pressure to succeed at least as well as his older siblings. His college education prepared him for business administration, and he had achieved some success in low-key middle management, earning a modest income. He had married at 24 to a woman three years his junior and had two teenage daughters. His marriage had been marred by his wife's limited interest in sex with him and her fairly constant criticism of his achievements and his style. She disparaged him by describing him as too soft and saintly.
Although acquiescing periodically to his sexual interests, she participated very little in the encounters and had told him several times of late that she loved him but was not in love with him. His sexual history for many years had included prostitutes and masturbation with occasional uninspired relationships at home. He could not remember having had difficulty with erections prior to the impotence experienced by him in the weeks preceding his request for treatment.
He had come to believe but was unable to prove that his wife's choice of divorce had to do with her recent involvement with an assertive and successful physician who had been part of their social circle. The course of events over the following six months were to prove him correct.
Clinical course. In describing his sexual difficulties, he made it clear that he was now troubled by his feelings of tension and long-unexpressed anger at his wife's fairly constant denigration of him. He was encouraged to elaborate on this in the sessions, and to refrain in the immediate future from sexual intercourse and attempts to prove his sexual competence. After three sessions in which he talked openly for the first time ever about his dissatisfactions with his marriage, he felt relieved but still anxious about his adequacy to complete the sexual act with his new partner. It was at this point that the topic of hypnosis was introduced as a means of assisting him to relax and regain his confidence. He rapidly agreed to the idea.
In the fourth visit, he, responded in a limited way to a hypnotic induction, experiencing good relaxation and a tingling feeling in his forearm when altered perceptions were suggested. There was, however, no response to the suggestion that the hand and forearm would involuntarily float upwards, and little to suggest a marked alteration in his state of awareness. He nevertheless was able to achieve considerable calm and comfort, and in this state was able to visualize himself in a successful sexual encounter. He was confident that he could practice the self-hypnosis and relaxation exercise at home, and also rehearse sexual success in his mind's eye while doing so.
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He returned for the fifth visit, having accomplished the act on more than one occasion to his and his partner's total satisfaction. He claimed that the exercise had boosted his confidence to such an extent that he had known with certainty that he would succeed, so he went ahead.
He reported a year later that all was well and that he and his new partner were planning on marriage.
Formulation: Cases 1 and 2
In both cases 1 and 2, progress became apparent when the individuals succeeded in mastering the physical accompaniments of the anxiety, in case 1 through EMG feedback and in case 2 through hypnosis and self-hypnosis. In case 1, this paved the way to the uncovering of repressed memories and insight, and in case 2 it led to a surge of justifiable confidence.
In case 1, the group plus individual therapy could well have been primarily responsible for the progress in treatment. Similarly, in case 2 the relaxation and successful imagery in hypnosis could have contributed to the patient's success, but the three previous psychotherapy sessions had been very supportive and had freed him from a considerable affective burden he had not been able to share with others before then.
To both patients, success was attributable largely to the adjunctive methods that were added to the treatment plan-a difficult position to argue with because it might be partially accurate. However, the addition of a noticeably different therapeutic procedure in which patient participation was emphasized might well have provided opportunities for enhancing self-esteem. Both patients believed that gaining control of some aspect of their dysfunction enabled them to work more effectively toward resolving the whole problem.
Case 3
A 50-year-old business executive had been prevented from flying for 18 years by an intense fear of flying. He had been a flight engineer in World War II and had then flown for five or six years as a passenger. Experiencing increasing anxiety, he finally found himself backing away from a planned business flight at the last moment and had not flown since. He talked of a sense of increasing anxiety when he thought of flying and his concern that he would make a fool of himself on the plane if the anxiety got out of control. He believed his knowledge of engineering added to his problems, and the introduction of the large jet carriers reaffirmed his belief that flying was dangerous.
He sought assistance through hypnosis on the recommendation of an associate who had successfully overcome his fear through hypnotically aided therapy, because business interests were at stake. Having to delegate the long-distance trips to his subordinates was affecting the level of his business success.
His past and personal histories appeared to be noncontributory, other than his report of a fear of riding in elevators that had arisen about the time of the flight phobia and that had improved but not completely disappeared after a few years. He was the youngest of four siblings who flew frequently as had his parents (now deceased). His wife and three teenage sons took air trips; his wife, however, was generally concerned about flying and fully sympathetic. He was surprised and embarrassed at his complacency when driving his family to the airport to board their flights, which he viewed as completely safe provided he was not a fellow passenger.
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He was a warm person who related well, with a sense of humor when discussing his problems. He was clear in his intent that he was less interested in understanding the origins of his fears and keen only to resolve them. He was matter-of-fact in discussing his feelings about the issues under consideration, with a very practical approach that shunned any psychological interpretations. He had studied business methods after graduating from high school and was very much attuned to that style. He had no exposure to hypnosis and knew only what his associate had told him about his own experience. He scored nine out of a possible 12 on the Harvard Group Scale of Hypnotic Susceptibility (Shor and Orne 1962), which placed him in the high category of hypnotizability.
After some deliberation, he agreed to follow a course of hypnotically aided imaginal desensitization, meeting on a weekly basis for about an hour.
Clinical course. After the second treatment session in which he had experienced hypnosis and learned to induce it himself at home, he reported that he had been more relaxed and had been able to sleep restfully at night and to curb his occasional intolerance of the excesses and noise created by his teenage children.
Having successfully dealt in hypnosis with the total of 15 items on the hierarchy by the end of the next three sessions, he continued to practice self-hypnosis at home and to discuss his progress and his plans in each subsequent session. Thereafter, about 15 to 20 minutes at the end of each visit were devoted to a hypnosis exercise in which his skills were reaffirmed and positive suggestions were added. He planned first to focus on flights in small aircraft. He got close to taking short local flights on a few occasions but changed his mind when he found he was unable to carry out the self-hypnosis exercises on the day before the scheduled trip. Encouragement was constant throughout the interviews, and he was repeatedly reminded of the value of the hypnotic methods by the subjectively real trance phenomena he was able to achieve in the hypnosis exercises. Without any intimation from the therapist, he feared that the treatment would be discontinued were he to delay for too long his plans to fly. He requested repeatedly during this period that the treatments continue, claiming that even if he did not succeed in flying, the treatment was helpful to him in many other ways.
At the 13th session, eight sessions after mastering the last item on the hierarchy, which involved the imagined rehearsal of sitting in a plane as it took off from the runway, he announced that he had flown. He had attended the funeral of a close relative in a city 2,000 miles away, an event that could not have been accomplished in the limited time available by any other means. This marked the initiation of increasingly ambitious flights involving transAtlantic trips within the next six months. During this time his therapy visits were spaced at two- to four-weekly intervals. He was proud of his achievement and claimed that his flights were already of benefit to his business interests.
Roughly a year after his first request for treatment he began to experience back pain. His medical advisors recommended bed rest and relaxation, and he returned for an appointment to determine whether he could use hypnosis to alleviate the pain. During the trance, in addition to suggestions for comfortable relaxed feelings in his back, he was advised to imagine a very restful scene in which he could feel totally relaxed and at peace. He disclosed, with some amusement, after the hypnosis exercise that the scene he found most helpful was the memory of a flight he had taken over the Swiss Alps.
A follow-up six years later revealed a story of continued success with few if any concerns about flying.
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Case 4
A 34-year-old banker sought help for his fear of heights. This soft-spoken and very pleasant man had fallen from a tree at the age of seven, after which time he had experienced mild anxiety whenever he was obliged to climb trees or scale heights with his friends.
At the age of 20, after he had already left home, his parents moved to a 16thfloor apartment. It was here that he became aware of the more severe nature of his problem. He found himself avoiding the balcony, and experiencing discomfort when even thinking of stepping on to it. He would stand well back from the edge. For a few years prior to his request for treatment, he had become aware of an increasingly panic-like experience whenever he made his way on to the balcony or thought of doing so. Rather than subsiding with time, the problem appeared to be worsening, extending to involve other situations. Traveling on elevated highways and bridges had become threatening, and for some time before his first visit he had become aware of a fear that he might jump off or drive over the edge unless he exercised considerable control. Furthermore, he began to recognize in these situations that he experienced physical distress with palpitations, cold sweats, muscle tension, and shortness of breath. The panic lasted the full length of the exposure to the feared situation.
His strong tendency for several months had been to avoid the challenges and to remain indoors when he visited his parents' home. He found that when he was closed in, there seemed to be less reality to the height, and he therefore learned to protect himself as often as possible by escaping the visual impact of the fearsome scene. This avoidance seemed eventually to aggravate the problem, according to him, and he was irked by his growing concern. The factor most responsible for his request now for treatment was his recent reluctance to drive on a convenient route near his home because it entailed traveling over a bridge. He was struck by the fact that as he recounted his history in the interview, he found himself recreating the phobic fear and panic response as he spoke. This was his first attempt to get help for the problem.
Personal history. He was the oldest of three siblings in a comfortable middle class family with little in the way of obvious or unusual problems. He claimed uneventful and reassuring relationships with his parents and his siblings. He had attended a fine undergraduate school, and then went on to acquire a degree in business administration and a very satisfactory post in a bank. His marriage at 23 to a woman of the same age was described as happy, as were his relationships with his four children, the oldest of whom had become vaguely aware of his problem.
Clinical course. He was keen on obtaining relief as rapidly as possible, and came asking whether he could be treated in a program that involved hypnosis, which he had learned about as an undergraduate. He proved to be highly responsive, achieving a score of 10 out of a possible 12 on the Harvard Group Scale (Shor and Orne 1962).
In the subsequent two sessions, he readily mastered a seven-item hierarchy of increasingly fearsome situations. This accelerated program, modeled on the imaginal desensitization procedure of Wolpe (1958), was administered while the patient was in hypnosis. He was ultimately able to rehearse successfully, in his mind's eye, an encounter with the most threatening of bridges, and a view through the window of a 13th story apartment. During his practice sessions in self-hypnosis at home, he then modified the item by adding a balcony to the situation. He was enthusiastic throughout the procedure and strongly encouraged by his discovery of the evidence that it
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was his frame of mind rather than the external situation that influenced the level of his anxiety.
The evaluation, hypnotizability rating, and treatment program were thus accomplished in a total of four sessions. Two months later, he sent a postcard with the following message: "Thanks for allowing me to increase my enjoyment of my vacation. I've enjoyed the sheer cliffs of the Oregon coast and now the depths of the Grand Canyon."
Formulation: Cases 3 and 4
These case histories demonstrate how the hypnotic experience can be shaped to augment imaginal desensitization and the mastery of phobic fear. It is well known that in some instances a single session involving hypnosis and instruction in selfhypnosis can enable fearful individuals to board a plane and sit through the journey in a sort of self-induced trance state. Patients benefit both from a sense of calm and a sense of mastery over a situation that had previously seemed beyond their control.
The treatment plan is predicated on the idea that the intense fearful states (in which phobic patients keep suggesting to themselves that doom or panic is close at hand) are akin to spontaneous dissociative or hypnosis-like events. These can occur in hypnotizable persons as a defense against intense affects. The experience in selfhypnosis then informs the individual patient that he can initiate a trance state voluntarily, and end it at will. The similarity between the self-induced trance state and the spontaneous dissociative phobic state becomes apparent.
Case 5
A 25-year-old musician, raped two years earlier, was referred by her current therapist to determine whether hypnosis would help her resolve her problems. Although engaged in psychotherapy for much of the period since the rape, she continued to experience occasional flashbacks, disturbing dreams, and a high level of anxiety. She dwelt for lengthy periods of time on questions regarding her role in the rape and whether she could have escaped or done otherwise to prevent it. She was especially concerned that her passivity and compliant style had been seen by her assailant as encouragement. She requested hypnosis hoping that it would enable her to recall the event in greater detail and establish for her what the facts had indeed been.
The rape took place in a remote building on a college campus, where she worked alone. After returning to her floor from a visit to the restroom downstairs, she came upon her assailant, masked and armed, crouching at the door to her office. He spotted her as she entered the corridor, moved rapidly toward her, and getting behind her placed his right hand over her mouth as he placed the gun in his left hand against her neck. She felt paralyzed and rooted to the spot as he walked her into the office, demanding the keys to the safe and the money. As he forced her to search through desks and her own pocketbook, all the while standing close up against her, threatening and abusive in a hoarse whisper, she realized he had an erection. With the gun at her neck she felt forced to undress at his command and was subjected to sexual assault.
She felt frozen throughout the event and shattered by it. With the act completed he left with the money, leaving her to telephone her husband to come to pick her up and begin the arduous course of trying to put her life together again with a visit to the nearest emergency ward.
Despite what she described as useful therapy for almost two years, she continued
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to wonder whether she had indeed had the time to flee from the hallway when she first spotted him at the door of her office, and whether her subservience had not led him to shift his intentions from robbery only, to include rape as well.
Her own tendency to passivity had been a problem for her since adolescence, a problem initiated by her struggle to come to terms with her verbally abusive father. She had sought therapy during her late teens and had developed a fair understanding of her ambivalent feelings toward him. Having been his favorite until she reached puberty, she now recognized that the shift in his attitude was related in some way to her physical maturity. She knew from her discussions in therapy since the rape that she had seen similarities between her father's style and the demands of the rapist.
In other respects her personal history revealed sympathy for her mother, whom she saw as browbeaten, and a long-standing ambivalence toward authority figures. She was a college graduate with keen intellectual interest and had married at 21 to a geologist six years her senior.
Clinical course. She was intent on revisiting the traumatic episode in hypnosis, to determine whether she could recall it or describe it under those circumstances, in a manner that would help her resolve her major question: namely, had she in some way caused the event to happen and could she have escaped it? Despite her commitment to the procedure, she recognized that she was likely to interpret hypnosis as another version of a rape, with herself passive and under the control of someone else. To obviate this, the second and third sessions were devoted by the therapist to discussing hypnosis and modeling it. When, in the fourth session, an induction procedure was introduced, she was invited to keep her eyes open or open them whenever she chose as she became accustomed to the events that were to lead to relaxation and recall. In the subsequent six sessions, constant and firm but gentle emphasis was placed on the fact that she was entitled to feel relaxed, and that, although in hypnosis, she was nonetheless at liberty to recall only as much as she chose to. Furthermore, she was invited to share with the therapist only that which she felt comfortable sharing. She acknowledged that she was deeply embarrassed at the thought of describing the details of the assault, and was encouraged to report only that which she felt she could.
In the fifth visit with the aid of hypnosis she recounted the events of the rape with considerable affect. She described how she had loathed doing what he demanded of her and argued back and forth about how much she could or could not have resisted the muzzle of the gun at her neck. She pleaded for patience and assistance in the therapy while coming to terms with the event. In subsequent hypnotic sessions much of the same ground was covered, with her repeating some of the same details but able to do so with less distress. She required constant reassurance and reminders of the fact that whatever had taken place during the rape had occurred under duress.
In discussions before the hypnosis in each session, and then during hypnosis, time was spent dealing with her resentment at having to accept the rape as part of her experience. She discussed at length how her previous two therapists had encouraged her to accept the rape as a part of herself and her history and to attempt to integrate it. Her desire was to keep it outside of herself, attached to her body or limbs perhaps, but because of its evil nature she preferred it to remain outside of her body rather than be part of her. In discussion she tried to think of it as a corn or a callus, extraneous, somewhat bothersome, but not capable of influencing or shaping. the whole of her self-image and her future.
By the 12th session, she described feeling considerably easier about the problem although not yet totally at peace about it. The turning point had come after the sixth
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session when she experienced a dream in which she found herself reporting that she had aborted the rape. This was interpreted by her to mean that she would be able to accept as much of the rape as she had to and yet be able to survive.
She described the most valuable part of the procedure as being her ability to view the hypnotic event as a protected situation. Behind this protective screen, once she had gone through the induction procedure, she felt she could examine the history of the details closely, gain familiarity with them, and then emerge from the protective environment of the trance with as much of the rape as she chose to carry out with her. She appreciated the permission not to have to say everything that came into her mind, and that in some way she could own the feelings she felt before having to describe them. This all provided a means for her to exert some mastery over the memories and over the event that had seemed until then to be totally beyond her control.
Formulation
In the process of coming to terms with the painful affect associated with the original trauma, she found the trance state useful in allowing her to titrate just how much turbulence she would tolerate at any one time. By degrees, she permitted herself to experience increasing amounts of discomfort, confident that she could retreat behind the hypnotic screen should she prefer to do so. This helped to allow her to see the rape as aborted, as not part of her intimate self, and merely an external attachment denigrated to the role of a corn or a callus.
It is difficult to deny the importance of the altered state of awareness in the hypnosis in allowing her to feel protected and in control to this extent. However, in evaluating the role of hypnosis in this case, one must also weigh the use of therapeutic techniques that have little to do with hypnosis, and that are useful to any form of therapy dependent on compassionate understanding. She was introduced in stages to the new procedure; she was supported and encouraged in remembering only that which she felt prepared for; she was given permission to share only that information which she chose to; and she was free to interpret the technique in a way that was meaningful to her. All of these criteria contribute to a trusting relationship and in many instances to an effective therapy, regardless of the particular type.
Discussion
The clinical vignettes may help to illustrate how procedures like hypnosis, selfhypnosis, and biofeedback can be integrated into either the dynamic or the behavioral approach. The use of this group of procedures in the manner illustrated is congenial at least to the present authors and appears clinically useful. Certainly, therapists with other perspectives report having used these techniques in a different therapeutic context, following other rationales more congenial to their own theoretical views.
We have tried to emphasize that the procedures discussed here are used in an overall therapeutic context. Although both the patient and the therapist may view a technique such as hypnosis as the treatment, it may not be so. Inevitably complex treatment packages are involved, and it is rarely possible to identify the active component. This problem is clearly demonstrated in outcome studies using hypnosis. Because individuals differ greatly in their ability to respond to hypnosis, one would expect that those individuals who are able to enter hypnosis to a profound degree
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should obtain significantly more help from the technique than those who are not so responsive if the therapeutic effect depends upon the presence of hypnosis. Such a relationship has not been demonstrated in the use of hypnosis to help individuals stop smoking (Wadden and Anderton 1982). On the other hand, there is a very clear and reliable correlation between hypnotizability and the extent to which hypnosis can help the individual block the experience of acute pain (Hilgard and LeBaron 1984).
Few data are available about the relationship of hypnotizability to the amount of relief that is provided to patients with anxiety symptoms. One study does indicate that more hypnotizable individuals obtain more relief from anxiety with hypnosis than less hypnotizable patients. Meditation training was equally effective; moreover, the therapeutic effectiveness of meditation also correlated positively with hypnotizability assessed independently (Benson et al. 1978). These findings would indicate that the ability to respond to hypnotic suggestion is related to the effectiveness of hypnosis in the treatment of generalized anxiety disorders. Furthermore, the fact that hypnotizability also predicts the therapeutic response to meditation implies that these two procedures may belong in the same domain.
In our present state of knowledge, it seems reasonable to assume that if the positive therapeutic effects of muscle biofeedback are frequently not correlated with a decrease in muscle tension, then the active therapeutic agent is not the specific biofeedback treatment (American Psychiatric Association 1980 and Gatchel 1982). Similarly, in those circumstances where hypnotizability is unrelated to the likelihood of therapeutic success with hypnosis, it is also unlikely that it involves a specific hypnotic process. In each instance, nonspecific factors are likely to play a major role. This observation should not, however, obscure the fact that both of these procedures are effective in helping a great many patients.
Of considerable clinical importance is a phenomenon described by Borkovec and his associates (Borkovec et al. 1978; Heide and Borkovec 1983) that is called. "relaxationinduced anxiety" (RIA). They point to the fact that while patients generally find relaxation exercise calming and reassuring, some find that it exacerbates the anxiety. In a recent study, Heide and Borkovec (1983) reported that 31 percent of subjects gave clinical evidence of increased anxiety while using progressive relaxation and 54 percent showed increased anxiety while using a meditative technique of relaxation. Case 1 described earlier is an excellent example of this phenomenon, demonstrating RIA in response to EMG feedback training.
Not only is RIA of considerable importance for the clinical use of relaxation technique, but it also speaks to the likelihood that there are some specific consequences of relaxation-inducing procedures, and it underscores the importance of establishing a meaningful therapeutic relationship even when using those techniques that superficially seem to involve simple relaxation.
As we have pointed out, there are important similarities between relaxation training, hypnosis, self-hypnosis, biofeedback, and meditative disciplines. Each seeks to use an ability of the person to master anxiety, panic, or other forms of stress. The goal of these therapies is to have the patient learn how to treat himself so that he can not only tolerate the discomfort but prevent its occurrence. They all involve the focusing of attention on mental processes, an induction of hypoarousal, and a purposive ignoring of extraneous bodily sensations. Each of the techniques involves an element of learning, though there are considerable individual differences in the ability to practice these skills. Each method creates strong expectations that undoubtedly produce powerful placebo effects.
To the extent that one is able to quantify an individual's responsivity as, for example, with hypnosis, it becomes possible to do systematic research. It is likely
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that criteria will eventually be developed to identify the extent of an individual's skill for each of these processes. For instance, Zen meditators are able to identify those who are virtuosos (masters) and those who are not, even though they may have meditated for the same number of years. The question to what extent the mental processes involved overlap in these procedures is a question that future research will need to answer.
Meanwhile, it is worth considering integrating those methods that are congenial to the therapist into his treatment of anxiety, phobia, and panic. The fact that there may be no overall differences in results from biofeedback as opposed to relaxation training should not obscure the equally important fact that some patients respond far better to one technique than to another. Unfortunately, until these processes are better understood, we can only illustrate their use with clinical vignettes and point to the possible differences and similarities among them.
Notes
1 We wish to express our appreciation to our fellow task force members who commented on this manuscript and to our colleagues David Dinges, Emily Carota Orne, and Thomas Wadden, who made valuable comments and suggestions. The substantive research upon which the theoretical outlook presented in this chapter is based was supported in part by grant MH-19156 from the National Institute of Mental Health and in part by a grant from the Institute for Experimental Psychiatry.
2 Although one study (Frischholz et al. 1982) has thus far not confirmed this finding, others have (Foenander et al. 1980; Gerschman et al. 1979; John et al. 1983). 3 Acknowledgments to C. N. Legalos (1973), who first reported Case 1.