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Hypnosis
Hypnosis Burkhard Peter, MEG-Stiftung, München, Germany Ó 2015 Elsevier Ltd. All rights reserved.
Abstract Hypnosis is defined as the art of creating an alternative reality through imagination. The experience of evidence (illusion) and involuntariness (shift in agency) seems helpful, if not crucial, to the feeling of being hypnotized. Several variables are important to the quality of the hypnotic response, such as hypnotizability, hypnotic or trance state, hypnotic phenomena, hypnotic suggestions, context variables, motivation, and expectancy as well as relationship (hypnotic rapport). These factors are described, illustrated in its meaning and practical use, and substantiated by research results. Applications in medicine, dentistry, and psychotherapy are described, and relevant data supporting the efficacy of its use in these fields are provided. The role of Franz Anton Mesmer in historical reference as founder of modern hypnotism is challenged.
Hypnosis can be defined as the art of creating an alternative reality by imagination, which, ideally, should be experienced like a hallucination or illusion. In order to accomplish this, a person, with the help of hypnotic induction rituals, is ‘put into’ a hypnotic or ‘trance’ state, which is assumed to be a distinctive state different from normal experience. It is thought that being in a hypnotic trance makes it easier for the hypnotized person to use his/her hypnotizability to construe this alternative reality. Two experiences are helpful, if not crucial, for the feeling to be hypnotized: evidence (i.e., the subjective conviction of experiencing it ‘as real’), and a shift in agency, from voluntariness to involuntariness (i.e., allowing for a kind of an ‘alien control’). The more intense and real (evident) this alternative reality feels and the more it is experienced in form of hypnotic phenomena (i.e., hallucinations, illusions, and involuntary responses), the more likely normal reality is dismissed or dissociated, partially or as a whole, during the time of the trance state; and the more likely therapeutic relevant features of this alternative reality will be eventually implemented in everyday life. In that way, hypnotized patients can better tolerate aversive medical procedures, or, in the course of a hypnotherapy, can change their feelings, cognitions, and behavior. Usually, the hypnotic trance is induced, and hypnotic phenomena are suggested by another person (heterohypnosis). However, they can also be self-induced (self-hypnosis). Several variables, which are more or less interconnected, play a role in the quality of the hypnotic response: the amount of hypnotic suggestibility or hypnotizability, the presence of a trance state and its depth, the kind of hypnotic phenomenon that is intended, the way in which suggestions aiming at a specific hypnotic phenomenon are presented, and the variables related to the context in which suggestions are presented. Motivation and expectancies are important too, as well as variables pertaining to the relationship between the person who gets hypnotized and the particular hypnotist or hypnotherapist in addition to his or her hypnotic skills.
Hypnotizability The expressions hypnotizability, hypnotic susceptibility, hypnotic responsiveness, or hypnotic suggestibility are used interchangeably when the measurement of suggestibility is
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preceded by a formal hypnotic induction procedure. If there is no preceding hypnotic induction, terms like nonhypnotic, imaginative, or waking suggestibility are used. Hypnotic and nonhypnotic suggestibility are highly correlated. To assess hypnotizability, subjects or patients are presented with various suggestions that are intended to elicit certain hypnotic phenomena. The amount of hypnotizability is measured by the number of suggestions that are passed successfully. Similar to other personality traits, hypnotizability is normally distributed, with approximately 20% being high hypnotizables, 60% medium hypnotizables, and 20% low hypnotizables – depending on the choice of cutoff values (e.g., Peter et al., 2014). Because correlations are unstable, the amount of an individual’s hypnotizability cannot be reliably predicted from other personality traits; it can only be measured with hypnotizability scales. In recent years, a number of studies support the assumption that there may be two distinctive groups of high hypnotizables: individuals who like to be involved in hypnosis (‘hypnosis prone’), that is, the classical ‘fantasizers’ with high imaginative abilities (‘fantasy proneness’), and individuals who are highly dissociative and probably vulnerable to psychopathology (Peter et al., 2014). Twin studies and longitudinal studies point to the heritability of hypnotizability, as well as recent results from genetics: hypnotizability has been associated with genetic polymorphism in catechol-O-methyltransferase, an enzyme that is involved in dopaminergic metabolism. This led to the conclusion that high hypnotizables supposedly show greater frontal lobe dopamine-mediated flexibility than low hypnotizables (Lichtenberg et al., 2004). This might be the reason why ‘hypnotic prone’ individuals obviously showed markedly higher scores in charming (‘charming/histrionic’) and optimistic (‘optimistic/rhapsodic’) personality traits. This special attitude of social approachability of high hypnotizables (in case that they are securely attached; see Peter et al., 2014) can obviously also be artificially created by oxytocin administration (Bryant and Hung, 2013) or by disrupting the dorsolateral prefrontal cortex with low frequency repetitive transcranial magnetic stimulation (Dienes and Hutton, 2013) – i.e., a temporal enhancement of (state) hypnotizability. Furthermore, according to recent data (Geiger et al., 2014), hypnotizability seems to be positively correlated with intelligence after all, at least in women; the negative correlation found in men might explain why this association was not found in earlier studies.
International Encyclopedia of the Social & Behavioral Sciences, 2nd edition, Volume 11
http://dx.doi.org/10.1016/B978-0-08-097086-8.21069-6
Hypnosis
Hypnotic Trance Suggestions presented in hypnotizability scales are normally preceded by a so-called hypnotic or trance induction, during which the person is invited – after some introductory and explanatory words – to relax and enter a hypnotic trance. The benefit of using trance induction procedures has been discussed controversially. According to Braffman and Kirsch (1999), hypnotizability test scores were improved by preceding trance induction only in a small part of subjects, and only marginally so. The hypnotic induction showed no effect for about half of the subjects’ and in fact a negative effect for a quarter of the subjects. Does this mean hypnosis induction rituals are expendable or even detrimental in some individuals? From a socio-cognitive perspective, trance induction works by creating expectancies of how one will response to the subsequent suggestions, and these expectancies make it easier for subjects or patients to use their suggestibility for achieving the aims of hypnosis. Hence, in clinical practice, hypnosis is preceded by a shorter or longer, direct or indirect induction of a hypnotic trance, before actual suggestions are implemented during hypnotherapeutic work. Both the wording and grade of elaboration in presenting the induction formula are of particular importance for the effect of the subsequent hypnotic suggestions. For example, responses to suggestions in hypnotizability scales are less pronounced if introducing words convey the expectation that relaxation is induced rather than hypnosis (Gandhi and Oakley, 2005). Obviously, highly hypnotizable individuals need to hear precisely what they should be doing, that is, whether they are expected to relax or to enter a hypnotic trance. Culturally shaped meanings imply that these two are not exactly the same. High hypnotizables seem to respond easily to simple direct suggestions while medium hypnotizables need longer and more elaborated suggestions (Szabó, 1996), like the so-called indirect approaches in Ericksonian hypnosis, such as conversational inductions, embedded commands, or therapeutic metaphors. Neuroimaging studies show that, in highly hypnotizable individuals, the induction of a hypnotic state is accompanied by changes in brain activity. These changes consist mainly of decreased activation of certain prefrontal regions (Dietrich, 2003; Egner et al., 2005) and relate to the so-called default mode network (DMN; McGeown et al., 2009). With this, the old controversy in hypnosis research between state theorists and nonstate theorists (e.g., socio-cognitive theorists) seems to be resolved, at least insofar as the latter denied the existence of a specific hypnotic state. However, the significance of the effect of hypnotic induction in relation to hypnotizability is still unclear (e.g., Mazzoni et al., 2012).
Hypnotic Phenomena: Practical Uses and Scientific Results Hypnotic phenomena are characterized by changes in perception, experience, cognition, and behavior, which are different from an individual’s everyday experience, and different from deliberately produced imagination. Accompanied by psychophysiological and neurophysiological concomitants, they
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exhibit a high degree of evidence, so that they can be experienced as actual hallucinations or illusions. This can be called the ratification of a hypnotic trance. Hypnotically suggested behaviors are perceived to have a high degree of involuntariness or automatism. The experience of agency and the perceived control of an action should be significantly altered, sometimes right up to the experience of an alien control. In addition to the feeling of evidence of the imaginations, the perceived involuntariness of the suggested action is an essential element to the experience of being hypnotized. By involuntariness, the hypnotized person indicates that she/he willingly transfers the agency of her/his actions to another agent and allows a kind of alien control. Without voluntary help, a suggested action can occur (such as an arm lifting without voluntary effort following a suggestion for arm levitation) or an action may not be executed in spite of deliberate effort to do so (a cataleptic arm cannot be bent, or one’s eyes, when closed, cannot be opened willfully). These are classical dissociative phenomena, which are typically perceived as unusual or unfamiliar and therefore attributed to the state of being hypnotized. The connection of two in everyday life’s continuous mental processes is interrupted, such as that between intention (‘I want to open my eyes’) and execution (‘I can open them’). The important factor is the exact attribution of this source of alien control because it conveys, among other things, the preconceived notion that hypnosis is operated by a ‘lack of will,’ in the case of the ‘hypnotic power’ of a stage hypnotist. A neutral attribution in scientific studies, for example, usually refers to the hypnotizability of the subject. In the psychotherapeutic context, an internal locus of reattribution is exclusively appropriate, such as one’s unconscious resources, the power and capabilities of the unconscious mind, or unconscious creativity, in order to expand a patient’s sense of self-efficacy. The classic hypnotic responses (hypnotic phenomena), which are also produced through hypnotizability assessments, can be categorized according to phenomenological aspects into the following groups.
Motor-Kinesthetic Phenomena Motor-kinesthetic phenomena consist of so-called ideomotor behaviors, which are experienced as involuntary (e.g., hand levitation, eyelid closure), catalepsy, or paretic inhibition of behaviors. Most people can experience motor-kinesthetic phenomena, which do not typically require a high degree of suggestibility (Peter et al., 2013). Direct suggestions for ideomotor movements, such as for eye closure or arm levitation, are more easily and often followed than suggestions for the lack of bodily mobility, which challenge one’s personal agency, such as eye catalepsy (the eyes cannot voluntarily be opened) or entire bodily paralysis (the muscles cannot be moved willingly). The psychotherapeutic object for a full body paralysis through motor inhibition accompanied by sensory deprivation through eyelid closure can be seen in facilitating the construction of an alternative reality by increasing the capacity for imagination and deepening the absorption. Thus, the prerequisites for classical (Pavlovian) conditioning are created, i.e., for psychophysiological and emotional learning. If one’s
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own cause of an action cannot be experienced because of a catalepsy or paresis, the question arises as to whom or to what agency and control has been transferred. In the history of hypnosis, this is traditionally a ‘therapeutic Tertium (third),’ whose special form is shaped by socio-cultural beliefs. The contemporary gestalt of this therapeutic Tertium are the ‘unconscious’ resources of a person, which are often summarily referred to, especially in the context of Milton Erickson, as ‘the unconscious’ or, as is the actual traditional term, the ‘subconscious’ (Dessoir, 1896). The ritual of arm levitation is well suited for making this therapeutic construct of the unconscious available and to get in contact with it (“The more you come in contact with your unconscious, the higher goes your arm.”), such as through ideomotor signaling (“If your unconscious mind knows the answer to the question XY, then the right hand goes up; if not, the left hand.”). Through this or a similar therapeutic Tertium (unconscious knowledge, inner wisdom, hidden resources, etc.; see Peter, 2009a), a patient’s sense of self-efficacy can be restored and strengthened. In some severely disturbed patients, when suitable internal resources are lacking, a targeted therapeutic input is necessary. But even in this case, the form of a ‘representative’ figure (Bongartz and Bongartz, 2009) can be introduced and integrated into the patient’s reservoir of abilities. A series of research studies have shown that motorkinesthetic phenomena are not mere compliance reactions. Peter et al. (2012a) were able to demonstrate that electromyographic (EMG) muscle activity of the deltoid muscle during hypnotically induced arm levitation was 27% less than deliberately lifting and holding up the arm without hypnosis. Neurological studies have shown that the perception of involuntariness and alien control activates different parts of the brain than deliberate initiation and control of the movement. Blakemore et al. (2003) found activation of the parietal operculum only when an ideomotor arm levitation following a hypnotic induction was externally attributed. Pyka et al. (2011) found that a change in the authorship of an action (i.e., perceived control or agency) was associated with a change in the region of the neighboring angular gyrus. In a recent exploratory study, Deeley et al. (2013) showed brain images of ideomotor movements while using a joystick: Loss of perceived control of movements was associated with reduced connectivity between supplementary motor area and motor regions. In addition, reduced awareness of involuntary movements were associated with less activation of parietal cortices (BA 7), which are thought to be responsible for awareness of the bodily self and for somatosensory awareness (Insula).
Sensory-Affective Phenomena Sensory-affective phenomena include positive and negative hallucinations (or illusions) among all sensory modalities. These phenomena can be experienced by fewer people, which, among other things, depend on the sensory modality that is suggested to be hallucinatory or illusory, and on whether the experienced hallucination is challenged by external evidence. Positive visual phenomena (e.g., hallucinating a nonexistent person), for example, are easier to experience for more people than negative visual phenomena (e.g., a real existing person
cannot be seen) or a combination of negative and positive olfactory hallucinations (e.g., to enjoy a strong ammonia smell as a sweet scent of violets). Taste hallucinations (a sweet or sour taste in the mouth) are, in turn, easier to hallucinate than positive auditory hallucinations (e.g., listening to music). The latter is, in turn, easier than hallucinated auditory deafness (e.g., one can no longer hear an actual speaking voice). These phenomena find their traditional use in medical and dental applications, especially for hypnotically induced pain control; an efficient hypnotic anesthesia is by definition a negative-kinesthetic hallucination. The hypnotic amelioration of pain is, however, dependent on a patient’s (trait) suggestibility and of the special features of a given pain. The hypnotic control of somatosensoric aspects of pain is, for example, more dependent on a patient’s existing suggestibility, in contrast to the change of the affective parts of psychosomatic pain. In psychotherapeutic practice, these sensory-affective phenomena depend highly on the personal meaning or the affective significance of the patient and, therefore, contribute to his/her (state) suggestibility. In trauma therapy, for example, one can regain control over intrusions through numerous uses of positive and negative hallucinations and illusions: Using all modalities and qualities of the senses and through spatial orientation, the imagination of a ‘safe place’ as a hallucinated alternative reality should first be constructed. The next part consists of a planned deconstruction of the traumatic experience. Those aspects of hallucinated perceptions and exuberant emotions are dissociated with the help of negative hallucinations so that they can be better processed cognitively and emotionally. Only then does a gradual confrontation with the traumatic event become useful in order to establish a new interpretation and subsequent reintegration into one’s biography. Generally speaking, each hypnotic age regression entails positive and negative illusions and hallucinations, i.e., many different sensory-affective phenomena, which are based on real episodic and procedural memories from one’s personal history, or are entirely constructed in therapy (‘created memory’). This is especially useful when maladaptive representations of a patient’s biography must be reconstructed in order to view certain aspects of the past from a more adaptive perspective. This possibility, with the help of hypnosis or even by virtue of a given high suggestibility, of creating paramnesic phenomena has led to major controversies and law trials in the 1990s on the advantages of hypnotically uncovering ‘repressed memories’ versus the danger of the implantation of profound ‘false memories’ (cf Spiegel and Scheflin, 1994). There are now numerous studies that show that the perceived quality of sensory phenomena is verifiable through neurophysiological studies (e.g., cf Peter, 2009b). Such studies prove that sensory phenomena are caused not simply by a mechanism of distracting one’s perception but are the product of profound dissociative processes (cf Friederich et al., 2001). A basic neural mechanism for dissociative hypnotic phenomena, which play a role in negative hallucinations or illusions, seems to be that established normal functional connectivity networks are suspended by appropriate hypnotic suggestions, so that there will be a disruption in the synchronization of relevant areas of the brain that effect some action or
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perception (for pain, see Miltner and Weiss, 2007; Rainville et al., 1997). In contrast, those functional connectivity networks, which constitute a perception in normal circumstances, are activated when suggestions for positive phenomena are given (e.g., see Derbyshire et al., 2004 with respect to pain; Kosslyn et al., 2000 for visual illusions).
Cognitive Phenomena Most textbooks consider the sensory phenomena as cognitive phenomena. In the phenomenological classifications established here, cognitive phenomena are limited to explicit cognitive deficits, such as partial amnesia (e.g., following a suggestion to ‘forget’ a number, one cannot perform an arithmetic problem in which that number appears) or following, with seeming compulsivity, a given posthypnotic suggestions (e.g., upon a previously established signal, for which source amnesia is suggested, one reproduces a suggested hypnotic phenomenon following the termination of hypnosis). More complex phenomena that resemble neurological or psychiatric disorders and include sensory phenomena are selfreferenced illusions, such as being unable to recognize one’s own reflection in the mirror or believing it to be that of an opposite sex fraternal twin (Cox and Barnier, 2013). In the so-called golden era of hypnosis in Europe at the end of the nineteenth century, one thought that psychotherapeutic change could occur simply with phenomena such as amnesia and posthypnotic suggestion. However, one came to find that both were rare and relatively ineffective for many patients. Today they do not play a dominate role in hypnotherapy, at least not in the form of direct suggestions (“You will forget that for decades you have been a heavy smoker, and you will become nauseated whenever see a cigarette or smell cigarette smoke” – given the variety of smoking-related stimuli in an everyday environment, one would likely become desensitized to such a suggestion). More conceivable for psychotherapy are suggestions that are aimed at more complex changes in the self-concept of a person (“You are leaving your old lifestyle as a smoker behind you and develop a new self that can easily refrain from smoking”). That last example exemplifies that hypnosis in psychotherapy is not something in which the patient will follow wellintentioned suggestions without criticism or resistance. Rather, he should be encouraged to change more or less extensively and even profoundly his/her self-concept and conviction about his/her capacities to think, experience, and act along with his social role. This, actually, is not a new concept as the classical theory of suggestion already stated that any heterosuggestion must be accepted autosuggestively in order to be effective (Langen, 1972: p. 7). Various findings suggest that hypnosis shifts the balance between anterior effector and posterior sensory processing (Spiegel and Kosslyn, 2004). This can also be substantiated, based on recent data, as to the so-called DMN (e.g., see McGeown et al., 2009). The DMN is usually in a deactivated state when the brain is occupied with external tasks. It is activated when there are no external tasks to which to tend and a person has the time and inclination to let one’s mind wander and lead in internal self-talk. In particular, the posterior portions of the DMN, the precuneus, and the posterior
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cingulate are regarded as the cortical correlates of selfreferential processes, which are substantially involved when one constructs a mental image of oneself (Raichle et al., 2001). Following a hypnotic induction, the anterior portions of the DMN in the prefrontal cortex specifically seem to be deactivated. To that effect, McGeown et al. (2009) believe that the hypnotic situation followed by further suggested tasks will be inferred by subjects as an external task. In psychotherapeutic terms, the trance induction seems to contribute to the ceasing of the patient’s negative self-talk and prepares him/her to attend to another’s voice that offers alternatives for cognitive restructuring (Kraiker, 1985). Results of Cojan et al. (2009) and Pyka et al. (2011) show a significant activation of the posterior portions of the DMN when special hypnotic tasks are desired. These studies have shown, for example, that hypnotic paralysis is not caused by a direct inhibition of motor centers by the orbitofrontal cortex, as Ward et al. (2003) have shown. Rather, a hypnotically induced immobility is apparently mediated by the precuneus and thus possibly due to an extensive change in the self-representation of the hypnotized person. The suggestion for paralysis would not be interpreted strictly in the sense of “My arm is paralyzed” – the results of Ward et al. (2003) might stipulate that – rather it is much more complex like “I am hypnotized and have been told that my arm cannot move, thus I cannot move it.” One can hope that future clinical studies will show that more comprehensive hypnotherapeutic changes in self-concept, particularly in depressive or anxious patients, will correspond to analogue changes in the brain.
Ability to Hypnotize One could assume that it takes some skill or ability to use hypnosis that might go beyond the mastery of techniques. This is still a largely unexplored area. Our own results indicate that successful users of hypnosis possess the previously described hypnotic prone personality style and have good personal experiences with hypnosis (Peter et al., 2012b).
Context of Hypnosis In contrast, the numerous contextual factors that may influence the degree of a subject’s or patient’s hypnotizability have been well investigated by a variety of social psychological studies. It is obvious that task related motivation and expectations (see Lynn et al., 2008) are important factors, not only for highs but also for medium suggestible people, in order to experience hypnotic phenomena. The so-called indirect hypnotic techniques of Milton H. Erickson, particularly the elaborate instructions used to create and use hypnotic rapport, the therapeutic relationship in the hypnotic context, serve this purpose (see Rossi, 1980; for further details).
Techniques and Rituals The techniques and rituals of the hypnotic induction as well as the subsequent utilization of the hypnotic trance state for
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certain purposes, such as in medicine or psychotherapy, are very simple in its direct form. They are easy to learn and require no prerequisites. The techniques are described in detail in many manuals. In a simple, direct form, they are obviously on the hypnotizability of the subject or patient. Depending on the hypnotic phenomenon, they may only be suitable for high hypnotizables and only with limited effectiveness. The large number of medium hypnotizables requires techniques that present the necessary phenomenon in an elaborate form (Szabó, 1996). This function can be fulfilled by the indirect techniques created by Milton H. Erickson and his followers (Revenstorf and Peter, 2009).
Areas of Application When hypnosis is used in the field of medicine or dentistry, it is referred to as clinical or medical/dental hypnosis, while it is referred to as hypnosis therapy or hypnotherapy, and sometimes therapy in trance, when used in psychotherapy. The use of hypnosis has increased since the end of the last century in medicine, dentistry, and especially in psychotherapy in German speaking countries as well as in other European and in English speaking countries. Since the 1990s, a special focus has been placed on the use of the so-called Ericksonian hypnosis or hypnotherapy. The scientific evidence regarding the efficacy of medical hypnosis is good, but unsatisfactory in the field of hypnotherapy (for more details see Hagl, 2013, 2014). The still valid meta-analysis of the efficacy of hypnosis conducted by Flammer and Bongartz (2003) incorporated 57 randomized control trials (RCTs), in which the clinical use of hypnosis was compared with untreated or treatmentas-usual control groups, and yielded a weighted effect size of d ¼ 0.56. Approximately three quarters of the 57 studies (from the years 1973–2002) investigated the application of hypnosis for somatic complaints or as an adjunct to medical treatments. Studies on affective and obsessive–compulsive disorder, however, have been lacking since the 1970s. There were some studies of anxiety disorders, which focused mainly on test anxiety with an effect size of d ¼ 0.69, and seven studies on smoking cessation, which had an effect size of d ¼ 0.59. A further meta-analysis by Flammer and Alladin (2007) of 21 RCTs considered only trials for the treatment of psychosomatic disorders that had a weighted effect size of d ¼ 0.61. In general, the use of hypnosis in medicine is considered to be rather effective. The effectiveness of hypnosis for the reduction of experimental and clinical pain is considered good (Montgomery et al., 2000). The effectiveness of reducing anxiety and stress prior to surgical and other medical invasive procedures is well documented. Tefikow et al. (2013) calculated of 34 studies, small to medium effect sizes: g ¼ 0.53 for the reduction of psychological stress, g ¼ 0.36 for pain intensity, g ¼ 0.56 for impairment caused by pain, and g ¼ 0.36 for drug consumption. These results prompted the Wissenschaftliche Beirat Psychotherapie (WBP; Scientific Advisory Board) of the Federal Republic of Germany to pronounce the recognition of hypnotherapy as a treatment for the ICD diagnosis group F54 (mental and social factors in somatic disease) in 2006;
this implies that the use of hypnosis is financed by legal and private health insurance. There is a particularly diverse and extensive collection of individual reports and case studies for the use of hypnosis with dissociative, posttraumatic stress, and anxiety disorders. There are only a few reports for the treatment of obsessive– compulsive disorder and even fewer for depression alone. For anxiety disorders, the evidence of effectiveness is focused mainly on hypnotherapy for patients with test anxiety. In a meta-analysis of eight studies (Flammer, 2006) in which hypnosis was compared with a placebo of simply paying attention to patients, there was a medium effect size of d ¼ 0.66. Another eight RCTs compared with a waiting list control group had an effect size of d ¼ 1.02. There are only two controlled studies for posttraumatic stress and acute stress disorders, which showed a slight superiority of hypnosis compared to psychodynamic (Brom et al., 1989) or cognitive behavioral therapy (CBT; Bryant et al., 2005). For affective disorders, only one study thus far has met RCT standards: Alladin and Alibhai (2007) compared the combination of hypnosis with CBT and CBT alone, and found the former was slightly superior. In an older metaanalysis, Kirsch (1996) found a substantial effect of hypnotherapy for eating disorders when hypnosis was used in addition to behavioral weight loss programs. More recent data are not available. There is some controversy over the results with substance dependence, particularly in regard to the value of hypnosis for smoking cessation. A Cochran study (Barnes et al., 2010) was judged to be ineffective. The WBP (2006) in Germany, however, has scientifically recognized hypnotherapy for smoking cessation (as well as methadone withdrawal). Still, the overall effectiveness of hypnosis for psychic disorders is largely not well proven by RCTs. Another application of hypnosis is within the area of basic scientific research, referred to as scientific hypnosis. Researchers from other psychological disciplines, such as bioand neuropsychology, make use of hypnotic techniques to investigate cognitive and emotional phenomena, often in the last two decades with the aid of brain imaging. Stage hypnosis, in which hypnotic techniques are used for entertainment purposes, is still being used to the chagrin of almost all professional users of hypnosis. With the exception of a few countries such as Israel, Sweden, and Denmark, it is not illegal in most countries. Lay applications of hypnosis for show as well as healing purposes can be seen throughout the entire history of hypnosis as an accompanying phenomenon.
History Hypnosis has a long history and is sometimes seen as the mold for all forms of psychotherapy, and it certainly applies for all psychodynamic therapies. Behavioral therapies date back to other sources, particularly with respect to experimental and learning psychology. The physician Franz Anton Mesmer, with his theory of animal magnetism, is often considered to be the great grandfather of modern hypnosis. This, however, has to be doubted for several reasons. His
Hypnosis theory postulates a universal fluid, animal magnetism, of which the flow is disrupted in ill people and had to be harmonized though certain physical applications such as the so-called passes or through a baquet. This theory has nothing to do with the modern understanding of psychotherapy. During the Romantic Era of the first third of the nineteenth century, the understanding of the original physical magnetism as conceived by Mesmer changed basically. The still practiced passes were no longer thought to transfer a physical force but to create a special somnambulistic state, which empowers the sick with special abilities, such as self-diagnosing and self-therapy. From a modern view, one could see this as a rudimentary concept of orientation toward the resources of the patient. This new and even more psychological understanding of the ‘magnetic rapport’ dates back to Puységur, who was one of Mesmer’s students and first formulated the approach that was 100 years later elaborated by Janet and Sigmund Freud at the end of the nineteenth century. It is referred today as the therapeutic relationship and is thought to play an important role in psychotherapy and hypnotherapy (Peter and Iost-Peter, 2014). Mesmer’s original ideas continue to live today in many lay and healing practitioners as fluidists and magnetists. Lay magnetists and lay hypnotists were an inseparable part of the history of hypnosis; they continued the techniques when they were forgotten in professional circles and even banned from them. James Braid, for example, developed his idea of monoideism – induced nervous sleep (Neurypnology, from which the term hypnosis is derived) – from a lay magnetist. Freud was impressed by the stage hypnotist Hansen in Vienna, then later learned eventually at the end of the nineteenth century from Jean Martin Charcot in Paris and Hippolyte Bernheim in Nancy. The theory of the latter about the effect of hypnotic suggestion would dominate the basis on scientific research of hypnosis starting in the 1920s by Clark Hull (cf 1933) in Wisconsin and later at Yale and Ernest Hilgard (cf 1979) in the 1960s at Stanford. Milton H. Erickson was a student of Clark Hull and developed a very divergent opinion about hypnosis: instead of standardizing the suggestions, as Hull used and demanded particularly for the purposes of research, the hypnotic inductions and suggestions should be adjusted to the needs and individual possibilities of each hypnotized person. From this, he developed, with great creativity, a variety of elaborate verbalizations for suggestions and suggestive strategies for therapeutic change, which are known today as the so-called indirect or Ericksonian hypnosis, and are indispensible to modern hypnotherapy. As mentioned previously, the major advantage of these techniques is that hypnosis can be used with more patients, namely those who are of medium suggestibility. Thus Erickson becomes the father of modern hypnosis and hypnotherapy. If one wants to find the great grandfather of today’s psychotherapy and hypnosis, then the Exorcist Johann Joseph Gassner fulfills this role better than Franz Anton Mesmer because his special form of exorcism involves many elements of hypnotic rituals and also comprises the important principles of behavior-therapeutic self-control (Peter, 2005).
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See also: Behavior Therapy: Background, Basic Principles, and Early History; Classical Conditioning Methods in Psychotherapy; Psychological Treatment, Effectiveness of; Therapist–Patient Relationship; Virtual Reality in Psychotherapy.
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Hagl, M., 2014. Studien zur Wirksamkeit von klinischer Hypnose und Hypnotherapie im Jahre 2013. Hypnose-ZHH 9 (1 and 2), 147–167. Hilgard, E.R., 1979. A Saga of Hypnosis: Two Decades of the Stanford Laboratory of Hypnosis Research 1957–1979. Dept. of Psychology, Stanford University, Stanford, CA. Hull, C.L., 1933. Hypnosis and Suggestibility: An Experimental Approach. D. Appleton-Century Company, New York. Kirsch, I., 1996. Hypnotic enhancement of cognitive-behavioral weight loss treatments – another meta-reanalysis. Journal of Consulting and Clinical Psychology 64, 517–519. Kosslyn, S.M., Thompson, W.L., Constantini-Ferrando, M.F., Alpert, N.M., Spiegel, D., 2000. Hypnotic visual illusion alters color processing in the brain. American Journal of Psychiatry 157, 1270–1284. Kraiker, C., 1985. Kognitive Modelle hypnotischer Phänomene. In: Peter, B. (Ed.), Hypnose und Hypnotherapie nach Milton H. Erickson: Grundlagen und Anwendungsfelder. Pfeiffer, München, pp. 20–30. Langen, D., 1972. Kompendium der medizinischen Hypnose: Einführung in die ärztliche Praxis. Karger, Basel. Lichtenberg, P., Bachner-Melman, R., Epstein, R.P., Crawford, H.J., 2004. Hypnotic susceptibility: multidimensional relationships with Cloniger’s tridimensional personality questionnaire, COMT polymorphisms, absorption, and attentional characteristics. International Journal of Clinical and Experimental Hypnosis 52 (1), 47–72. Lynn, S.J., Kirsch, I., Hallquist, M., 2008. Social cognitive theories of hypnosis. In: Nash, M.R., Barnier, A.J. (Eds.), The Oxford Handbook of Hypnosis. Oxford University Press, Oxford, pp. 111–140. Mazzoni, G., Venneri, A., McGeown, W.J., Kirsch, I., 2012. Neuroimaging resolution of the altered state hypothesis. Cortex 49, 400–410. McGeown, W.J., Mazzoni, G., Venneri, A., Kirsch, I., 2009. Hypnotic induction decreases anterior default mode activity. Consciousness and Cognition 18, 848–855. Miltner, W.H., Weiss, T., 2007. Cortical mechanisms of hypnotic pain control. In: Jamieson, G.A. (Ed.), Hypnosis and Conscious States. The Cognitive Neuroscience Perspective. Oxford University Press, Oxford, pp. 51–66. Montgomery, G.H., DuHamel, K.N., Redd, W.H., 2000. A meta-analysis of hypnotically induced analgesia: how effective is hypnosis? International Journal of Clinical and Experimental Hypnosis 48 (2), 138–153. Peter, B., 2005. Gassner’s exorcism – not Mesmer’s magnetism – is the real predecessor of modern hypnosis. International Journal of Clinical and Experimental Hypnosis 53 (1), 1–12. Peter, B., 2009a. Therapeutisches Tertium und hypnotische Rituale. In: Revenstorf, D., Peter, B. (Eds.), Hypnose in Psychotherapie, Psychosomatik und Medizin. Ein Manual für die Praxis, second ed. Springer, Heidelberg, pp. 69–77. Peter, B., 2009b. Is it useful to induce a hypnotic trance? A hypnotherapist’s view on recent neuroimaging results. Contemporary Hypnosis 26 (3), 132–145. Peter, B., Bose, C., Piesbergen, C., Hagl, M., Revenstorf, D., 2012b. Persönlichkeitsprofile deutschsprachiger Anwender von Hypnose und Hypnotherapie. Hypnose-ZHH 7 (1 and 2), 31–59. Peter, B., Geiger, E., Prade, T., Vogel, S.E., Piesbergen, C., 2014a. Norms of German adolescents for the Harvard group scale of hypnotic susceptibility, form A. International Journal of Clinical and Experimental Hypnosis. Peter, B., Iost-Peter, A., 2014. Der “Fall Wolfart“ oder das Problem mit dem magnetischen Rapport. Zur Entwicklung der therapeutischen Beziehung in den Anfängen der Psychotherapie. Hypnose-ZHH 9 (1 and 2), 169–207.
Peter, B., Piesbergen, C., Lucic, T., Staudacher, M., Hagl, M., 2013. The role of tactile support in arm levitation. American Journal of Clinical Hypnosis 56 (2), 115–142. Peter, B., Schiebler, P., Piesbergen, C., Hagl, M., 2012a. Electromyographic investigation of hypnotic arm levitation: Differences between voluntary arm elevation and involuntary arm levitation. International Journal of Clinical and Experimental Hypnosis 60 (1), 88–110. Peter, B., Vogel, S.E., Prade, T., Geiger, E., Mohl, J., Piesbergen, C., 2014. Hypnotisability, personality style and attachment. An exploratory study. Part 1: general results. American Journal of Clinical Hypnosis 57. Pyka, M., Burgmer, M., Lenzen, T., Pioch, R., Dannlowski, U., Pfleiderer, B., et al., 2011. Brain correlates of hypnotic paralysis – a resting state fMRI study. NeuroImage 56 (4), 2173–2182. Raichle, M.E., MacLeod, A.M., Snyder, A.Z., Powers, W.J., Gusnard, D.A., Shulman, G.L., 2001. A default mode of brain function. Proceedings of the National Academy of Sciences of the United States of America 98 (2), 676–682. Rainville, P., Duncan, G.H., Price, D.D., Carrier, B., Bushnell, M.C., 1997. Pain affect encoded in human anterior cingulate but not somatosensory cortex. Science 277, 968–971. Revenstorf, D., Peter, B. (Eds.), 2009. Hypnose in Psychotherapie, Psychosomatik und Medizin. Manual für die Praxis, second ed. Springer, Heidelberg. Rossi, E.L. (Ed.), 1980. The Collected Papers of Milton H. Erickson, vols. 1–4. Irvington Publishers, New York. Spiegel, D., Kosslyn, S.M., 2004. Glauben ist Sehen: Die Neurophysiologie der Hypnose. Hypnose und Kognition 21 (1 and 2), 119–137. Spiegel, D., Scheflin, A.W., 1994. Dissociated or fabricated? Psychiatric aspects of repressed memory in criminal and civil cases. International Journal of Clinical and Experimental Hypnosis 42 (4), 411–432. Szabó, C., 1996. Differences between direct and indirect hypnotic techniques. In: Peter, B., Trenkle, B., Kinzel, F.C., Duffner, C., Iost-Peter, A. (Eds.), Munich Lectures on Hypnosis and Psychotherapy. M.E.G.-Stiftung, München, pp. 171–175. Tefikow, S., Barth, J., Maichrowitz, S., Beelmann, A., Strauss, B., Rosendahl, J., 2013. Efficacy of hypnosis in adults undergoing surgery or medical procedures: a meta-analysis of randomized controlled trials. Clinical Psychology Review 33, 623–636. Ward, N.S., Oakley, D.A., Frackowiak, R.S.J., Halligan, P.W., 2003. Differential brain activations during intentionally simulated and subjectively experienced paralysis. Cognitive Neuropsychiatry 8, 295–312. WBP – Wissenschaftlicher Beirat Psychotherapie nach x 11 PsychThG, 2006. Gutachten zur wissenschaftlichen Anerkennung der Hypnotherapie. HypnoseZHH 1 (1 and 2), 165–172.
Relevant Websites http://www.asch.net. http://www.ishhypnosis.org. http://www.meg-hypnose.de. http://www.meg-stiftung.de. http://www.sceh.us.
Abstract Hypnosis is defined as the art of creating an alternative reality through imagination. The experience of evidence (illusion) and involuntariness (shift in agency) seems helpful, if not crucial, to the feeling of being hypnotized. Several variables are important to the quality of the hypnotic response, such as hypnotizability, hypnotic or trance state, hypnotic phenomena, hypnotic suggestions, context variables, motivation, and expectancy as well as relationship (hypnotic rapport). These factors are described, illustrated in its meaning and practical use, and substantiated by research results. Applications in medicine, dentistry, and psychotherapy are described, and relevant data supporting the efficacy of its use in these fields are provided. The role of Franz Anton Mesmer in historical reference as founder of modern hypnotism is challenged.
Hypnosis can be defined as the art of creating an alternative reality by imagination, which, ideally, should be experienced like a hallucination or illusion. In order to accomplish this, a person, with the help of hypnotic induction rituals, is ‘put into’ a hypnotic or ‘trance’ state, which is assumed to be a distinctive state different from normal experience. It is thought that being in a hypnotic trance makes it easier for the hypnotized person to use his/her hypnotizability to construe this alternative reality. Two experiences are helpful, if not crucial, for the feeling to be hypnotized: evidence (i.e., the subjective conviction of experiencing it ‘as real’), and a shift in agency, from voluntariness to involuntariness (i.e., allowing for a kind of an ‘alien control’). The more intense and real (evident) this alternative reality feels and the more it is experienced in form of hypnotic phenomena (i.e., hallucinations, illusions, and involuntary responses), the more likely normal reality is dismissed or dissociated, partially or as a whole, during the time of the trance state; and the more likely therapeutic relevant features of this alternative reality will be eventually implemented in everyday life. In that way, hypnotized patients can better tolerate aversive medical procedures, or, in the course of a hypnotherapy, can change their feelings, cognitions, and behavior. Usually, the hypnotic trance is induced, and hypnotic phenomena are suggested by another person (heterohypnosis). However, they can also be self-induced (self-hypnosis). Several variables, which are more or less interconnected, play a role in the quality of the hypnotic response: the amount of hypnotic suggestibility or hypnotizability, the presence of a trance state and its depth, the kind of hypnotic phenomenon that is intended, the way in which suggestions aiming at a specific hypnotic phenomenon are presented, and the variables related to the context in which suggestions are presented. Motivation and expectancies are important too, as well as variables pertaining to the relationship between the person who gets hypnotized and the particular hypnotist or hypnotherapist in addition to his or her hypnotic skills.
Hypnotizability The expressions hypnotizability, hypnotic susceptibility, hypnotic responsiveness, or hypnotic suggestibility are used interchangeably when the measurement of suggestibility is
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preceded by a formal hypnotic induction procedure. If there is no preceding hypnotic induction, terms like nonhypnotic, imaginative, or waking suggestibility are used. Hypnotic and nonhypnotic suggestibility are highly correlated. To assess hypnotizability, subjects or patients are presented with various suggestions that are intended to elicit certain hypnotic phenomena. The amount of hypnotizability is measured by the number of suggestions that are passed successfully. Similar to other personality traits, hypnotizability is normally distributed, with approximately 20% being high hypnotizables, 60% medium hypnotizables, and 20% low hypnotizables – depending on the choice of cutoff values (e.g., Peter et al., 2014). Because correlations are unstable, the amount of an individual’s hypnotizability cannot be reliably predicted from other personality traits; it can only be measured with hypnotizability scales. In recent years, a number of studies support the assumption that there may be two distinctive groups of high hypnotizables: individuals who like to be involved in hypnosis (‘hypnosis prone’), that is, the classical ‘fantasizers’ with high imaginative abilities (‘fantasy proneness’), and individuals who are highly dissociative and probably vulnerable to psychopathology (Peter et al., 2014). Twin studies and longitudinal studies point to the heritability of hypnotizability, as well as recent results from genetics: hypnotizability has been associated with genetic polymorphism in catechol-O-methyltransferase, an enzyme that is involved in dopaminergic metabolism. This led to the conclusion that high hypnotizables supposedly show greater frontal lobe dopamine-mediated flexibility than low hypnotizables (Lichtenberg et al., 2004). This might be the reason why ‘hypnotic prone’ individuals obviously showed markedly higher scores in charming (‘charming/histrionic’) and optimistic (‘optimistic/rhapsodic’) personality traits. This special attitude of social approachability of high hypnotizables (in case that they are securely attached; see Peter et al., 2014) can obviously also be artificially created by oxytocin administration (Bryant and Hung, 2013) or by disrupting the dorsolateral prefrontal cortex with low frequency repetitive transcranial magnetic stimulation (Dienes and Hutton, 2013) – i.e., a temporal enhancement of (state) hypnotizability. Furthermore, according to recent data (Geiger et al., 2014), hypnotizability seems to be positively correlated with intelligence after all, at least in women; the negative correlation found in men might explain why this association was not found in earlier studies.
International Encyclopedia of the Social & Behavioral Sciences, 2nd edition, Volume 11
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Hypnotic Trance Suggestions presented in hypnotizability scales are normally preceded by a so-called hypnotic or trance induction, during which the person is invited – after some introductory and explanatory words – to relax and enter a hypnotic trance. The benefit of using trance induction procedures has been discussed controversially. According to Braffman and Kirsch (1999), hypnotizability test scores were improved by preceding trance induction only in a small part of subjects, and only marginally so. The hypnotic induction showed no effect for about half of the subjects’ and in fact a negative effect for a quarter of the subjects. Does this mean hypnosis induction rituals are expendable or even detrimental in some individuals? From a socio-cognitive perspective, trance induction works by creating expectancies of how one will response to the subsequent suggestions, and these expectancies make it easier for subjects or patients to use their suggestibility for achieving the aims of hypnosis. Hence, in clinical practice, hypnosis is preceded by a shorter or longer, direct or indirect induction of a hypnotic trance, before actual suggestions are implemented during hypnotherapeutic work. Both the wording and grade of elaboration in presenting the induction formula are of particular importance for the effect of the subsequent hypnotic suggestions. For example, responses to suggestions in hypnotizability scales are less pronounced if introducing words convey the expectation that relaxation is induced rather than hypnosis (Gandhi and Oakley, 2005). Obviously, highly hypnotizable individuals need to hear precisely what they should be doing, that is, whether they are expected to relax or to enter a hypnotic trance. Culturally shaped meanings imply that these two are not exactly the same. High hypnotizables seem to respond easily to simple direct suggestions while medium hypnotizables need longer and more elaborated suggestions (Szabó, 1996), like the so-called indirect approaches in Ericksonian hypnosis, such as conversational inductions, embedded commands, or therapeutic metaphors. Neuroimaging studies show that, in highly hypnotizable individuals, the induction of a hypnotic state is accompanied by changes in brain activity. These changes consist mainly of decreased activation of certain prefrontal regions (Dietrich, 2003; Egner et al., 2005) and relate to the so-called default mode network (DMN; McGeown et al., 2009). With this, the old controversy in hypnosis research between state theorists and nonstate theorists (e.g., socio-cognitive theorists) seems to be resolved, at least insofar as the latter denied the existence of a specific hypnotic state. However, the significance of the effect of hypnotic induction in relation to hypnotizability is still unclear (e.g., Mazzoni et al., 2012).
Hypnotic Phenomena: Practical Uses and Scientific Results Hypnotic phenomena are characterized by changes in perception, experience, cognition, and behavior, which are different from an individual’s everyday experience, and different from deliberately produced imagination. Accompanied by psychophysiological and neurophysiological concomitants, they
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exhibit a high degree of evidence, so that they can be experienced as actual hallucinations or illusions. This can be called the ratification of a hypnotic trance. Hypnotically suggested behaviors are perceived to have a high degree of involuntariness or automatism. The experience of agency and the perceived control of an action should be significantly altered, sometimes right up to the experience of an alien control. In addition to the feeling of evidence of the imaginations, the perceived involuntariness of the suggested action is an essential element to the experience of being hypnotized. By involuntariness, the hypnotized person indicates that she/he willingly transfers the agency of her/his actions to another agent and allows a kind of alien control. Without voluntary help, a suggested action can occur (such as an arm lifting without voluntary effort following a suggestion for arm levitation) or an action may not be executed in spite of deliberate effort to do so (a cataleptic arm cannot be bent, or one’s eyes, when closed, cannot be opened willfully). These are classical dissociative phenomena, which are typically perceived as unusual or unfamiliar and therefore attributed to the state of being hypnotized. The connection of two in everyday life’s continuous mental processes is interrupted, such as that between intention (‘I want to open my eyes’) and execution (‘I can open them’). The important factor is the exact attribution of this source of alien control because it conveys, among other things, the preconceived notion that hypnosis is operated by a ‘lack of will,’ in the case of the ‘hypnotic power’ of a stage hypnotist. A neutral attribution in scientific studies, for example, usually refers to the hypnotizability of the subject. In the psychotherapeutic context, an internal locus of reattribution is exclusively appropriate, such as one’s unconscious resources, the power and capabilities of the unconscious mind, or unconscious creativity, in order to expand a patient’s sense of self-efficacy. The classic hypnotic responses (hypnotic phenomena), which are also produced through hypnotizability assessments, can be categorized according to phenomenological aspects into the following groups.
Motor-Kinesthetic Phenomena Motor-kinesthetic phenomena consist of so-called ideomotor behaviors, which are experienced as involuntary (e.g., hand levitation, eyelid closure), catalepsy, or paretic inhibition of behaviors. Most people can experience motor-kinesthetic phenomena, which do not typically require a high degree of suggestibility (Peter et al., 2013). Direct suggestions for ideomotor movements, such as for eye closure or arm levitation, are more easily and often followed than suggestions for the lack of bodily mobility, which challenge one’s personal agency, such as eye catalepsy (the eyes cannot voluntarily be opened) or entire bodily paralysis (the muscles cannot be moved willingly). The psychotherapeutic object for a full body paralysis through motor inhibition accompanied by sensory deprivation through eyelid closure can be seen in facilitating the construction of an alternative reality by increasing the capacity for imagination and deepening the absorption. Thus, the prerequisites for classical (Pavlovian) conditioning are created, i.e., for psychophysiological and emotional learning. If one’s
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own cause of an action cannot be experienced because of a catalepsy or paresis, the question arises as to whom or to what agency and control has been transferred. In the history of hypnosis, this is traditionally a ‘therapeutic Tertium (third),’ whose special form is shaped by socio-cultural beliefs. The contemporary gestalt of this therapeutic Tertium are the ‘unconscious’ resources of a person, which are often summarily referred to, especially in the context of Milton Erickson, as ‘the unconscious’ or, as is the actual traditional term, the ‘subconscious’ (Dessoir, 1896). The ritual of arm levitation is well suited for making this therapeutic construct of the unconscious available and to get in contact with it (“The more you come in contact with your unconscious, the higher goes your arm.”), such as through ideomotor signaling (“If your unconscious mind knows the answer to the question XY, then the right hand goes up; if not, the left hand.”). Through this or a similar therapeutic Tertium (unconscious knowledge, inner wisdom, hidden resources, etc.; see Peter, 2009a), a patient’s sense of self-efficacy can be restored and strengthened. In some severely disturbed patients, when suitable internal resources are lacking, a targeted therapeutic input is necessary. But even in this case, the form of a ‘representative’ figure (Bongartz and Bongartz, 2009) can be introduced and integrated into the patient’s reservoir of abilities. A series of research studies have shown that motorkinesthetic phenomena are not mere compliance reactions. Peter et al. (2012a) were able to demonstrate that electromyographic (EMG) muscle activity of the deltoid muscle during hypnotically induced arm levitation was 27% less than deliberately lifting and holding up the arm without hypnosis. Neurological studies have shown that the perception of involuntariness and alien control activates different parts of the brain than deliberate initiation and control of the movement. Blakemore et al. (2003) found activation of the parietal operculum only when an ideomotor arm levitation following a hypnotic induction was externally attributed. Pyka et al. (2011) found that a change in the authorship of an action (i.e., perceived control or agency) was associated with a change in the region of the neighboring angular gyrus. In a recent exploratory study, Deeley et al. (2013) showed brain images of ideomotor movements while using a joystick: Loss of perceived control of movements was associated with reduced connectivity between supplementary motor area and motor regions. In addition, reduced awareness of involuntary movements were associated with less activation of parietal cortices (BA 7), which are thought to be responsible for awareness of the bodily self and for somatosensory awareness (Insula).
Sensory-Affective Phenomena Sensory-affective phenomena include positive and negative hallucinations (or illusions) among all sensory modalities. These phenomena can be experienced by fewer people, which, among other things, depend on the sensory modality that is suggested to be hallucinatory or illusory, and on whether the experienced hallucination is challenged by external evidence. Positive visual phenomena (e.g., hallucinating a nonexistent person), for example, are easier to experience for more people than negative visual phenomena (e.g., a real existing person
cannot be seen) or a combination of negative and positive olfactory hallucinations (e.g., to enjoy a strong ammonia smell as a sweet scent of violets). Taste hallucinations (a sweet or sour taste in the mouth) are, in turn, easier to hallucinate than positive auditory hallucinations (e.g., listening to music). The latter is, in turn, easier than hallucinated auditory deafness (e.g., one can no longer hear an actual speaking voice). These phenomena find their traditional use in medical and dental applications, especially for hypnotically induced pain control; an efficient hypnotic anesthesia is by definition a negative-kinesthetic hallucination. The hypnotic amelioration of pain is, however, dependent on a patient’s (trait) suggestibility and of the special features of a given pain. The hypnotic control of somatosensoric aspects of pain is, for example, more dependent on a patient’s existing suggestibility, in contrast to the change of the affective parts of psychosomatic pain. In psychotherapeutic practice, these sensory-affective phenomena depend highly on the personal meaning or the affective significance of the patient and, therefore, contribute to his/her (state) suggestibility. In trauma therapy, for example, one can regain control over intrusions through numerous uses of positive and negative hallucinations and illusions: Using all modalities and qualities of the senses and through spatial orientation, the imagination of a ‘safe place’ as a hallucinated alternative reality should first be constructed. The next part consists of a planned deconstruction of the traumatic experience. Those aspects of hallucinated perceptions and exuberant emotions are dissociated with the help of negative hallucinations so that they can be better processed cognitively and emotionally. Only then does a gradual confrontation with the traumatic event become useful in order to establish a new interpretation and subsequent reintegration into one’s biography. Generally speaking, each hypnotic age regression entails positive and negative illusions and hallucinations, i.e., many different sensory-affective phenomena, which are based on real episodic and procedural memories from one’s personal history, or are entirely constructed in therapy (‘created memory’). This is especially useful when maladaptive representations of a patient’s biography must be reconstructed in order to view certain aspects of the past from a more adaptive perspective. This possibility, with the help of hypnosis or even by virtue of a given high suggestibility, of creating paramnesic phenomena has led to major controversies and law trials in the 1990s on the advantages of hypnotically uncovering ‘repressed memories’ versus the danger of the implantation of profound ‘false memories’ (cf Spiegel and Scheflin, 1994). There are now numerous studies that show that the perceived quality of sensory phenomena is verifiable through neurophysiological studies (e.g., cf Peter, 2009b). Such studies prove that sensory phenomena are caused not simply by a mechanism of distracting one’s perception but are the product of profound dissociative processes (cf Friederich et al., 2001). A basic neural mechanism for dissociative hypnotic phenomena, which play a role in negative hallucinations or illusions, seems to be that established normal functional connectivity networks are suspended by appropriate hypnotic suggestions, so that there will be a disruption in the synchronization of relevant areas of the brain that effect some action or
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perception (for pain, see Miltner and Weiss, 2007; Rainville et al., 1997). In contrast, those functional connectivity networks, which constitute a perception in normal circumstances, are activated when suggestions for positive phenomena are given (e.g., see Derbyshire et al., 2004 with respect to pain; Kosslyn et al., 2000 for visual illusions).
Cognitive Phenomena Most textbooks consider the sensory phenomena as cognitive phenomena. In the phenomenological classifications established here, cognitive phenomena are limited to explicit cognitive deficits, such as partial amnesia (e.g., following a suggestion to ‘forget’ a number, one cannot perform an arithmetic problem in which that number appears) or following, with seeming compulsivity, a given posthypnotic suggestions (e.g., upon a previously established signal, for which source amnesia is suggested, one reproduces a suggested hypnotic phenomenon following the termination of hypnosis). More complex phenomena that resemble neurological or psychiatric disorders and include sensory phenomena are selfreferenced illusions, such as being unable to recognize one’s own reflection in the mirror or believing it to be that of an opposite sex fraternal twin (Cox and Barnier, 2013). In the so-called golden era of hypnosis in Europe at the end of the nineteenth century, one thought that psychotherapeutic change could occur simply with phenomena such as amnesia and posthypnotic suggestion. However, one came to find that both were rare and relatively ineffective for many patients. Today they do not play a dominate role in hypnotherapy, at least not in the form of direct suggestions (“You will forget that for decades you have been a heavy smoker, and you will become nauseated whenever see a cigarette or smell cigarette smoke” – given the variety of smoking-related stimuli in an everyday environment, one would likely become desensitized to such a suggestion). More conceivable for psychotherapy are suggestions that are aimed at more complex changes in the self-concept of a person (“You are leaving your old lifestyle as a smoker behind you and develop a new self that can easily refrain from smoking”). That last example exemplifies that hypnosis in psychotherapy is not something in which the patient will follow wellintentioned suggestions without criticism or resistance. Rather, he should be encouraged to change more or less extensively and even profoundly his/her self-concept and conviction about his/her capacities to think, experience, and act along with his social role. This, actually, is not a new concept as the classical theory of suggestion already stated that any heterosuggestion must be accepted autosuggestively in order to be effective (Langen, 1972: p. 7). Various findings suggest that hypnosis shifts the balance between anterior effector and posterior sensory processing (Spiegel and Kosslyn, 2004). This can also be substantiated, based on recent data, as to the so-called DMN (e.g., see McGeown et al., 2009). The DMN is usually in a deactivated state when the brain is occupied with external tasks. It is activated when there are no external tasks to which to tend and a person has the time and inclination to let one’s mind wander and lead in internal self-talk. In particular, the posterior portions of the DMN, the precuneus, and the posterior
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cingulate are regarded as the cortical correlates of selfreferential processes, which are substantially involved when one constructs a mental image of oneself (Raichle et al., 2001). Following a hypnotic induction, the anterior portions of the DMN in the prefrontal cortex specifically seem to be deactivated. To that effect, McGeown et al. (2009) believe that the hypnotic situation followed by further suggested tasks will be inferred by subjects as an external task. In psychotherapeutic terms, the trance induction seems to contribute to the ceasing of the patient’s negative self-talk and prepares him/her to attend to another’s voice that offers alternatives for cognitive restructuring (Kraiker, 1985). Results of Cojan et al. (2009) and Pyka et al. (2011) show a significant activation of the posterior portions of the DMN when special hypnotic tasks are desired. These studies have shown, for example, that hypnotic paralysis is not caused by a direct inhibition of motor centers by the orbitofrontal cortex, as Ward et al. (2003) have shown. Rather, a hypnotically induced immobility is apparently mediated by the precuneus and thus possibly due to an extensive change in the self-representation of the hypnotized person. The suggestion for paralysis would not be interpreted strictly in the sense of “My arm is paralyzed” – the results of Ward et al. (2003) might stipulate that – rather it is much more complex like “I am hypnotized and have been told that my arm cannot move, thus I cannot move it.” One can hope that future clinical studies will show that more comprehensive hypnotherapeutic changes in self-concept, particularly in depressive or anxious patients, will correspond to analogue changes in the brain.
Ability to Hypnotize One could assume that it takes some skill or ability to use hypnosis that might go beyond the mastery of techniques. This is still a largely unexplored area. Our own results indicate that successful users of hypnosis possess the previously described hypnotic prone personality style and have good personal experiences with hypnosis (Peter et al., 2012b).
Context of Hypnosis In contrast, the numerous contextual factors that may influence the degree of a subject’s or patient’s hypnotizability have been well investigated by a variety of social psychological studies. It is obvious that task related motivation and expectations (see Lynn et al., 2008) are important factors, not only for highs but also for medium suggestible people, in order to experience hypnotic phenomena. The so-called indirect hypnotic techniques of Milton H. Erickson, particularly the elaborate instructions used to create and use hypnotic rapport, the therapeutic relationship in the hypnotic context, serve this purpose (see Rossi, 1980; for further details).
Techniques and Rituals The techniques and rituals of the hypnotic induction as well as the subsequent utilization of the hypnotic trance state for
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certain purposes, such as in medicine or psychotherapy, are very simple in its direct form. They are easy to learn and require no prerequisites. The techniques are described in detail in many manuals. In a simple, direct form, they are obviously on the hypnotizability of the subject or patient. Depending on the hypnotic phenomenon, they may only be suitable for high hypnotizables and only with limited effectiveness. The large number of medium hypnotizables requires techniques that present the necessary phenomenon in an elaborate form (Szabó, 1996). This function can be fulfilled by the indirect techniques created by Milton H. Erickson and his followers (Revenstorf and Peter, 2009).
Areas of Application When hypnosis is used in the field of medicine or dentistry, it is referred to as clinical or medical/dental hypnosis, while it is referred to as hypnosis therapy or hypnotherapy, and sometimes therapy in trance, when used in psychotherapy. The use of hypnosis has increased since the end of the last century in medicine, dentistry, and especially in psychotherapy in German speaking countries as well as in other European and in English speaking countries. Since the 1990s, a special focus has been placed on the use of the so-called Ericksonian hypnosis or hypnotherapy. The scientific evidence regarding the efficacy of medical hypnosis is good, but unsatisfactory in the field of hypnotherapy (for more details see Hagl, 2013, 2014). The still valid meta-analysis of the efficacy of hypnosis conducted by Flammer and Bongartz (2003) incorporated 57 randomized control trials (RCTs), in which the clinical use of hypnosis was compared with untreated or treatmentas-usual control groups, and yielded a weighted effect size of d ¼ 0.56. Approximately three quarters of the 57 studies (from the years 1973–2002) investigated the application of hypnosis for somatic complaints or as an adjunct to medical treatments. Studies on affective and obsessive–compulsive disorder, however, have been lacking since the 1970s. There were some studies of anxiety disorders, which focused mainly on test anxiety with an effect size of d ¼ 0.69, and seven studies on smoking cessation, which had an effect size of d ¼ 0.59. A further meta-analysis by Flammer and Alladin (2007) of 21 RCTs considered only trials for the treatment of psychosomatic disorders that had a weighted effect size of d ¼ 0.61. In general, the use of hypnosis in medicine is considered to be rather effective. The effectiveness of hypnosis for the reduction of experimental and clinical pain is considered good (Montgomery et al., 2000). The effectiveness of reducing anxiety and stress prior to surgical and other medical invasive procedures is well documented. Tefikow et al. (2013) calculated of 34 studies, small to medium effect sizes: g ¼ 0.53 for the reduction of psychological stress, g ¼ 0.36 for pain intensity, g ¼ 0.56 for impairment caused by pain, and g ¼ 0.36 for drug consumption. These results prompted the Wissenschaftliche Beirat Psychotherapie (WBP; Scientific Advisory Board) of the Federal Republic of Germany to pronounce the recognition of hypnotherapy as a treatment for the ICD diagnosis group F54 (mental and social factors in somatic disease) in 2006;
this implies that the use of hypnosis is financed by legal and private health insurance. There is a particularly diverse and extensive collection of individual reports and case studies for the use of hypnosis with dissociative, posttraumatic stress, and anxiety disorders. There are only a few reports for the treatment of obsessive– compulsive disorder and even fewer for depression alone. For anxiety disorders, the evidence of effectiveness is focused mainly on hypnotherapy for patients with test anxiety. In a meta-analysis of eight studies (Flammer, 2006) in which hypnosis was compared with a placebo of simply paying attention to patients, there was a medium effect size of d ¼ 0.66. Another eight RCTs compared with a waiting list control group had an effect size of d ¼ 1.02. There are only two controlled studies for posttraumatic stress and acute stress disorders, which showed a slight superiority of hypnosis compared to psychodynamic (Brom et al., 1989) or cognitive behavioral therapy (CBT; Bryant et al., 2005). For affective disorders, only one study thus far has met RCT standards: Alladin and Alibhai (2007) compared the combination of hypnosis with CBT and CBT alone, and found the former was slightly superior. In an older metaanalysis, Kirsch (1996) found a substantial effect of hypnotherapy for eating disorders when hypnosis was used in addition to behavioral weight loss programs. More recent data are not available. There is some controversy over the results with substance dependence, particularly in regard to the value of hypnosis for smoking cessation. A Cochran study (Barnes et al., 2010) was judged to be ineffective. The WBP (2006) in Germany, however, has scientifically recognized hypnotherapy for smoking cessation (as well as methadone withdrawal). Still, the overall effectiveness of hypnosis for psychic disorders is largely not well proven by RCTs. Another application of hypnosis is within the area of basic scientific research, referred to as scientific hypnosis. Researchers from other psychological disciplines, such as bioand neuropsychology, make use of hypnotic techniques to investigate cognitive and emotional phenomena, often in the last two decades with the aid of brain imaging. Stage hypnosis, in which hypnotic techniques are used for entertainment purposes, is still being used to the chagrin of almost all professional users of hypnosis. With the exception of a few countries such as Israel, Sweden, and Denmark, it is not illegal in most countries. Lay applications of hypnosis for show as well as healing purposes can be seen throughout the entire history of hypnosis as an accompanying phenomenon.
History Hypnosis has a long history and is sometimes seen as the mold for all forms of psychotherapy, and it certainly applies for all psychodynamic therapies. Behavioral therapies date back to other sources, particularly with respect to experimental and learning psychology. The physician Franz Anton Mesmer, with his theory of animal magnetism, is often considered to be the great grandfather of modern hypnosis. This, however, has to be doubted for several reasons. His
Hypnosis theory postulates a universal fluid, animal magnetism, of which the flow is disrupted in ill people and had to be harmonized though certain physical applications such as the so-called passes or through a baquet. This theory has nothing to do with the modern understanding of psychotherapy. During the Romantic Era of the first third of the nineteenth century, the understanding of the original physical magnetism as conceived by Mesmer changed basically. The still practiced passes were no longer thought to transfer a physical force but to create a special somnambulistic state, which empowers the sick with special abilities, such as self-diagnosing and self-therapy. From a modern view, one could see this as a rudimentary concept of orientation toward the resources of the patient. This new and even more psychological understanding of the ‘magnetic rapport’ dates back to Puységur, who was one of Mesmer’s students and first formulated the approach that was 100 years later elaborated by Janet and Sigmund Freud at the end of the nineteenth century. It is referred today as the therapeutic relationship and is thought to play an important role in psychotherapy and hypnotherapy (Peter and Iost-Peter, 2014). Mesmer’s original ideas continue to live today in many lay and healing practitioners as fluidists and magnetists. Lay magnetists and lay hypnotists were an inseparable part of the history of hypnosis; they continued the techniques when they were forgotten in professional circles and even banned from them. James Braid, for example, developed his idea of monoideism – induced nervous sleep (Neurypnology, from which the term hypnosis is derived) – from a lay magnetist. Freud was impressed by the stage hypnotist Hansen in Vienna, then later learned eventually at the end of the nineteenth century from Jean Martin Charcot in Paris and Hippolyte Bernheim in Nancy. The theory of the latter about the effect of hypnotic suggestion would dominate the basis on scientific research of hypnosis starting in the 1920s by Clark Hull (cf 1933) in Wisconsin and later at Yale and Ernest Hilgard (cf 1979) in the 1960s at Stanford. Milton H. Erickson was a student of Clark Hull and developed a very divergent opinion about hypnosis: instead of standardizing the suggestions, as Hull used and demanded particularly for the purposes of research, the hypnotic inductions and suggestions should be adjusted to the needs and individual possibilities of each hypnotized person. From this, he developed, with great creativity, a variety of elaborate verbalizations for suggestions and suggestive strategies for therapeutic change, which are known today as the so-called indirect or Ericksonian hypnosis, and are indispensible to modern hypnotherapy. As mentioned previously, the major advantage of these techniques is that hypnosis can be used with more patients, namely those who are of medium suggestibility. Thus Erickson becomes the father of modern hypnosis and hypnotherapy. If one wants to find the great grandfather of today’s psychotherapy and hypnosis, then the Exorcist Johann Joseph Gassner fulfills this role better than Franz Anton Mesmer because his special form of exorcism involves many elements of hypnotic rituals and also comprises the important principles of behavior-therapeutic self-control (Peter, 2005).
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See also: Behavior Therapy: Background, Basic Principles, and Early History; Classical Conditioning Methods in Psychotherapy; Psychological Treatment, Effectiveness of; Therapist–Patient Relationship; Virtual Reality in Psychotherapy.
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Relevant Websites http://www.asch.net. http://www.ishhypnosis.org. http://www.meg-hypnose.de. http://www.meg-stiftung.de. http://www.sceh.us.