Personal pre-publication copy of a paper eventually published as Orne, M.T., & Whitehouse, W.G. Hypnosis. In G. Fink (Ed.), Encyclopedia of stress (Vol. 2). New York: Academic Press, 2000. Pp. 446-452.
University of Pennsylvania School of Medicine
I. Historical Background
II. Induction of Hypnosis
III. Hypnotizability Assessment and the Phenomena of Hypnosis
IV. Hypnosis for Stress Management
V. Conclusion
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GLOSSARY
hypnotic induction A series of suggestions that focus attention and bring about the transition from an ordinary waking experience to hypnosis.
hypnotizability The potential to experience hypnosis, a stable trait that varies from person to person, which can be assessed by standardized test procedures.
nonspecific effect A therapeutic outcome (e.g., symptom relief) that follows a hypnotic procedure but which occurs regardless of the patient's ability to experience deep hypnosis.
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Hypnosis is a psychological state or condition that occurs when appropriate suggestions produce alterations in a person's perception, memory, or mood. As a treatment modality, hypnosis provides a versatile technique to alleviate the impact of stress in a majority of individuals.
I. HISTORICAL BACKGROUND
Special healing properties have been ascribed to trancelike conditions throughout civilizations and time. Priests of ancient Egypt and Greece induced a state of "temple sleep" in afflicted individuals, accompanied by incantations designed to promote recovery. Similarly, witchcraft practiced during the middle ages and exorcisms to alleviate spiritual possession by demons, as well as faith-healing in relatively modern times, each appear to involve elements of what is today subsumed by the term "hypnosis."
Historically, explanations for the effectiveness of many of these practices appealed to supernatural or metaphysical causes. More modern perspectives arose from controversies surrounding the work of the Austrian physician, Franz Anton Mesmer (1734-1815) and his followers. Working in France at the time of the American Revolutionary War, Mesmer observed that some patients derived benefit from the passing of magnets over their bodies. In due time, Mesmer concluded that he, himself, possessed the critical "animal magnetism," a putative fluid within the body that, in combination with certain accoutrements, could be transferred to others as needed to heal them. This claim expressly identified the source of the healing power as a property of the magnetizer. Indeed, one of Mesmer's students, the Marquis de Puysegur, claimed to have successfully magnetized a tree on his estate, where some of his
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peasant workers obtained relief from their respective ailments. Eventually, de Puysegur found that he could influence the behavior of mesmerized patients merely by talking with them, much the same way that hypnosis is used today. The fluid theory of animal magnetism was soon to be discredited, however, in a series of investigations conducted by such scientific luminaries as Benjamin Franklin and Antoine-Laurent Lavoisier (1784). Nevertheless, the therapeutic effects -- at first dismissed as the products of imagination and suggestion -- were too striking to be ignored for very long.
By the 1840s, the current term "hypnosis" had been coined by James Braid, a surgeon from Edinburgh, Scotland, who conceptualized the process as one of focusing attention, leading ultimately to a state of artificial sleep. Subsequently, demonstrations of its analgesic uses in surgery -- many by James Esdaile, a physician employed by the East India Company in Calcutta -- were being documented in British medical periodicals. It was not long before hypnosis was adopted for use in the treatment of psychiatric and neurologic disorders, following a number of celebrated cases by such renowned academics and physicians as Hippolyte Bernheim, Jean-Martin Charcot, Sigmund Freud, Pierre Janet, and Morton
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Prince. Today, hypnosis is commonly employed in clinical practice as an adjunctive psychological technique for the management of a variety of conditions -- both acute and chronic -- such as pain, anxiety, addiction, mood disturbance, dissociative disorders, and stressrelated disorders.
II. INDUCTION OF HYPNOSIS
A typical hypnotic induction begins with the establishment of rapport between the hypnotist (sometimes referred to as the "operator") and the to-be-hypnotized person ("subject"). This serves not only to assure the subject of the hypnotist's competence and trustworthiness, but also to create a favorable expectation for a positive response to hypnosis (i.e., by explaining how hypnosis will be used with the subject and correcting any misconceptions about the procedure the individual may have). After this the subject is invited to relax and be comfortable and to pick some target on which to fix his or her gaze. The hypnotist then exhorts the subject to experience a growing feeling of relaxation and proceeds to direct attention to simple, suggested perceptual changes (e.g., "Your eyelids are becoming heavier and heavier . . . they will soon shut of their own accord . . ."). The specific suggestions are often designed to take advantage of normal bodily responses to the situation, such as the strain and fatigue associated with prolonged visual fixation. Because most individuals readily share such experiences and respond successfully, judiciously selected suggestions of
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this sort may also serve to enhance expectations for further responsiveness to hypnosis. Once eye closure has been accomplished, the hypnotist will often test whether the subject is truly beginning to experience the condition of hypnosis or is merely complying. Thus, the hypnotist may suggest that it is becoming increasingly difficult, perhaps impossible, for the subject to open his or her eyes. The majority of subjects who "pass" this challenge (i.e., fail to open their eyes) are indeed capable of positive responses to ensuing hypnotic suggestions, provided they are administered in a generally graded sequence of increasing difficulty.
Often early suggestions attempt to promote subjective alterations involving sensory and motor responses, such as the hand growing lighter and lighter and beginning to float upward from the armrest of the subject's chair. Coupled with complementary remarks that, as the hand rises, the subject will sink deeper and deeper into hypnosis, such a relatively easily experienced suggestion is but one of several "deepening techniques" intended to shift awareness from the subject's ambient surroundings to a nearly exclusive focus on experiencing the hypnotist's suggestions. At this point, a suitable subject may experience marked distortions of perception, memory, and mood in response to carefully and methodically linked suggestions that are appropriate to the individual's level of hypnotic skill.
III. HYPNOTIZABILITY ASSESSMENT AND THE PHENOMENA OF HYPNOSIS
Contrary to the view espoused by the 18th century mesmerists and many modern-day stage hypnotists that the power of hypnosis
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resides in the influence of the hypnotist, the scientific evidence is compelling that only a subset of people are capable of experiencing the full range of phenomena that constitute the domain of hypnosis. Thus, it is clear that the ability to respond to hypnosis is determined, in large part, by the individual about to undergo the procedure.
Formal attempts to measure hypnotic ability and to quantify aspects of hypnotic experience began in the United States in the 1930s. The most popular hypnotizability scales in use worldwide today were derived from these early efforts by Andre Weitzenhoffer and Ernest Hilgard of Stanford University in 1959. A tape-recorded adaptation of their Stanford Hypnotic Susceptibility Scales (SHSS), suitable for use with groups of individuals, was published in 1962 by Ronald Shor and Emily Carota Orne of Harvard University and is known as the Harvard Group Scale (HGS). The general design of these instruments includes a standardized induction and order of administration of hypnotic suggestions that is characterized by increasing difficulty over the course of 12 items. A person's hypnotizability is determined by the number of suggestions (which can range from 0 to 12) that evoked positive behavioral responses as judged by the hypnotist (SHSS) or by the subject (HGS).
With the development of standardized scales for hypnotizability assessment, researchers have been able to identify distinct clusters of hypnotic phenomena.
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A. Ideomotor Responses
One type of hypnotic response that nearly all individuals can experience to some degree is the tendency for vividly imagined bodily movement to produce corresponding physical movement on a seemingly involuntary basis. Such is the case, for example, when a subject responds to suggestions that his or her "forearm is beginning to feel lighter . . . as if a large helium-filled balloon is attached to the wrist and is gently lifting the arm . . . allowing it to float effortlessly upward and upward . . . ." Response to ideomotor suggestions can also occur in the absence of prior hypnotic induction, indicating that some degree of suggestibility may also operate under normal waking conditions. However, while waking suggestibility is moderately correlated with hypnotic responsivity, evidence shows that the hypnotic induction procedure contributes to hypnotic outcomes. Thus, it is exceedingly rare for an individual to respond to suggestions in the waking condition and fail to respond following induction; however, many individuals' responsiveness to suggestion is increased substantially following an appropriate hypnotic induction.
B. Challenge Suggestions
Challenge items are intended to create a contradictory subjective experience involving the inability to carry out one's own will. For instance, the hypnotized subject might be told to "interlock your fingers tightly . . . so tightly that they will be impossible to separate.
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In a moment, you may wish to try to separate your fingers, but you will find that you are unable to do so. Go ahead . . . try . . . just try to pull your fingers apart." If passed successfully (e.g., in this case, the fingers do not separate), challenge suggestions provide a compelling impression of external control over the individual's behavior -- an impression that is often shared by the hypnotized person and onlookers.
C. Cognitive/Perceptual Alterations
Among the more difficult hypnotic suggestions are those designed to induce some kind of perceptual hallucination and those intended to alter the ability to remember personal experiences from the immediate or remote past. Hallucinatory suggestions can be either positive, in which a nonexistent stimulus is introduced by the hypnotist (e.g., it is suggested that a mosquito is buzzing annoyingly around the subject's face), or negative, in which an actual physical stimulus loses its perceptibility (e.g., the subject is told that he or she will be unable to smell anything, after which a bottle of ammonia is passed under the nose). Suggested amnesia is an example of a commonly administered cognitive suggestion, whereby the subject is instructed that, upon awakening, he or she will have no recollection of the events that transpired during the hypnotic proceedings. Similarly, posthypnotic suggestions are sometimes given during hypnosis with the intent that, following termination of hypnosis, the subject will perform a specific behavior in response to a prearranged cue, but will not remember being told to do so. When properly designed, amnesia and posthypnotic suggestions can be important clinical tools that may extend therapeutic gains outside the therapist's office.
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In addition to delineating the general factor structure of hypnosis into ideomotor, challenge, and cognitive domains, the use of standardized assessment scales has resulted in a great deal of information about hypnotizability in general. One important feature, from both clinical and research perspectives, is the manner in which hypnotizability is distributed in the general population. Hilgard and associates found that hypnotizability, like many other human skills, follows a normal or bell-shaped pattern in which the majority of persons have the capacity to experience most hypnotic phenomena to some degree, whereas 15-20% are generally unresponsive and an approximately equal number of persons are highly responsive. Recognition of such individual differences in the ability to respond to hypnotic procedures is an important consideration for its use clinically, particularly when treatment is predicated on a successful response to difficult cognitive suggestions, such as to experience analgesia -- a negative hallucination -- for either acute (e.g., dental) or chronic (terminal stage cancer) pain. Similarly, the finding that a small minority of individuals can be identified who are relatively refractory to hypnotic techniques has given rise to important methodological procedures aimed at understanding mechanisms of social influence that are unique to hypnosis.
Although scores on standardized assessment scales prove useful in predicting the types of hypnotic suggestions that individuals are most likely to experience, they are not absolute prognosticators of hypnotic potential. This is because, for individuals with scores in the moderately hypnotizable range, various combinations of passed items from different realms of difficulty are possible. The
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hypnotizability score is determined merely by the sum of items that are passed, and not by their classification as ideomotor, challenge, or cognitive, which corresponds roughly to their difficulty level. Thus, while there is virtual assurance that a subject with a score of 2 (out of a possible 12 points) would be unable to experience a positive hallucination, the same could not be said of a subject with a score of 5 or 6. Modifications of the original Stanford scales have been published to identify and characterize individual hypnotic profiles, but their use has been limited generally to research purposes.
A final, yet particularly important observation made possible by the availability of standardized scales of hypnotic ability is the general stability of an individual's hypnotic potential over time. This has been confirmed in numerous laboratories throughout the world using correlations between scores obtained for the same participants at varying test-retest intervals, in some cases spanning several decades. Although some research suggests that environmental circumstances can occasionally increase responsiveness to hypnotic suggestion (e.g., situations involving extreme sensory deprivation or explicit training in the skills necessary to respond positively to specific suggestions), the overall consensus of evidence is that hypnotizability is one of several relatively enduring characteristics of an individual's personality.
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IV. HYPNOSIS FOR STRESS MANAGEMENT
While hypnosis is widely regarded as an effective cognitive-behavioral method for alleviating stress, there is surprisingly little formal research directed at this issue. There are, however, numerous clinical and experimental studies concerned with specific problems that are often regarded as stressors. From this kindred literature, we will attempt to extrapolate conclusions pertaining to the effectiveness of hypnotic techniques in reducing stress. Before doing so, however, it seems prudent to characterize the type of stress to which we refer.
Conceptualizations of stress vary widely. Some investigators have identified stress primarily as a stimulus, in which some aspect of the physical or psychological environment exacts a toll upon individuals and/or society; others view stress as the psychological or physiological response to such hostile environmental provocation; still others embrace a more dynamic view whereby the individual's appraisal of the specific environmental pressures, his or her own coping resources and available options, all converge to determine the nature and extent of the stressful experience. From the perspective of scientists and practitioners concerned with the use of hypnotic interventions for stress management, each of these variant emphases holds viability. This is because hypnosis is one of the few psychological techniques that, given an appropriately responsive individual, can be introduced at various points to modify the
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experience of stress. Thus, it has the potential to mitigate the stimulus impact of a stressor by altering perceptual experience. It can also be enlisted to modify cognitive and affective factors that influence one's appraisal of the stressor and the ability to cope. In addition, hypnosis may provide specific relief of symptoms precipitated or maintained by exposure to stress.
A. Pain Control
The use of hypnosis to suppress pain provides dramatic evidence of the technique's value for stress management. Although the widespread availability and safety of chemoanesthesia today obviate the use of hypnosis as a general method of surgical anesthesia, there are numerous documented cases in which hypnotic techniques were employed effectively as the sole anesthetic for surgery, including procedures involving limb amputations, temporal lobectomy, cardiac surgery, tooth extractions, appendectomies, cesarean sections, and others. An important caveat, however, is that the effectiveness of hypnosis in blocking acute pain, such as that illustrated in these examples, is often correlated with the patient's ability to be hypnotized. This has been demonstrated in both clinical samples, using acutely painful medical procedures (e.g., bone marrow aspirations, lumbar punctures, debridement and dressing of burn
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wounds) and experimental studies involving painful laboratory stressors (e.g., prolonged immersion of the hand in ice water). Another feature that may contribute to the efficacy of hypnosis in the control of acute pain among hypnotically responsive persons is the use of direct suggestions delivered in a heterohypnotic or self-hypnotic context.
Hypnosis is decidedly less helpful in the management of certain forms of chronic pain, particularly those with a psychogenic component. Two issues are relevant here. The first concerns the impracticality of heterohypnotic treatments based on direct suggestion in blocking the experience of persistent chronic pain, most of which occurs outside the therapist's office. The alternative strategy, training in self-hypnosis, often requires regular contact with the therapist to reinforce its continued use by the patient in his or her daily life. The more formidable problem, however, concerns the powerful reinforcing value that pain behavior can acquire among family, friends, and other important members of the community (e.g., employers, clergy). Thus, the expectations, sympathy, and support provided by others -- so-called "secondary gains" -- may serve to maintain the individual's pain and undermine the incentive to practice hypnotic techniques that otherwise might be helpful in bringing about relief. The most promising prognosis for patients suffering from functional pain of this nature is achieved by a combination of behavior therapeutic principles aimed at extinguishing pain behavior and the implementation of hypnotic or self-hypnotic approaches to minimize pain-related discomfort.
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For other forms of chronic pain that do not involve substantial functional components (e.g., pain from shingles, trigeminal neuralgia, and many types of cancer), hypnosis and self-hypnosis have proven useful as an adjunct to long-term pain management programs. Even when carried out self-hypnotically, hypnosis derives much of its benefit from the interpersonal relationship between patient and therapist, which, among other consequences, tends to shape expectations for therapeutic improvement. In an appropriately supportive context, therefore, hypnotic techniques may prove beneficial without particular regard to the patient's overall ability to respond to hypnosis. For example, we have observed significant improvement among children and adolescents during the course of an 18-month intervention involving regular group training in self-hypnosis to control unpredictable episodes of pain associated with sickle cell disease. Prior to the intervention, many of the children experienced frequent absences from school, occasionally for weeks at a time, and the only treatments available included analgesics, narcotic medications, or hospitalization. Although the participants were enrolled in the study based on their expressed wish to help identify an effective nonpharmacologic treatment for the disease and without regard to hypnotic ability, our findings indicated that, in this case, the ability to respond to hypnotic suggestion was not an overriding factor in determining how often self-hypnosis was practiced or how beneficial it would prove to be. Apparently, self-hypnosis training, along with consistent reinforcement of the technique during the regular group sessions, provided a much-needed coping skill, but the group treatment sessions themselves were critical to maintaining motivation and providing a forum for the patients
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to share their common fears, misunderstandings, and concerns, which were not being addressed adequately by conventional medical management systems. For the group as a whole, the combination of these therapeutic approaches led to increased school attendance, improved nighttime sleep, less dependence on medication, and fewer bouts of pain, although the more severe episodes of pain still required nonhypnotic supplements for pain management.
B. Anxiety
Stress is linked inextricably to anxiety states, whether they are circumscribed by some anticipated source of realistic concern (e.g., impending open heart surgery) or are more persistent, but specific fears (e.g., elevators, spiders) or are unrelenting and pervasive hindrances to normal functioning (e.g., agoraphobia or social phobia). Hypnotic techniques have proven extremely effective in treating anxiety conditions. Available evidence suggests that there may be two distinct mechanisms responsible for the high success rate. The first, which is nonspecific to hypnosis, is the tendency for hypnotic induction to promote a profound state of relaxation and comfort in many individuals, regardless of their hypnotic capacity. As Joseph Wolpe has demonstrated in his behavior therapeutic approach to the treatment of anxiety disorders, relaxation is incompatible with fear. Thus, the cultivation of extreme relaxation, whether accomplished with hypnosis, self-hypnosis, or some other cognitive-behavioral technique (e.g., autogenic training,
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meditation, progressive relaxation), will tend to inhibit symptoms of anxiety. The second mechanism is directly related to the ability to experience hypnotic-like conditions and applies to some of the more severe forms of anxiety disorder. Fred Frankel, a psychiatrist at Beth-Israel Hospital in Boston, has compiled extensive data from case studies, which suggest that high hypnotizability may be a risk factor for the development of phobic anxiety. The same individuals who exhibit such an increased propensity to develop phobias, however, also benefit markedly from psychotherapy that involves the use of hypnosis and training in self-hypnosis as a coping strategy. The success of hypnotic methods in treating patients exposed regularly to anxiety-provoking stressors has also been extended to survivors of trauma whose symptoms are maintained by uncontrollable, intrusive "flashbacks" and recurrent nightmares. In the treatment of posttraumatic stress disorders, hypnosis is employed most effectively as an adjunctive technique, secondary to pharmacotherapy and/or supportive psychotherapy.
C. Psychophysiologic Disorders and Psychoneuroimmunology
Stressors trigger specific neuroendocrine and sympathetic nervous system responses, which, if prolonged, can lead to a number of clinical manifestations linked to parasympathetic inhibition, including dysregulation of respiratory, cardiovascular, digestive, eliminative, and sexual functions. An abundance of case studies attests to the value of hypnotic and self-hypnotic procedures in the
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treatment of such conditions as asthma, tension headache, irritable bowel syndrome, Crohn's disease, insomnia, and many others. However, there is a paucity of controlled studies in which the distinctive contributions of hypnotic responsiveness and placebo factors toward clinical improvement can be evaluated. Unfortunately, a similar lack of methodologically sound investigations is also characteristic of other behavioral stress management techniques. Available evidence suggests that hypnosis may be as effective as related methods, (e.g., biofeedback, progressive relaxation) aimed at countering sympathetic arousal in the treatment of psychophysiologic disorders. The mechanism of action appears to involve the induction of a profoundly relaxed condition, which can be achieved in a majority of individuals regardless of their capacity to respond to hypnotic suggestion.
Molecular and pharmacological studies have identified the intricate patterns of communication that exist between the immune system and the central nervous system, thereby lending credibility to the long-held belief that stress can precipitate illness. Hypnosis is a versatile psychological approach that can alter the perception, evaluation, or symptoms of stress and might therefore prove effective in the management of infectious or malignant disease. The question has been addressed in several ways, often with encouraging results. However, the overall conclusion is the same as that concerning stress-related disorders in general: Although hypnosis appears to be beneficial in reducing stress symptomatology, which may result in corresponding improvement in immune function, the benefit is not more likely to occur in highly hypnotizable individuals than in relatively unhypnotizable persons. In other words, the immune
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enhancement related to hypnosis or self-hypnotic exercises appears to be due to nonspecific effects (e.g., relaxation, interpersonal support) associated with hypnosis that might also be achieved by other behavioral stress management techniques. However, in one study conducted by our laboratory, we were able to confirm a relation between ratings of the depth of relaxation and increases in both the number and the cytotoxic capacity of natural killer cells from whole blood samples among medical students who were trained to manage stress using self-hypnosis. Other investigators have reported findings suggesting a relationship between the practice of hypnotic methods and indices of humoral and cellular immunocompetence, but nonsignificant findings have also been obtained. At present, we can only conclude that hypnotic techniques have proven effective in reducing reactivity to stress, which might otherwise impair immunity to disease. Whether hypnosis can be employed strategically to bolster specific immune functioning awaits further investigation.
V. CONCLUSION
As with any clinical intervention, hypnosis can lay claim to the efficacy of both specific and nonspecific components. Because the benefit from hypnotic therapy is a function of the treatment itself, as well as the patient's ability to experience hypnosis, several aspects can function independently or synergistically to determine therapeutic outcome. For those individuals who are able to
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profoundly experience hypnotic suggestion, the stimulus, evaluation, or symptom features of a stressor can be directly addressed in treatment, whereas the same persons may be able to avail themselves of the additional benefits that accrue from generalized relaxation and positive expectancies. For individuals of lesser hypnotic capacity, the noncognitive aspects of hypnosis, particularly relaxation, clearly provide an effective technique for inhibiting sympathetic arousal. Finally, because hypnosis requires the establishment of a strong and trusting therapeutic alliance between the therapist and the patient, mutual expectations regarding milestones for improvement, coupled with regular contact, may serve to enhance motivation sufficiently to assure adherence to treatment protocols. In some instances of stress, the ability to experience hypnosis may be paramount to effective coping, whereas for other stressors, simply the belief in one's ability to benefit from the exercise may prove helpful. The versatility of hypnotic methods in modifying cognitive responses and anxiety associated with stressful life events underscores their usefulness in the prevention and treatment of stress-related disorders.
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Bibliography
Bowers, K. S. (1983). "Hypnosis for the Seriously Curious." Norton, New York.
Crasilneck, H. B., and Hall, J. A. (1985). "Clinical Hypnosis: Principles and Applications." Grune & Stratton, Orlando.
Frankel, F. H. (1979). "Hypnosis: Trance as a Coping Mechanism." Plenum, New York.
Hilgard, E. R. (1965). "Hypnotic Susceptibility." Harcourt, Brace & World, New York.
Hilgard, E. R., and Hilgard, J. R. (1983). "Hypnosis in the Relief of Pain." Kaufmann, Los Altos.
Orne, M. T., and Dinges, D. F. (1989). "Hypnosis." Churchill Livingstone, London.
The preceding paper is a reproduction of the personal pre-publication copy of a submission to the Encyclopedia of Stress (Orne, M.T., & Whitehouse, W.G. Hypnosis). It was eventually published as Orne, M.T., & Whitehouse, W.G. Hypnosis. In G. Fink (Ed.), Encyclopedia of stress (Vol. 2). New York: Academic Press, 2000. Pp. 446-452. The personal pre-publication copy is reproduced here with the kind permission of Elsevier for Academic Press. Single copies of this article can be downloaded and printed only for the reader's personal research and study. Please consult the published version to cite quotations.