Hypnosis

HYPNOSIS: THEORIES, RESEARCH AND APPLICATIONS No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services. HYPNOSIS: THEORIES, RESEARCH AND APPLICATIONS GAEL D. KOESTER AND PABLO R. DELISLE EDITORS Nova Science Publishers, Inc. New York Copyright © 2009 by Nova Science Publishers, Inc. All rights reserved. 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Includes bibliographical references and index. ISBN 978-1-61668-216-3 (E-Book) 1. Hypnotism--Therapeutic use. I. Koester, Gael D. II. Delisle, Pablo R. [DNLM: 1. Hypnosis. 2. Psychotherapy--methods. WM 415 H99833 2009] RC495.H985 2009 615.8'512--dc22 2009029340 Published by Nova Science Publishers, Inc.  New York Éva I. Yves-Jean Bignon and Alain Blanchet Chapter 10 The Valencia Model of Waking Hypnosis and its Clinical Applications 237 Antonio Capafons and M. M. Meditation. Elena Mendoza 207 . Jamieson 161 Chapter 7 The Neurophysiology of Hypnosis in Mass Psychogenic Illness Felipe A. Tallabs G 175 Chapter 8 Relaxation. Nancy Uhrhammer. Bányai and Anna C.CONTENTS Preface Chapter 1 Chapter 2 vii A New Theory for Understanding and Appreciating the Power of Hypnosis: Comparing this Theory to Previous Theories and Noting its Many Benefits Alfred Barrios Patterns of Interactional Harmony: The Phenomenology of Hypnosis Interaction Katalin Varga. Absorption and the Neurobiology of Self-Regulation Graham A. Elena Mendoza and Antonio Capafons Chapter 4 Language. Gősi-Greguss Chapter 3 Applications of Waking Hypnosis to Difficult Cases and Emergencies Carlos Lopes-Pires. Metaphor and Neuroscience: Scientific Explanation and Pragmatic Rules for Effective Communication in Hypnosis Renzo Balugani. Emese Józsa. and Hypnosis for Skin Disorders and Procedures Philip D. Shenefelt 187 Chapter 9 Hypnosis and Cancer: A Dead-End Story? Fabrice Kwiatkowski. and Giuseppe Ducci 1 53 99 131 Chapter 5 The Relational (Intersubjective) Approach to Hypnosis Udi Bonshtein 145 Chapter 6 Hypnosis. vi Chapter 11 Index Contents Hypnosis in the Management of Chronic Pain Conditions, and the Acute Pain Accompanying their Treatment John F. Chaves 271 293 PREFACE This book presents new research on hypnosis, including a clinical review comparing the effectiveness of hypnotherapy to psychoanalysis and behavior therapy. Some of the recent clinical evidence contradicting the common criticisms and misconceptions surrounding hypnotherapy are presented, providing a good indication of how to make the best use of this tool, and to provide a rational explanation for its hard-to-believe therapeutic effects. This book also describes and illustrates the use of waking hypnosis based on the Valencia Model and applied to clinical cases considered difficult and/or emergencies. Furthermore, the relationship between hypnosis and psychoanalysis is extensively reviewed. The main assumptions of the intersubjective approach and how it is used in hypnosis, through case stories, is presented as well. Finally, this book presents evidence that the neural mechanisms of hypnosis is a fundamental prerequisite for the environmental context to provide the onset of MPI (Mass Psychogenic Illness). Other topics examined in this book include the effects of hypnosis on cancer patients and its use on people with skins disorders and procedures, as well as its effect on people with chronic pain. Chapter 1 - This chapter will first present a clinical review comparing the effectiveness of hypnotherapy to psychoanalysis and behavior therapy. This review indicated that the average number of sessions needed and success rates were: 600 and 38% for psychoanalysis; 22 and 72% for behavior therapy; and 6 and 93% for hypnotherapy. This is followed by an overview of a comprehensive theory of hypnosis based on principals of conditioning and inhibition explaining hypnosis including why hypnotherapy is so much more effective. The theory is then compared to three other current hypnosis theories, the Sociocognitive, the Dissociation / Neo-Disassociation, and the Response-Expectancy perspectives as well as with Erickson’s strategic approach to therapy. Research in support of the theory is next presented, including an experiment done by the author on the effectiveness of post-hypnotic suggestion which presents ways of eliminating many of the methodological shortcomings of previous hypnosis experiments. Finally, additional benefits of the theory are discussed. This includes its providing: (1) a further understanding of the hallucinogens, schizophrenia, bi-polar disorder, biofeedback, higher-order conditioning, placebos and religion; (2) development of more effective methods of hypnotic induction; (3) development of more effective methods of giving post-hypnotic suggestions; (4) and development of Self-Programmed Control (SPC), a positive-oriented behavioral improvement program aimed at achieving self-actualization, greater self-efficacy, and higher emotional intelligence. The dramatic positive results of viii Contents SPC’s application in the areas of: education, welfare, industry, medicine and drug rehabilitation are presented. Chapter 2 - In this chapter the authors review the process of the formulation of our interactional approach to hypnosis together with the development of a new methodology through various experiments. The first interactional method developed to detect interactional synchrony between hypnotist and subject on the subjective level is the Parallel Experiential Analysis Technique (PEAT). PEAT is suitable for eliciting and simultaneously gathering free reports on the subjective experiences from both interactants that later can be parallelly processed. On the basis of four experimental series, characteristic data are shown as examples of the phenomenology of the subjective experiences of hypnotists and subjects. The free reports of hypnotists about their subjective experiences were analysed separately as well and yielded three common topics that are illustrated by verbatim quotations from the original reports. Another possibility of the interactional analysis is the use of the same paper/pencil tests for the hypnotist and subject. First we used the Phenomenology of Consciousness Inventory (PCI) for this purpose, and in several of our experiments the authors compared their subjective experiences along their scores on the PCI factors. Later they developed a new paper/pencil test, the Dyadic Interactional Harmony (DIH) questionnaire, for directly measuring the synchrony of an interaction. DIH was validated in a series of experiments and it is a promising measure for tapping the interactional aspects of a hypnotic relationship. They used PCI and DIH from hypnotist and subject as means of interactional analysis of subjective data along with the concept of hypnosis styles (maternal/paternal scores) in a real-simulator design. They exemplify the special possibilities of the interactional approach of phenomenological data by a recent empirical result: they demonstrate the very different pattern of heritability in the case of subjective data as opposed to the behavioral score of hypnosis. In their experiments, in which standardised hypnosis interactions of subjects of various kinship had been analyzed, results showed that the phenomenological experience of hypnosis is not based on genetic determination, but the way interactants evaluate the session (the interaction itself) seems to be closely related to the degree of kinship. All of these empirical results seem to add special new possibilities to the understanding of hypnosis and the authors encourage every researcher to follow this interactional approach and methodology. Chapter 3 - In this chapter, the authors describe the use of this approach for difficult cases and/or emergencies based on the Valencia Model, albeit introducing substantial modifications to adapt it to the specific characteristics of the intervention in these cases. Difficult cases and/or emergencies are defined as follows: 1) people who have gone through a number of treatments without receiving significant benefits, and, consequently, they have fewer therapeutic options; 2) people in despair (for several reasons); 3) people whose problem needs to be solved or improved immediately; 4) people in shock; 5) people who, due to their poor clinical condition, are not amenable to starting a treatment using the choice techniques for their problem, such as exposure, behavioral activation, etc. As a result, their approach puts forth three intervention models for difficult cases and/or emergencies, which correspond to the different types of cases that have been considered the most relevant according to our clinical experience. Chapter 4 - Neuroscience, in particular thanks to imaging techniques, now makes it possible to express the embodied, sensorimotor nature of many cognitive domains including Preface ix action perception, simulation and imagery. There is also growing neurophysiological evidence regarding the sensorimotor basis of language and concept formation, as previously theorized by cognitive linguistics. The role of metaphor posited by Lakoff and Johnson in the construction of the thought and abstract thinking is described. Conceptual metaphors and their use in everyday language are discussed, emphasizing both their universality and their variations in specific pathological populations. Arguments about the close link between hypnosis and metaphor are given; the opportunity of a finely graded assessment of the particular use of metaphors in any particular patient is suggested in order to build up a more effective intervention in the practice of Ericksonian psychotherapy. Chapter 5 - The main aim of this chapter is to discuss how intersubjectivity can be applied to hypnosis. Intersubjectivity is the sharing of subjective states by two or more individuals. This is a major perspective in psychoanalysis. Adopting an intersubjective perspective in psychoanalysis means, above all, abandons the myth of the isolated mind. First, the chapter reviews the relationship between hypnosis and psychoanalysis. Three splits are described: a) psychoanalysis splits off from brain science; b) psychoanalysis splits off from hypnosis and c) splits occur within psychoanalysis. I discuss how these splits can be healed, so that hypnosis can be considered a two-person rather than a one person process. Next, the chapter presents the main assumptions of the intersubjective approach and how it is used in hypnosis, through case stories. The assumptions are based on theoretical and empirical from neuroscience. Chapter 6 - In hypnosis, suggested behaviours are characteristically accompanied by a diminished sense of effort and personal agency while suggested experiences, which strongly contradict objective reality, appear to be accepted without conflict. Dissociated control theory is a cognitive neuroscience account of hypnosis that emphasises functional disconnections (dissociations) within the predominantly anterior brain networks, which implement cognitive control. Profound alterations in the ongoing experience of the self outside the hypnotic context (labelled by Tellegen as absorption) are a key predictor of a person’s ability to experience suggested distortions of reality. Tellegen (1981) defined the trait of absorption as arising from the interplay of two mutually inhibitory mental sets, the instrumental and the experiential mental sets. The capacity to set aside an instrumental set finds a clear counterpart in current neuroimaging and EEG studies of dissociated control in hypnosis. The consequent ability to adopt an experiential set has a clear counterpart in the recent discovery of a characteristic brain network during quiescent mental activity. Neuroimaging studies of suggestions used to induce hypnotic analgesia show strongly overlapping activations with the loci of this network which generates core aspects of internally focused self experience. Tellegen pointed to distinctive roles for the instrumental and experiential mental sets in psychophysiological self-regulation in order to explain the importance of the trait absorption in mediating the mixed pattern of results in earlier biofeedback studies. This account finds further support in recent studies on the roles of these mutually inhibitory neural networks in differing patterns of regulation of peripheral physiology. These findings provide an important foundation from which to understand the unique contributions of absorption and hypnosis in effective practices of self-regulation. Chapter 7 - Mass Psychogenic Illness (MPI) is typically defined as the collective occurrence of a constellation of similar physical symptoms and related beliefs, for which there is no plausible pathogenic explanation, and which can be divided in two possible conditions, Mass Anxiety Hysteria and Mass Motor Hysteria. Evidence has emerged that the x Contents cultural context is of utmost importance in the mechanism of both variants of Mass Psychogenic Illness. However, there is an underestimated variable that relates both conditions even in a more meaningful manner, and this is the neurophysiology of hypnosis. This study presents evidence that the neural mechanism of hypnosis is a fundamental prerequisite for the environmental context to exert pressure and provoke the onset of MPI; the role of empathy is assessed as a part of the mechanism of suggestibility during MPI, as well as a possible mirror neuron system that could be the cornerstone of symptomatology transmission. Fundamental differences are presented from the two variants of MPI, Mass Anxiety Hysteria and Mass Motor Hysteria. Chapter 8 - Relaxation, meditation, and hypnosis can help calm and rebalance the inflammatory immune response, which in turn can ameliorate inflammatory skin disorders. The relaxation response has been shown to help rebalance immune functioning. Mindfulness meditation has been shown to enhance the response of psoriasis to ultraviolet light treatments. Hypnosis has been shown to decrease inflammation and discomfort in a number of skin disorders and to improve the patient's attitude about having the condition. Hypnosis has also been shown to be more effective than relaxation alone in alleviating inflammatory skin disorders. Psychocutaneous hypnoanalysis permits diagnostic evaluation as to whether psychosomatic issues are initiating or exacerbating specific skin disorders. If psychosomatic issues are present, hypnoanalysis also permits treatment by reframing the initiating event in a way that defuses the negative emotional charge associated with it. Rapid induction hypnosis followed by deepening and then self-guided imagery has also been effective in alleviating anxiety and discomfort associated with dermatologic procedures. Chapter 9 - Oncology is a domain where hypnosis has a role to play, since medical treatments are still not sufficient. Although the impact of many types of psychosocial intervention have been tested in cancer patients with disappointing results on survival, hypnosis has not yet been assessed using appropriate methodology. Surveys testing hypnosis that include survival as an end-point need still to be performed. On the other hand, the impact of hypnosis on patients’ well-being has been well studied, and appears to be very useful against depression, pain, treatment side-effects and other symptoms. It can now be proposed to children or adults, and has proven to be a great help to terminally ill cancer patients. It can also prevent distress during invasive medical procedures. In most trials, hypnosis appears to be superior to standard educational and/or cognitive-behavioral interventions. Sometimes sessions can be performed by nurses and physicians having followed a short course in the technique, although for prospective trials testing wider end-points, we suggest that welltrained hypnotists participate, preferably practitioners trained in psychology. These trials should explore various dimensions of the patient’s psyche, examine the impact of the alleviating past trauma, promote behaviors known to reduce the risk of relapse, including physical activity, diet, and biological rhythms. The effect of hypnosis on immunity should also be evaluated since some authors have shown a positive impact on natural killer cell count and activity. For research purposes, measures concerning susceptibility to hypnosis should be collected and new indicators developed in order to facilitate future progress. Oncology is only just beginning to take advantage of the diverse possibilities of hypnotism. Chapter 10 - In this chapter, authors describe in detail the Valencia Model of Waking Hypnosis. The concept of waking hypnosis, originally introduced by Wells in 1924, was developed in Spain, and several standardized methods were generated shaping this Model. It is based on the socio-cognitive or cognitive-behavioral paradigm of hypnosis, and represents Preface xi the first approach to waking hypnosis that disregards the concept of trance. Rather it advocates the continuity between hypnotic and everyday life behaviors, and is focused on variables such as expectations, motivation, attitudes, beliefs, etc. The model consists of a number of efficient methods intending to be straightforward and pleasant for the patient as well as quick to learn and to apply. The procedures implemented as part of the model in order to achieve good rapport with clients are the following: a cognitivebehavioral introduction to hypnosis, a clinical assessment of hypnotic suggestibility, and a metaphor for hypnosis. Furthermore, two induction methods of waking hypnosis are added to these procedures, namely, Rapid Self-Hypnosis and Waking-Alert Hypnosis, the latter also known as Alert-Hand Hypnosis. During the intervention, hypnosis is used in combination with motivational questions to help clients understand the relevance of their thoughts in the maintenance of their problems and the usefulness of hypnosis in changing them. The sequence is structured while flexible to be adapted to the intervention. Thus, the ultimate aim is to enable patients to activate therapeutic suggestions in those everyday situations in which they need them. Some of the advantages of waking hypnosis are the following: clients show less fear of losing control; it usually takes less time to obtain results; clients can remain self-hypnotized with eyes open while engaged in other activities, which enables them to give themselves therapeutic self-suggestions that can go unnoticed when the problem occurs in public situations; it is easy to generalize to everyday life; it is versatile and efficient; and it is easily convertible into a general coping and self-control set of skills. Therefore, due to its versatility, the Valencia Model of Waking Hypnosis presents many clinical applications. An illustrative case of the clinical application of this model is described in this chapter. Chapter 11 - The effective management of chronic pain continues to present a serious challenge to the health professions. Even though we now have a wide array of medical therapies that are relatively safe and largely effective in managing many forms of chronic and acute pain, these therapies have significant limitations, especially in the management of chronic pain. The pain relief achieved with traditional biomedical and surgical therapies is often incomplete and sometimes ineffective. Moreover, relief too often comes at a high cost in terms of the patient’s quality of life. Adding to these considerations has been our growing awareness of the limitations of a narrow biomedical perspective on health and well-being and a recognition of the need to embrace a broader biopsychosocial perspective that encourages our examination of alternative approaches to pain management. This chapter describes and evaluates the ways in which one such alternative, clinical hypnosis, has been used in the management of chronic pain, including the management of acute pain associated with the treatment of underlying medical conditions producing chronic pain. It describes the nature of hypnotic interventions and the manner in which they have been used in chronic pain management. It also considers the spectrum of application of hypnosis in chronic pain management and reviews systematically collected data as well as case studies pertaining to several chronic pain problems. The emphasis is placed on finding reported since recent critical reviews by Spanos and Chaves. My goal is to provide a framework for clinicians who may be unfamiliar with this modality to understand better the nature of hypnotic treatment, help them appreciate the empirical evidence supporting its use, and introduce some of the practical issues involved in its effective use in chronic pain management. have the potential to play an important role in contemporary pain management. Soon. That fact is due. diagnosis. however. the biomedical perspective has continued to dominate contemporary medical practice. Favorable results have contributed to a growing acceptance of the notion that interventions like hypnosis. in part. the articulation of a formal theory that provided explicit mechanisms by which this modulation of pain could be produced had an enormous impact on research and clinical practice and helped to encourage the development of multidisciplinary approaches to pain management. there has been substantial growth in the amount of research. Although substantial gains in the clinical practice of pain management have been made since the Gate Control Theory was promulgated.xii Contents To put this topic in context. it is important to note that contemporary approaches to chronic pain management have increasingly coming to reflect an awareness of the significant contribution of psychosocial factors in the etiology. or reduce reliance on them. to the reconceptualization of pain perception provided by the gate control theory of pain that offered new ways of understanding the neurophysiological mechanisms by which psychosocial factors could amplify or attenuate the pain experience. . including randomized clinical trials. being conducted on psychological interventions for chronic pain management. In recent years. systematic efforts were underway to refine older therapeutic strategies and to develop new strategies for exploiting psychological resources that were already available to patients as well as assisting them in developing new skills that could be beneficially applied to reducing their symptoms. that can augment more traditional medical or pharmacological approaches. Although the basic observation that pain could be profoundly modulated by various psychological interventions was already well known. and treatment of many painful medical conditions. even as more sophisticated psychological interventions for pain management were developed. Finally. welfare. (2) development of more effective methods of hypnotic induction. Delisle ISBN 978-1-60456© 2009 Nova Science Publishers. medicine and drug rehabilitation are presented. Koester and P. This is followed by an overview of a comprehensive theory of hypnosis based on principals of conditioning and inhibition explaining hypnosis including why hypnotherapy is so much more effective. placebos and religion. schizophrenia. Research and Applications Editors: G. and higher emotional intelligence. (4) and development of Self-Programmed Control (SPC). . This review indicated that the average number of sessions needed and success rates were: 600 and 38% for psychoanalysis. The dramatic positive results of SPC’s application in the areas of: education. The theory is then compared to three other current hypnosis theories. and 6 and 93% for hypnotherapy. a positive-oriented behavioral improvement program aimed at achieving self-actualization. additional benefits of the theory are discussed. and the Response-Expectancy perspectives as well as with Erickson’s strategic approach to therapy. CA. R. USA ABSTRACT This chapter will first present a clinical review comparing the effectiveness of hypnotherapy to psychoanalysis and behavior therapy. greater self-efficacy. D. 22 and 72% for behavior therapy. Inc. including an experiment done by the author on the effectiveness of post-hypnotic suggestion which presents ways of eliminating many of the methodological shortcomings of previous hypnosis experiments. Research in support of the theory is next presented. This includes its providing: (1) a further understanding of the hallucinogens. the Dissociation / Neo-Disassociation. Culver City. bi-polar disorder. the Sociocognitive. higher-order conditioning.In: Hypnosis: Theories. Chapter 1 A NEW THEORY FOR UNDERSTANDING AND APPRECIATING THE POWER OF HYPNOSIS: COMPARING THIS THEORY TO PREVIOUS THEORIES AND NOTING ITS MANY BENEFITS Alfred Barrios SPC Center. (3) development of more effective methods of giving post-hypnotic suggestions. industry. biofeedback. Overview of Recent Literature There have been 1. actually limited to a small range of problems. This review – which comprised the first third of my Ph. there is far too much clinical evidence contradicting these statements. obsessive-compulsive neurosis. Such evidence can no longer be ignored. Theoretical & Experimental Approach” and which I am proud to say was nominated that year for the national Creative Talent Award.D. The purpose of the present paper is to present some of the recent clinical evidence contradicting the common criticisms and misconceptions surrounding hypnotherapy. Yet. hysterical . In the same period we find 899 articles on psychoanalytic therapy and 355 on behavior therapy.018 articles dealing with hypnosis in the past three years (1966 through 1968). to provide a good indication of how to make the best use of this tool. dissertation – was published as an article entitled “Hypnotherapy: A Reappraisal” in the APA journal Psychotherapy: Theory. Why? Is it because the criticisms usually leveled at hypnosis are true? That it is overrated. This includes anxiety reaction. in spite of such claims. there still appear to be relatively few therapists using hypnosis as a major tool. and to provide a rational explanation for its hard-to-believe therapeutic effects.2 Alfred Barrios INTRODUCTION The work and ideas presented herein evolved from my 1969 Ph. Contrary to popular opinion that hypnosis is only effective in certain specific symptomremoval cases. unable to produce lasting changes? Will removal of symptoms by hypnosis lead to new symptoms? Is it dangerous? No. Research and Practice (1970). It is mainly its unknown nature that has led to the many misconceptions surrounding hypnosis and has kept us from making the best use of it. One important point to keep in mind when assessing this review is that although the studies referred to took place over forty years ago. It is felt that the major reason behind the rejection of hypnosis has been that for most people it is still virtually an unknown.D. It seems to be human nature to stay clear of or reject anything that doesn’t seem to fit in or be explained rationally. approximately forty per cent of which dealt with its use in therapy. especially when it seems to be something potentially powerful. dissertation in psychology at UCLA entitled “Toward Understanding the Effectiveness of Hypnotherapy: A Combined Clinical. a wide range of diagnostic categories have been successfully treated by hypnotherapy. Many extraordinary phenomena have been attributed to its effects and great claims made as to its effectiveness in therapy. the results and conclusions still hold true today. HYPNOTHERAPY: A REAPPRAISAL Introduction Throughout the years there have been periodic surges of great interest in hypnosis. The presentation will start with a review of the clinical literature of the time comparing the effectiveness of hypnotherapy to psychoanalytic therapy and behavior therapy. dysmenorrhea.g. insomnia. as well as epilepsy (Stein. fear of her own mother. Chong Tong Mun’s (1964. stammering and homosexuality (Alexander. and inability to make decisions and future plans. He reports no hypnotic induction failures. 1963). The criteria for judging improvement were complete or almost complete removal of symptoms. 1966).7% of the patients improved. Chong Tong Mun’s method of treatment was a three-fold approach. alcoholism. 1964). In follow-ups ranging from six months to two years no instance of relapse or symptom substitution was noted. 1963). sexual promiscuity. alcoholism (Chong Tong Mun. Prior to treatment. hysterical reactions. He reports 94.2%. Richardson’s method of treatment was a combination of direct symptom removal. frigidity (Richardson. insomnia. 1964. feelings of inadequacy at being a mother. 1966). Richardson’s (1963) study dealt with seventy-six cases of frigidity. dermatitis. and impotence. allergic rhinitis. the patient feeling unloved and unwanted in regards to her marriage.. Biddle. since he had found that direct symptom removal alone was not always sufficient. fear of responsibility and making decisions. The average number of sessions needed was 1. spontaneous abortions. Follow-ups (exact length not given) showed that only two patients were unable to continue realizing climaxes at the same percentages as when treatment terminated. The percentage of patients reported improved was 95. 1965). With others he would first regress the patient back to the original onset of the symptom. Hussain pinpointed the various fears and negative attitudes which he felt were underlying the symptoms – e. The number of sessions needed ranged from four to sixteen. alcoholism. anxiety state. In addition. . The percentage of patients reported improved was 90%. Once regressed. With some patients he would work on reeducating the patient with regard to the behavior patterns immediately underlying the symptoms. ulcers. uncovering. 1963. The average follow-up period was nine months. dermatitis.53. depression with suicidal tendencies. various psychosomatic disorders including asthma. The criteria for judging improvement were removal or improvement of symptoms. speech disorders. Hussain’s (1964) study reports on 105 patients suffering from alcoholism. behavior disorders of school children. Three Large Scale Studies Three large scale studies in the past five years contain basic findings. dysmenorrhea. 1964.A New Theory for Understanding and Appreciating the Power of Hypnosis 3 reactions and sociopathic disorders (Hussain. The average number of sessions was five. impotence and frigidity. The criterion for judging improvement was increase in percentage of orgasms. The percentage of orgasms rose from a pre-treatment average of 24% to a post-treatment average of 84%. 1966) study covered 108 patients suffering from asthma. sociopathic personality disturbance. sexual promiscuity. and removal of underlying causes. infertility and essential hypertension (Chong Tong Mun. Also in the past few years an increasing number of reports indicate that the psychoses are quite amenable to hypnotherapy (Abrams. he usually used supplementary suggestions of direct symptom removal. Hussain’s approach is illustrated by the case of a 35 year old woman exhibiting the following symptoms: anxiety. and guilt over her sexual promiscuity. and a number of different psychosomatic illnesses. he would reeducate the patient to the fact that the original cause was no longer operative. 1967). Wolpe does not often use hypnosis. For example. when direct symptom removal alone was practiced and nothing was done to strengthen the patients’ ability to cope with his difficulty or to encourage him to stand on his own two feet (Hartland. Secondly. 1965). First of all.” Many therapists have rejected hypnosis because its direct symptom approach of the past clashed violently with their dynamic approach. 43-51). maladaptive behavior patterns. Psychiatric hypnotherapy.” This patient was discharged from the hospital after twelve sessions. 1965). 1963). Abrams (1963) refers to it as an “artificial situation” technique. Wolpe has the patient go through a hierarchy of “imagined situations. the main use of hypnosis is not as a means of direct symptom removal. pp. Now we see that such a clash need no longer exist. This particular approach is very often used now in one form or another. It is incumbent upon us [hypnotherapists] to concentrate on treating the particular patient who presents the symptom rather than the symptom presented by the patient (Mann.) With the above patient Hussain also used direct symptom-removal suggestions. This artificial situation technique was incorporated into the SPC program discussed below and is referred to as the “Projection Method” for self-programming of positive suggestions (Barrios. and negative self-images underlying the symptoms. as practiced today by the leading practitioners in the field. so much emphasis was directed towards symptoms and disease processes that some of us were guilty of forgetting the person in the body.” an imagined situation. fears. The objection that the results of symptom removal will seldom be permanent is certainly not valid. (There is no reason. Through hypnosis the patient is able to experience his new attitudes in an “artificial situation. Uncovering and direct symptom removal are still used to a certain extent. “No relevant symptoms were left behind and there was no relapse during the six-month follow-up period. 1985. however.4 Alfred Barrios Hussain then used a therapeutic technique somewhat similar to Wolpe’s (1958) desensitization technique to eliminate these fears and negative attitudes. but usually in conjunction with this new main function. and this probably comes as a surprise to most therapists. he would have the patient think of a particular fear-producing situation and recondition her by suggesting she would find herself calm and relaxed in the situation. In the past. “aversion to the thought and sight of alcohol was also built up by direct suggestion. This change is being stressed in the present paper because it is part of its purpose to fit hypnotherapy into “the scheme of things. For example.” going from easiest to deal with to most difficult.” Current Method of Using Hypnosis As one can see in the above studies. . It differs from Wolpe’s approach in two respects. This may have been so in the past. has in common with all other forms of modern psychiatric treatment that it concerns itself not only with the presenting symptoms but chiefly with the dynamic impasse in which the patient finds himself and with his character structure (Alexander. why this hierarchy approach cannot be incorporated into hypnotherapy. Nor is its main use as an uncovering device. The current trend is to use hypnosis to remove the negative attitudes. With regard to the depth of hypnosis required for the reconditioning approach to work. However. or force. an appropriate expectancy and a high motivation toward hypnosis (Dorcus. The first type of mishap was produced by a therapist. Although many have thought that hypnotic susceptibility was a set character trait. 1963. Kline. 1959. most hypnotherapy is ahistorical and. a historical approach. 1958. the patient to become aware of repressed information which he was not strong enough to face. Hypnotizability of Patients Freud abandoned hypnosis because of “the small number of people who could be put into a deep state of hypnosis” at that time and because in the cathartic approach. If we wanted to change the direction of a river it might be much easier to work on the main current directly (once it had been located) rather than going back upstream. 1964) these dangers have been grossly exaggerated. 1966). 1963. it would seem. Abrams. Kroger. faster. In the above studies the only hypnotic induction failures were reported by Chong Tong Mun (eight failures out of 108 patients. or that the reconditioning approach used in these studies (as opposed to Freud’s cathartic approach) does not require very deep levels of hypnosis. 237). as well as by means of a pre-induction talk aimed at insuring a positive attitude.A New Theory for Understanding and Appreciating the Power of Hypnosis 5 The Ahistorical vs. there are a number of studies which now seem to indicate that this is not the case. 1958. 1965. Abrams. According to a number of investigators (Kroger. Chong Tong Mun.) This can mean one of two things: the hypnotic induction procedures have improved since Freud’s day. There is evidence that both factors may be involved. or the substitution of more damaging symptoms. A Comment on the Dangers Ascribed to Hypnosis In the past there have been certain dangers ascribed to the use of hypnosis – for example. the danger of a psychotic break. Barrios. Baykushev. and that responsiveness can be increased by certain changes in the hypnotic induction procedure (Pascal and Salzberg. 1969). going back into the patient’s childhood and changing his attitudes regarding the causes of these patterns (Fromm. 1967. 1969). Sachs and Anderson. whatever dangers there were have been virtually eliminated by this new approach. who would allow. symptoms would disappear at first. p. 1964. The second type of mishap occurred when the therapist wrested away a symptom which the patient was using as a crutch before he was strong enough to stand on his own. the Historical Approach in Therapy Some hypnotherapists use. 1963) A study by Barrios (1969) gives this contention some support. . 1955. 1963. in part. it was found that an increase in the conditioning of the salivary response could be produced almost as effectively by lighter levels of hypnosis as by deeper levels. there are a number of therapists who feel that only a light state of hypnosis is necessary (Van Pelt. but reappear later if the patient-therapist relationship were disturbed (Freud. and pointing each one in a new direction. The few mishaps that have occurred in the past resulted either from (1) the misuse of hypnosis as an uncovering agent. or (2) its misuse as a direct symptom remover. 1969. locating all the tributaries. Barber. However. concedes the hypnosis apparently does facilitate the conditioning: “Patients who cannot relax will not make progress with this method.6 Alfred Barrios The latter point brings us to the question of whether hypnotic induction is necessary at all for the re-conditioning approach to work. 1969). Salter. it should not only increase recovery rate. Also. the real question to be answered is not whether hypnotic induction is absolutely necessary. although apparently more slowly than when hypnosis is used. Averaging the above figures.” (Wolpe. if a form of therapy is truly effective. but also shorten the number of sessions necessary (as well as widen the range of cases treatable). The duration of treatment for the improved patients was an average of thirty sessions in the former and fourteen in the latter. although Barrios’ (1969) study indicated that conditioning could be increased during lighter levels of hypnosis. the recovery rate was 65% in his own study involving 295 patients (usually [misleadingly] reported as 90% of 210 patients) and 78% in a study by Lazarus involving 408 patients. 1964). Comparison with Psychoanalysis and Behavior Therapy In Wolpe’s comparison of his and the psychoanalytic approaches (Wolpe. 141. hypnotic and waking suggestion are on the same continuum and hypnotic induction should be looked upon as a procedure whereby we can increase the probability of getting a more positive response to suggestion. 1958. italics added). based on all patients seen. and for hypnotherapy we can expect a recovery rate of 93% after an average of 6 sessions. Wolpe. it was also found that there was no increase in conditioning with those subjects indicating no response to the hypnotic induction.g. p. we find that for psychoanalysis we can expect a recovery rate of 38% after approximately 600 sessions. However. we can expect a recovery rate of 72% after an average of 22 sessions. Those who cannot or will not be hypnotized but who can relax will make progress. 1969) but what variables in the hypnotic induction are playing the key roles and what can be done to strengthen the effectiveness of these factors. . The next question to be decided now is not so much whether hypnotic induction procedures increase responsiveness (this is fairly well accepted – e. we find the following: Based on all psychoneurotic patients seen. However. himself. This would also be supported by the work of Barber (1961. The average duration of treatment for the improved patients (given only for the first study) was three to four years at an average of three to four sessions per week. Barber. For Wolpian therapy. 1965) who found that hypnotic phenomena could be produced without a prior hypnotic induction. or an average of approximately 600 sessions per patient. As pointed out in the theory (Barrios. but whether it can further facilitate the conditioning process. For Wolpe’s approach we find that. and Reyna.. the number of patients cured or much improved by psychoanalysis was 45% in one study involving 534 patients and 31% in the other study involving 595 patients (the only two large scale studies in the literature on psychoanalysis). It is interesting to note the negative correlation between number of sessions and percentage recovery rate. Judging from the work of Wolpe (1958) it would appear that hypnosis is not an absolutely necessary requirement. At first sight this seems paradoxical. 1960) tend to support this contention.A New Theory for Understanding and Appreciating the Power of Hypnosis 7 The Need for a Rational Explanation In spite of all the encouraging reports.293-294). whereby the latter’s words will be much more effective. however – what exactly is the process whereby “mere words” can produce such great changes in personality. An Explanation Based on Principles of Conditioning The experienced therapist really should not be so surprised at the effectiveness of hypnosis in facilitating therapy. no matter how great the claims on its behalf. we would pair the words “people” (A) and “relaxed” (B). 1960. according to principles of high-order conditioning we know that by paring word B with word A we should transfer the response produced by word B to word A and consequently anything that would evoke word A.” Mower’s theoretical formulations on the sentence as a conditioning device (Mowrer. if we wanted to condition a person to be more relaxed in the presence of people. we know that under ordinary circumstances suggestions are not always accepted (and thus conditioning doesn’t always result when an appropriate suggestion is given). on account of the whole preceding life of the adult. Thus. Hypnotic induction can be looked upon as a technique for establishing a very strong rapport. it will continue to be rejected by many. Hypnosis is still looked upon as an “unknown” by most therapists. there continues to be considerable hesitation on the part of psychotherapists to use hypnosis. signaling all of them and replacing all of them. Of course. “From now on you will find yourself more relaxed in the presence of people. we know that words can act as conditioned stimuli. one of the common features among all methods of psychotherapy is the attempt to “create a strong personal relationship that can be used as a vehicle for constructive change… It is a significant fact that many theoretical writers. 407). come to place much more emphasis on this variable” (pp. as their experience increases. is connected up with all the internal and external stimuli which can reach the cortex. As pointed out in Barrios’ (1969) theory of hypnosis. for example. one that would tie these phenomena down to observable facts and laws. As Sundberg and Tyler (1962) point out. and therefore it can call forth all those reactions of the organism which are normally determined by the actual stimuli themselves (Pavlov. Pavlov recognized this fact: Obviously for man speech provides conditioned stimuli which are just as real as any other stimuli… Speech. First of all. the ability of words to produce behavior changes is really not so difficult to understand if we are familiar with the principles of higher-order conditioning. Now. using a sentence or suggestion such as. a greater belief in the therapist. The question still remains. p. It would seem that if there were some means of eliminating the latter we should be able to . for establishing a greater confidence. They are as yet not aware of any reasonable rational explanation for hypnotic phenomena that would satisfy them. Why is this? Osgood (1963) holds that a suggestion will tend to be rejected if it is incongruent with the subject’s previously held beliefs and attitudes or his present perceptions. As long as hypnosis continues to exude an air of mysticism and charlatanism. If under ordinary circumstances we suggested that he would no longer feel inadequate. OVERVIEW OF MY THEORY OF HYPNOSIS* In the theory (Barrios. p. italics added). usually ever-present and quite dominant. 2007 a & b) . The latter increases responsiveness to suggestion * Much of the remainder of this chapter is taken verbatim from my commentary articles. it would most likely accomplish little. Being more confident and relaxed he will naturally be more likely to be accepted. But in the hypersuggestible hypnotic state conditions are different. in Contemporary Hypnosis (Barrios. Thus we come to the reason hypnosis is so effective in facilitating therapy: the incongruent perceptions. This is because the patient’s negative self-image. They lead to his tensing up. But if this negative self-image has been replaced by a positive one. he will now be more open to believing and accepting praise and positive outcomes. the opposite cycle can result. he is unlikely to believe any praise or any positive occurrences should they chance his way. in correspondence with the general law. also referred to as a state of heightened belief. the conditioning can take place and new associations can be made. Hypnosis is defined then as the state of heightened suggestibility. As put by Pavlov: The command of the hypnotist. just as his old negative attitude had been kept permanent by self-reinforcement. concentrates the excitation in the cortex of the subject (which is in a condition of partial inhibition) in some definite narrow region.2001) a hypnotic induction is defined as the giving of a series of suggestions so that a positive response to a previous suggestion predisposes the subject to respond more strongly to the next suggestion. As long as the patient has negative attitudes. The person can truly picture himself feeling self-confident in various situations and these new conditioned associations in turn can lead to new behavior. Part I & II. Hypnosis is such a means.1969. 1960. Also. The patient’s negative self-image is now more easily inhibited and should therefore be less likely to interfere when we attempt to evoke the positive self-image through suggestion. What occurs during a hypnotic induction to increase suggestibility is a process of conditioning of an inhibitory set. at the same time intensifying (by negative induction) the inhibition of the rest of the cortex and so abolishing all competing effects of contemporary stimuli [present perceptions] and traces left by previously received ones [previously held beliefs and attitudes]. or at least keep it from being too vivid or real. acting awkward and making numerous mistakes. As an illustration. As a result. This accounts for the large and practically insurmountable influence of suggestions as a stimulus during hypnosis as well as shortly after it (Pavlov. 407.8 Alfred Barrios have a suggestion more readily accepted and thus facilitate the higher-order conditioning. and attitudes are kept from interfering with the suggestion (and thus with the conditioning). beliefs. would quickly suppress any positive image suggested. Also. produced by a hypnotic induction. This new attitude can now become permanent by means of self-reinforcement. these are self-reinforcing. let us say we wanted to change a patient’s self-image from that of an inadequate person to a more self-confident one. The various hypnotic and post-hypnotic phenomena can be explained in terms of how the inhibitory set can rearrange the dominant position of a particular stimulus (cognitive or sensory) focused on by the suggestion. one can see that hypnosis can be a natural everyday occurrence. some more strongly than others. It is expected that sociocognitive theorists would agree that these are also important individual difference factors. the explanation for how these factors play a part according to the theory might differ from the sociocognitive perspective. These include: the amplification of minute responses to suggestion such as with the use of biofeedback devices. With regards to age. motivation and imagination (or fantasy proneness). Since the theory defines hypnosis as a state of heightened belief. the greater this inhibitory set. may be traced to certain factors that vary with age.A New Theory for Understanding and Appreciating the Power of Hypnosis 9 by inhibiting thoughts and stimuli which would contradict the suggested response. we can understand why very young children whose language ability is not yet well-developed would make very poor subjects for hypnosis. the theory states that the reason initial suggestibility varies with age.. the minimization or inhibition of competing stimuli such as in sensory deprivation or under the influence of inhibitory drugs. The more effective the hypnotic induction. This is referred to as the stimulus dominance hierarchy. One of these is language ability. Salesmen. lawyers and politicians are constantly benefiting from a variation of hypnosis (the powers of persuasion). and thus why we would expect an initial gradual increase in suggestibility with increasing age . COMPARISON WITH OTHER THEORIES Comparison with Sociocognitive Theories Similarities Both perspectives discuss the importance of the part played by individual differences in affecting initial responsiveness to suggestion. So too are doctors (the power of the placebo) and ministers (the power of faith). Post-hypnotic behavior changes are explained as produced through a process of higher order conditioning where the inhibitory set facilitates such conditioning by suppressing any dominant stimuli present (cognitive or sensory) that would interfere with the intended conditioning. The following are included as individual influencing factors in both perspectives: subjects' expectations and beliefs about hypnosis.. . Since [according to the theory] hypnosis is dependent to a great extent on the conditioned response evoked by words. From the theory. Two areas of individual differences mentioned in the theory which apparently are not mentioned in the literature on sociocognitive theories are age of the subject and prestige of the hypnotist in the eyes of the subject. However. a number of ways can be deduced for increasing responsiveness to suggestion and thereby increasing the effectiveness of hypnotic induction. It is postulated that at any point in time there are any number of stimuli (both cognitive and sensory) that one can be responsive to. and the subtle introduction of stimuli that would naturally evoke the suggested response. for instance. with increasing age there will be a greater number of possible contradictory stimuli [competing with] a suggestion. 2001: 185) With regards to prestige. they point out that . In other words. would be expected to lead to the involuntary occurrence of the motor response called for by the suggestion' (Spanos.' And a corollary to this hypothesis. How Erickson's approach fits in with the sociocognitive perspective is discussed in a very extensive article by Lynn and Sherman (2000). (Barrios. 2001: 181) It will be recalled that in the theory a positive response to a series of suggestions (the hypnotic induction) conditions in an inhibitory set to automatically inhibit any stimuli (cognitive or sensory) in the stimulus dominance hierarchy that would contradict the suggestion. 1977: 211). the lower the probability of a reaction to any one of them . you might want to suggest that the subject was eating a delicious steak or. Another similarity between the sociocognitive and the theory's perspective revolves around the use of what the sociocognitives refer to as 'goal directed fantasies' (GDFs). a thick juicy steak smothered in onions. It is fairly well accepted that the more 'prestige' a hypnotist has in the eyes of subjects. that is. better yet. knowledge increases with age) and a corollary to the 'reciprocal inhibition' or 'stimulus dominance hierarchy' postulate is that the more stimuli in the hierarchy. Corollary 8. if they were to occur. the stronger the response to the suggestion’.. such a person evokes a greater inhibitory set to begin with.. This is so because what the authority says has usually turned out to be true! (Barrios. subjects have more information available with which to verify or contradict the suggestion. A third similarity between the two perspectives is how they apparently both seem to fit in with Milton Erickson's strategic approach to therapy. In general. people have previously been conditioned to accept at face value the statements of someone who is an authority in his field. the more cognitive stimuli used associated with the suggested response. Rivers and Ross. states: 'The more (compatible) cognitive stimuli associated with the response evoked by the suggestion. That is. Hypothesis IV states: 'A suggestion produces the desired response by first evoking a cognitive stimulus which is associated with that response. It is felt this is so because the statements. commands or suggestions of a person with prestige tend to be questioned less. that is. the more likely the response. an inhibitory set which inhibits contradictory stimuli [in the stimulus dominance hierarchy] has been previously conditioned (in much the same way as in the hypnotic induction process). The following includes some examples of how Erickson's ideas parallel those presented in the theory: Scripts In the section of Lynn and Sherman's article where they are discussing Erickson's strategy of using scripts. For example. to increase the probability of producing the involuntary response of salivation and/or the secretion of pepsin. In the theory.10 Alfred Barrios An explanation for the gradual decline in suggestibility after the age of eight is that with continued increasing age the number of cognitive stimuli competing with a suggestion increases (that is. the better his chances of success. GDFs are defined as 'imagined situations which. For example. (Lynn and Sherman. he would keep asking such questions. . 1985). These techniques and others for facilitating suggestion and post-hypnotic suggestion are derived from Corollary 8 of the theory (see above) and will be discussed further in Part II of the Commentary. 'Response sets can be established and reinforced by altering the accessibility of facts or events in memory . To see the similarity of this to what is said in the theory.' This very same procedure is referred to as the 'Punishment-Reward' technique. or more broadly to whatever response the patient made (Erickson. Patients would [then] apparently agree to things that they would not have agreed to in the absence of such a response set. This is very similar to one of the positive attitudes. one of several visualization techniques for facilitating reprogramming. 1985: 49 and 50). 1973b and Barrios. Also related to this 'yea saying' technique of Erickson is another he often used to get positive responses to his suggestions: 'He often tied suggestions to naturally or frequently occurring responses. Certain naturally occurring responses.A New Theory for Understanding and Appreciating the Power of Hypnosis 11 Erickson found this technique useful in engendering a 'yea saying' response pattern. in the self-programmed control (SPC) program for improving behavior (see Barrios. 2001: 178). Positive Attitude 4. provide immediate positive propioceptive feedback' (Lynn and Sherman.. then in both cases the individual is being put through a form of hypnotic induction according to the theory. For example. As stated by Hypothesis III of the theory: 'a positive response to a suggestion will induce within the responding person a more or less generalized increase in the normally existent tendency to respond to succeeding suggestions' (Barrios. imagining negative outcomes of smoking and overeating and positive outcomes of not doing so can make it easier to resist these urges. 2000: 306) This also explains the effectiveness of persuasive salesmen who 'prep' a person to buy by getting the person to respond with 'yeses' to a series of questions. to establish a pattern or response set. Erickson's Altering Accessibility According to Lynn and Sherman (2000: 306). 2000: 307). see Corollary 6 following Hypothesis III of the theory: 'The response could be "artificially" induced in a number of ways. one of his approaches to break a patient out of depression over certain deficits was to 'turn the patient's deficits into assets'. instead of the hypnotherapist giving only the general suggestion that the patient will no longer be depressed. If we can look upon these 'questions' as a variation of suggestions. 'Learn to look for the good in even the worst of situations. Rossi and Rossi: 1976). the suggestions that the eyes are going to get tired may be helped if a slight eye strain is placed on them by having the subjects look at an object at a difficult angle' (Barrios. it would be more effective if the patient is also given the suggestion that he will learn to look for the good in even the worst of situations. (Barrios. for instance.. If the goal of therapy is to help the patient break free of a depression caused by some negative life occurrence. in this way turning the patient's deficits into assets. such as lowering of an outstretched arm. He would start with questions with an obvious 'yes' answer. 2007b) Reframing Reframing was a technique of Erickson's to make general positive suggestions or treatment goals more attainable. For instance. 2001: 180).' in the chapter on positive attitudes in the SPC program (see Chapter IV of Barrios. 20). and the function of a formal induction is primarily to increase suggestibility to a minor degree (see Barber. 'inhibited.g. a placebo) is not as effective as belief plus guidance. cognitive stimuli whose presence would ordinarily preclude the establishment of the desired new cognitive patterns and need to be 'temporarily altered' or as the theory puts it.' in order for the new patterns to be made. As Lynn and Sherman (2000: 298) put it. This basic premise will be explored again later in Part II in the section on faith healing when pointing out that belief alone (e. Hilgard. All of these comments concur with the general thrust of response set theory [except for the concept of trance]. this is similar to what Lynn and Sherman (2000: 307) mean when they state that 'As implied by these examples. 58). or as Erickson puts it. 2001: 194-5). 1976: 20).. the authors define the 'therapeutic aspects of trance' as occurring when 'the limitations of one's usual conscious sets and belief system are temporarily altered so that one can be receptive to an experience of other patterns of association and modes of mental functioning . The sociocognitive perspective seems to feel that hypnotic inductions increase suggestibility only to a minor degree whereas the theory does not agree with this. In so many words. this is saying that general suggestions alone (regarding treatment goals) without guidance to substantiate the suggestions are not as effective as the combination of the general suggestion plus guidance. 1976) observation that. According to Lynn and Sherman (2000: 305): Erickson's appreciation of the crucial role of response sets is further revealed by his (Erickson. Erickson's approach involves considerable reframing of behaviors [so] as [to be] consistent with treatment objectives. 'so that one can be receptive to an experience of other patterns of association and modes of mental functioning' (Erickson.12 Alfred Barrios In essence. 'Suggestions can be responded to with or without hypnosis. that are usually experienced as involuntary by the patient (p.' Another area where Erickson's ideas fit in with the theory is where he talks about how it is that hypnosis plays a part in facilitating change in behavior. provides an especially effective means (the inhibitory set) whereby interfering stimuli can be readily inhibited' (Barrios. 'much initial effort in every trance induction is to evoke a set or framework of associations that will facilitate the work that is to be accomplished' (p. What Erickson refers to as 'the limitations of one's usual conscious sets and belief systems' the theory refers to as interfering stimuli. Differences Relative Importance of Hypnotic Inductions One major difference between the theory's perspective and the sociocognitive one revolves around the perceived importance of hypnotic inductions. 1965). it is felt. et al. 1969.. This is very similar to what is said following Hypothesis VII of the theory (in the section on posthypnotic suggestion) about how the inhibitory set aspect of hypnosis facilitates cognitive-cognitive conditioning and thereby facilitates positive behavioral change by eliminating any stimuli present that would interfere with the conditioning: 'Hypnosis. In fact. Rossi and Rossi.' . following Hypothesis III of the theory. some people can respond to suggestions without a hypnotic induction at the same level as another person who has gone through a hypnotic induction. see Barrios. Kirsh. 2001: 183 and 184). Barber. hypnotic responses were not particularly unusual. Wickless and Moffit. is capable of increasing suggestibility only to a minor degree. According to Lynn and Sherman. 1974) in demonstrating the importance of individual differenced in hypnotic responding showed that non-hypnotized subjects exhibited increments in responsiveness to suggestions that were as large as the increments produced by hypnotic procedures. but as indicated by Corollaries 5 and 6. But if we go on an intra-individual basis. Accordingly. as pointed out on pages 183 and 184 of the theory (see Weitzenhoffer. 1967. 2000: 298) There is some truth to this last statement. it may be true that the standard hypnotic induction emphasizing relaxation used in many of Barber's studies. 1999 and Wickramasekera. 1953. 1999. and Wickramasekera. State vs Non-state Another significant difference between the sociocognitive and the theory's perspective revolves around the state vs non-state issue. i. and Barber and Calverley. Barber and Calverley. This would be true especially amongst those subjects who were highly suggestible even without a hypnotic induction. 2001: 171) produced by the hypnotic induction. comparing the same . 1969. 1964.e. If it is true that certain hypnotic inductions can produce significantly higher levels of suggestibility (even in already highly suggestible individuals). A hypnotic state could be defined simply as the heightened state of suggestibility (or as Skinner would put it. because researchers like Barber and his colleagues (Barber. 1989. by following such recommendations as those presented by corollaries 5 and 6 following Hypothesis III of the theory.A New Theory for Understanding and Appreciating the Power of Hypnosis 13 The problem with this perspective is that it implies that all hypnotic inductions are able to increase suggestibility only to a minor degree. Spanos and Chavez. and thus it is implied that hypnotic inductions are really not that necessary. i. there is no need for clinicians to insure that their patients are in a 'trance' before meaningful therapeutic suggestions are provided. 1963. Kirsch et al. 1965 as cited in Barrios. 1967. Yes. it is true that on an inter-individual basis. and therefore did not require the positing of unusual states of consciousness. a heightened state of belief. In this sense there is no difference between states. Dorcus. (Lynn and Sherman. Yes. However. motivation and fears. 1969. comparing one individual to another individual. This research supported the idea that despite external appearances.e. there are ways of increasing the effectiveness of hypnotic inductions even more (see: Wilson. 1993). then I feel we can talk in terms of a hypnotic and nonhypnotic state. Wickless and Kirsch. Wickless and Kirsch.. 1989. the effectiveness of hypnotic inductions can be increased considerably more and responsiveness to suggestion (and therapeutic success) as a result raised significantly more than after a standard hypnotic induction (see: Wilson. And even those who might not initially be highly suggestible could have their initial responsiveness to suggestion increased by manipulating certain individual difference factors such as attitude. for instance. 1973). Some meaningful therapeutic changes can be produced with suggestions even without a formal hypnotic induction for some individuals. Many in the field. sensory stimuli are also included along with cognitive stimuli in this stimulus dominance hierarchy. especially after an effective hypnotic induction. The other possible way of determining dominant position. A hierarchy of subsystems is implied. although it is a shifting hierarchy under the management of the central mechanism. as per the theory. the hypnotic state for a given individual can be different than the waking state. 1997b: 213). One. this correlation will be less and it will become more appropriate to use the difference between hypnotic and waking suggestibility as the more correct measure of hypnotizability or hypnotic depth as I prefer to refer to it (See also section below on preventing methodological shortcomings in hypnosis experiments taken from Barrios. As he puts it. This is very similar to the stimulus dominance hierarchy referred to in the theory except. seem to feel that a measure of suggestibility after the hypnotic induction is more than sufficient to measure hypnotizability. is where the subsystems would fight for control of the final common path leading to action according to their relative strengths.14 Alfred Barrios individual before and after a hypnotic induction. the subsystems are actuated according to the demands and plans of the central system. 1977: 217-18) . Just one more thing: I would not recommend using the term 'trance' to designate a hypnotic state as it has 'zombie-like' connotations and we know a person can be in a hypersuggestible hypnotic state and still appear perfectly normal. However. which tends to increase suggestibility 'only to a minor degree'. In discussing ways that determine what actions a person will take at any one time. is by way of a central regulatory mechanism. Hilgard proposes two possible means for determining which subsystem will be in the dominant position of the hierarchy determining which action will take place. 1973a) A Comparison of the Theory with Hilgard's Neo-dissociation Theory There are a number of similarities as well as a number of key differences between the theory and Hilgard's neo-dissociation theory of hypnosis. and the way he seems to have finally leaned towards. Hilgard talks about a hierarchy of subsystems (habits or cognitive structures) that would vie for dominant position to determine the final common path leading to action. This central regulatory mechanism is responsible for the facilitations and inhibitions that are required to actuate the subsystem selectively. The Best Way to Measure Hypnotizability Also related to the question of whether there is that much difference between waking and hypnotic suggestion is the question of how best to measure hypnotizability. (Hilgard. They feel they need not use the difference between hypnotic and waking suggestion as the measure since they find the correlation between the two to be very high (see especially Kirsch. which he considers the old way. As more effective hypnotic inductions are used. Once a subsystem has been activated it continues with a measure of autonomy. especially those from the sociocognitive perspective. this high correlation could be due to the fact that the researchers are basing their results on studies where only the standard hypnotic induction has been used. . He posits two ways that hypnosis facilitates this rearrangement of the hierarchy (Hilgard.. As presented in the paper 'Science in support of religion' (Barrios. This free will factor can have developed over the years or in a short period of time by means of a series of reinforced self-suggestion much like a self-hypnotic induction where the subjects come to develop their power of controlling their involuntary behavior through the power of belief. Kirsch and Lynn (1998: 110) feel that Hilgard 'leaves many unanswered questions: How do the hypnotist's words produce this rearrangement? . Hence imagination more readily becomes hallucination . the theory leaned more to the old way of looking at how the subsystems arranged themselves in the hierarchy according to their individual strengths. I feel he does present at least a partial explanation or answer to these questions. it would work in favor of a deeper induction. everyone has a different level of willpower or free will that they bring with them. But now I also see the possibility of a central function playing a part in certain situations. or if the induction is presented along the lines of self-hypnosis. and how does this contribute to the production of suggested responses?' In fairness to Hilgard. free will is defined as control over one's involuntary functions (one's subconscious) via the power of belief.e. it would work against a deeper induction. we find that hypnotic procedures are designed to produce a readiness for dissaociative experiences by obstructing the ordinary continuities of memories and by distorting or concealing reality orientations through the power that words exert by direct suggestion.A New Theory for Understanding and Appreciating the Power of Hypnosis 15 He then states 'Suggestions from the hypnotist may influence the executive functions themselves and change the hierarchical arrangement of the subsystem' (p.e. These illustrations show how memory interference has .. It would more likely work in favor of a deeper induction if in the pre-induction talk the subject is assured that all suggestions given will be positive ones or to the benefit of the subject.. 226) And (2) 'The stress on muscular relaxation. 218). through selective attention and inattention. criticism also recedes. According to the original version (Barrios. The lack of appropriately aroused memories makes the hypnotically responsive person less critical.. 1969). 2002). as a means of developing even greater self control over one's involuntary behaviour.. If against their benefit. In a hypnotic induction this free will factor could either add to the depth of hypnosis achieved (the amount of heightened belief) or work against it. This central control function I would describe as the will of the hypnotic subject. 1977): (I) 'Looked at in other ways. and the inhibitory set part of the hypnotic suggestion was seen as directly influencing the eventual positioning of the dominant subsystem by inhibiting the competing subsystems. Now with regards to how according to Hilgard. which can be listed as another of the individual differences of hypnotic subjects which can influence a hypnotic induction. and through stimulating the imagination appropriately' (p. i. i. familiar in hypnotic inductions assists in disorientation . does the hypnotic induction rearrange the hierarchy of subsystems. belief in one's ability to control one's destiny (control one's involuntary functions). If the individuals see the suggestions given as working to their benefit. To be critical requires comparing a present observation with familiar ones to judge its veridicality. If the memory context recedes. . The advantage of subconscious behavior is that it allows us to do many things at once. response to stimulation provided by the hypnotist takes precedence over planned or self-initiated action [the central regulatory mechanism] and the voice of the hypnotist becomes unusually persuasive'. i.16 Alfred Barrios helped produce the dissociations found in hypnosis . The ‘subconscious’ is to be differentiated from the ‘unconscious’ which can be defined as engrams or memories below immediate conscious accessibility.7) It is the latter fact. that certain automatic behaviors are so hard to change. or conditioning in. (p. but he does not explain why or how the hypnotist's words have become even more powerful after a hypnotic induction . And the more . the behavior is so automatic that it becomes difficult to change. or subconscious behavior.. It appears that all current theories concur with this apparent fact.e. which the theory does. Hypnosis provides us a systematic means of controlling the subconscious. The main disadvantage is that once programmed in. With regards to the part suggestions of relaxation play in producing the state of hypnosis. Hilgard does talk about selective attention and inattention (both of which have inhibitory components) and stimulating the imagination appropriately (i. When first learning to drive.” (Barrios. the theory makes clear that a hypnotic state can be produced without any suggestions of relaxation or sleep. Most adult human behavior falls under the heading of subconscious behavior. 2001: 172). if any (i. it is pointed out in the theory that suggestions of relaxation or sleep may help since the relaxed or sleep-like state 'may provide for even greater inhibition of stimuli competing with the suggestion' (Barrios. However. can be defined as behavior (learned or innate) that is so deeply programmed as to occur automatically without the need for that much conscious attention.which the theory explains as the build-up of. The theory states that the suggested response occurs because the stimulus focused on by the suggestion rises to the dominant position in the hierarchy because the inhibitory set produced by the hypnotic induction inhibits the competing cognitive stimuli in the hierarchy (what Hilgard refers to as 'critical memories') as well as any present 'critical' sensory stimuli . Now all the movements have pretty much become automatic. that makes hypnosis such a valuable tool. you had to be aware of (be conscious of) every little movement. and relatively quickly. triggering a cognitive stimulus) as part of the power that words exert through direct suggestion. is how this inhibitory set referred to is built up during the hypnotic induction through a process of conditioning. Hilgard is saying the same thing that the theory is saying as to how and why hypnotic phenomena occur. Driving a car is an example of learned subconscious behavior. It has to do with the automaticity of most behavior. of a strong inhibitory set. Involuntary Behavior and the Subconscious There is one more thing that I would like to point out regarding similarities and differences between my perspective and Hilgard’s (and the sociocognitive & response set perspectives as well).e. 227) In somewhat different wording. Something else that Hilgard does not include. 2002. One difference is that I have gone on to label this behavior as subconscious behavior or “the subconscious”: “The subconscious. p.something Hilgard does not include in his explanation.e. below conscious awareness). Under such circumstances. of being able to rearrange the hierarchies of automatic behavior. The biggest problem with most people is that it is very hard for them to change.e. has a relatively small effect on the degree to which people respond to typical hypnotic suggestion' (Kirsch. The other way the therapist can help is by providing the patients with some good guidance. although this statement might be true for the standard relaxation-type induction. Kirsch seems to feel that the key to increasing hypnotic responding is by increasing the subject's response expectancy (see Kirsch 2000: 275). this is when an effective hypnotic induction can be especially beneficial. it is not for other more effective types of hypnotic induction (see: Wilson. As already pointed out. In the original theory I do refer more to 'suggestibility' as to what is being manipulated by a hypnotic induction. a major difference between the two is that Kirsch believes. However. Wickless and Kirsch. 1967. a good idea of what habits and cognitions need to be changed. I said humans have the potential for re-programming but this potential has to be brought out and it is with tools like hypnosis and self-hypnosis that this can be done. and Wickramasekera. Kirsch prefers to use the latter to describe what is being manipulated by a hypnotic induction whereas I would prefer to use the term 'belief'. So anything that can facilitate change or re-programming will play a major role in achieving therapeutic success. 1985.. The second major difference (and similarity) between the two revolves around his use of the term 'response expectancy'. 1997a. with some people possibly relating it to the term 'gullibility'. the higher in the hierarchy it is). 1999. 2000). for example. however. 1973). Now sometimes the latter is all that is needed and together with a sufficient level of free will to begin with the patients can then bring about the needed restructuring of the hierarchy on their own even without a hypnotic induction. 1989. I would be more inclined to agree with Kirsch if he were to use the term 'belief' in place of 'response expectancy'. It is this ability of hypnosis to facilitate post-hypnotic behavior change that plays the biggest part in making hypnotherapy so much more effective than any other form of therapy. 2000: 276). It should be realized that when hypnosis is used in a therapeutic setting there are two ways that a hypnotherapist can help: One is to help add to the suggestibility (belief) factor sufficiently with an effective hypnotic induction in order to transcend or overcome certain negative automatic habits or cognitions that the patients with their own level of free will have been unable to accomplish. as do most sociocognitivists.A New Theory for Understanding and Appreciating the Power of Hypnosis 17 deeply imbedded this automatic behavior that we wish to change is (i. Kirsch et a1. The following will present both the similarities and the differences. First. the more effective a hypnotic induction is needed. In a way one can say that all humans are automotons because most of their behavior is automatic. . I have come to see the term 'suggestibility' as having some negative connotations. But one major difference between humans and robots is that humans have the potential (through the free will factor) to reprogram themselves when necessary. that 'The induction of hypnosis. As Kirsch puts it: 'A path analysis supported the hypothesis that hypnotic inductions enhance responsiveness by altering response expectancies' (1985: 1195). A Comparison with the Response Set and Response Expectancy Theory of Hypnosis There are a number of similarities and differences between the theory and the response expectancy perspective (Kirsch. Keep in mind. But if the negative behavior is too high in the hierarchy for the patients’ own level of free will (own willpower) to rearrange it. but it seems to exemplify a heightened 'belief' in the present sense (Skinner. As he puts it. Yes. But where is the visible response when the response expectancy is that the subject will see the color red? Not all cognitions necessarily have a clearly visible response attached to them. our tendency to act upon the verbal stimuli which he provides. the behavior of the listener is also a function of what is called belief (a term very similar to suggestibility) . According to Kirsch: There are three kinds of cognitions that ought to affect response expectancies in hypnotic situations: (a) perceptions of the situation as more or less appropriate for the occurrence of .. Barrios 2001). 1957..18 Alfred Barrios Consequently I now prefer to follow Skinner's lead of using the term 'belief' in describing hypnosis.. 280). our belief will be strong . The main difference between mine and Kirsch's explanation for how belief/response expectancy leads to responses is that first of all I explain how there is a response connected to the suggestion (as a result of classical conditioning . behavior and physiology. then a change in perception is always a change in physiology.see the Pavlov quote on page 167 of the theory. So the real problem is to understand the effects of response expectancy on experience. For that reason. or identical with. so too the expectation of an overt automatic response promotes its occurrence' (p. Various devices used professionally to increase belief of a listener (for example by salesmen or therapists) can be analyzed in these terms. Kirsch himself poses the question thusly: 'To accept a suggestion is to believe or expect that these events will in fact happen. Later a strong reaction is obtained to statements which would otherwise have led to little or no response. (See Barrios. (Note how Kirsch uses the terms 'believe' and 'expect' interchangeably here which would lead one to believe that he might also be willing to use 'belief' and 'expectancy' interchangeably. expectancy induced changes in experience will always be accompanied by at least some physiological change' (Kirsch. The therapist may begin with a number of statements which are so obviously true that the listener's behavior is strongly reinforced. pp. as well. you can get someone to produce the visible response of 'arm rising' if he has a strong response expectancy of 'arm rising'.) Kirsch's answer to this question is to posit some underlying substrate or connection between actual responses and the expectancy of that response. Hypnosis is not at the moment very well understood. 159-160). 'Just as the expectation of an experiential response tends to generate that response. our belief in what someone tells us is similarly a function of. 'if we assume that there is a physiological substrate for any experiential state. Next comes the question of how response expectancy or belief produces responses. A third major difference between our perspectives is how we explain how response expectancy/belief can be increased in hypnotic situations. I explain the heightened response to hypnotic suggestion as resulting because of the greater inhibitory set produced by the hypnotic induction which inhibits competing stimuli.. And. and second. If we have always been successful when responding with respect to his verbal behavior. As Skinner put it: With respect to a particular speaker. 2001: 171) Now getting back to 'response expectancy' and why I prefer the term 'belief': one problem with the former term is that it implies that there is a visible response connected to the expectancy. How does response expectancy produce these changes?' (Kirsch 2000: 279). 2000: 280). then as subjects feel themselves responding. how both the theory and the Sociocognitive theories seem to fit in with Milton Erickson's strategic approach to therapy. What he describes as one way of manipulating judgments of hypnotizability by surreptitiously provided experiential feedback simply as 'an expectancy modification procedure' (Wickless and Kirsch. And Hypothesis III states 'A positive response to a suggestion will induce within the responding person a more or less generalized increase in the normally existent tendency to respond to succeeding suggestions.. (Kirsch.' It is interesting that Kirsch states that: 'According to response expectancy theory.A New Theory for Understanding and Appreciating the Power of Hypnosis 19 hypnotic responses. Now if he would also say that the number of suggestions to which subjects are able to respond successfully is in turn a determinant of people's belief about their hypnotic ability. 1959). With regards to how Kirsch describes methods of affecting response expectancies by manipulating 'judgments of one's hypnotizability'. 1989: 762). 1989: 762). 2001: 181-3). Among the similarities between the theory and the Sociocognitive and Response Expectancy theories is the emphasis on the importance of the part played by individual differences in affecting initial responsiveness to suggestion. hypnotic induction is defined as the giving of two or more suggestions in succession so that a positive response to one increases the probability of responding to the next one. 182). people's beliefs about their hypnotic ability are one of the determinants of the number of suggestions to which they are able to respond successfully' (Wickless and Kirsch. following Hypothesis III of the theory. This response can. and (c) judgments of one's hypnotizability. These are covered in the theory under the heading of 'Subjects' expectation' in the section on 'Individual differences factors influencing hypnotic induction' (see Barrios. As indicated on page 171 of the theory. subjects are more likely to ascribe correctly the occurrence of the 'strange' phenomena to the hypnotist than to some external cause' (p. which states that surreptitiously provided feedback would facilitate a hypnotic induction (p. The main difference between the theory and the Sociocognitive and Response Expectancy theories is that the latter two perspectives seem to imply that all hypnotic inductions can . he would be coming very close to saying what is said in Hypothesis III of the theory.. It is pointed out that (a) as a result of the expectancy of being hypnotized. 180). Summary of the above Similarities and Differences There were a number of similarities and differences presented between the theory and three current theoretical perspectives. as can any positive responses to previous suggestions' (p. (b) perceptions of the response as being appropriate to the role of a hypnotized subject . The main similarity between the theory and Hilgard's theory is the use of a stimulus dominance hierarchy concept to explain what actions a person will take at anyone time and how hypnotic induction influences a rearrangement of the hierarchy. I would directly refer to as an actual hypnotic induction according to Corollary 6. For example if the subjects are told that a catalepsy of the dominant hand occurs when they experience hypnosis (Orne. in turn influence the hypnotic induction. they are also indirectly being given the suggestion of catalepsy of the dominant hand. 183). and how similar the theory is to the Response Expectancy theory if one can look upon the term 'response expectancy' as equivalent to the term 'belief'. I differ significantly with Kirsch. 1985: 1194) As for his first two ways (a and b) I agree. and (b) 'Subjects' expectations of what hypnosis is like can influence hypnotic induction in other ways. as opposed to these other two perspectives. The results supported the three predictions made from the hypothesis: (a) The hypnosis group (N=43) showed greater conditioning (p<. which I did not become aware of until after I had submitted my dissertation. and (3) studies on sensory deprivation. 1969) revealed substantially higher scores among these subjects than among controls' (Wickless and Kirsch. (Barrios. once formed. This included the experiment done by the author to support Hypothesis VII of the theory – that hypnosis facilitates the higher-order conditioning produced via post-hypnotic suggestion (the explanation provided by the theory for how posthypnotic suggestion works). along with each of the first few suggestions given in a hypnotic induction. 'After suggesting that subjects imagine the color red. 1973a) Further Support for the Theory Further support for the theory since its original writing (Barrios.20 Alfred Barrios increase suggestibility only to a minor degree whereas the theory predicts that there are ways of increasing the effectiveness of hypnotic induction beyond just a 'minor degree'. once again. the actual sensory stimuli which would ordinarily evoke these suggested responses accompany the suggestions without the subject's knowledge. (1999) found that.' There are at least three studies whose results support this corollary. 1967).7% of the control group. Wilson imparted a faint red tinge to the room via a hidden light bulb. as evidence by little extinction and the phenomenon of spontaneous recovery. was a strong one. 1969). And related to this. concludes that there can be such a thing as a 'hypnotic state' which is significantly different from the 'waking state'. They found that 53% of the group that had been given surreptitiously provided experiential feedback scored as highly hypnotizable as compared to only 6. Subtle Reinforcement Studies Corollary 6 following Hypothesis III of the theory states: 'An hypnotic state can be facilitated if. 1969) comes from at least three areas: (1) studies on the use of subtle sensory reinforcement. for example.01).D dissertation submitted in 1967 (Wilson.that for this to occur it was important that the subjects not be aware of the artificial source of the reinforcement (as stated in Corollary 6). (2) the area of biofeedback. the theory. surreptitiously provided experiential feedback significantly increased responsiveness to suggestion.01) than the control group (N=42). Wilson had subjects experience surreptitiously provided reinforcement of suggestions. . and (c) this conditioned response. Subsequent testing of waking suggestibility on the Barber Suggestibility Scale (Barber. Support for the Theory Numerous studies and experiments in support of the theory were presented in the original publication of the theory (Barrios. A subsequent study by Wickless and Kirsch (1989) essentially confirmed Wilson's findings. (b) the amount of conditioning for the hypnotic group was correlated with hypnotic depth (p<. In a follow-up study Kirsch et al. The first was part of a Ph. And this time an additional important fact was determined . 1989: 762). Suggestions (or goals) of relaxation. per se. As I see it. 2001: 17). sans relaxation suggestions.g. One way to truly test the hypothesis that the use of biofeedback devices. a hypnotic induction 'is defined as the giving of two or more suggestions in succession so that a positive response to one increases the probability of responding to the next one' (Barrios. Remember. for example. one caveat to this study. slowing the heart rate down or raising fingertip temperature. one could use a temperature biofeedback device with suggestions of coldness in the hands (e. In fact a complete hypnotic induction procedure starting with suggestions of movements of the pendulum has been devised (see pendulum technique in Barrios. There is. subjects being treated with biofeedback are being put through a form of hypnotic induction as defined by the theory. the basic principle behind biofeedback has been used to facilitate hypnotic induction long before that if we can look upon the Chevreul Pendulum as a hypnotic aid device. the reason biofeedback has proven to be so effective for gaining control of involuntary physiological responses is that in actuality. produce initial minute relaxation responses which are immediately amplified by the device and thus made more visible to the subject. There has been at least one study where the use of autonomic biofeedback did lead to an increase in suggestibility. One does not know whether it was the deepened state of relaxation or the use of biofeedback. 'as if you were placing your hand in cold or ice water') to cause the device to indicate a drop in hand temperature. heart rate. One could also use a heart rate biofeedback device to feed back heart rate . A typical procedure might involve having the subject focus on thoughts of relaxation and being given the goal of causing the movement of the biofeedback measure in the appropriate direction. Many in the hypnosis field recommend use of the Chevreul Pendulum as a 'warm up' procedure to get subjects in a more receptive mood for hypnosis (e. the typical responses have been relaxation-related such as Galvanic Skin Response (GSR). can increase suggestibility is to not use relaxation suggestions. The resultant heightened belief should in turn allow the subjects to respond even more strongly to succeeding suggestions of relaxation.g. whether instigated by the biofeedback operator or by the subjects themselves. Biofeedback Studies Biofeedback can be defined as the use of special devices to amplify automatic responses for the purpose of gaining greater control of these responses.001) in suggestibility upon using EMG biofeedback to reinforce suggestions of relaxation. or a combination of the two that increased suggestibility. see Lynn and Sherman. These act as an immediate reinforcement letting the subjects know that they have responded positively to the suggestions of relaxation. What the pendulum does is amplify minute ideomotor movements of the hand when the thought of a particular movement is suggested. Electromyography (EMG) and fingertip temperature. For the most part. however. 1985: 36-8). 2000: 202). Wickramasekera (1973) using forms A and B of the Stanford Hypnotic Susceptibility Scale found a significant increase (p = 0. the Chevreul Pendulum is in actuality a biofeedback device. For instance. Although the widespread use of biofeedback devices has been around only since about the 1970s. although biofeedback need not be limited to just relaxation responses.A New Theory for Understanding and Appreciating the Power of Hypnosis 21 Those subjects that were allowed to detect that the reinforcement was artificial showed no increase in responsiveness. for if you stop to think about it. or. the demand characteristics of an experiment may be particularly pronounced in hypnotic experiments because Ss recognize that they are expected to do better in hypnosis and. Also using SHSS forms A and B. whereas controls were not. 1970) achieved similar results. but. . The standard procedure for recruiting college Ss was followed. In experiments where hypnotic Ss have been used as their own controls it is usually obvious to these Ss which is the control state. sensing that this is what E expects of them. and Ss were randomly assigned to one of the two groups. 3. This problem was specifically addressed in the above-mentioned study on testing Hypothesis VII of the theory (Barrios. each S acted as his own control. (This is especially true of the clinical studies. and not the high initial level of suggestibility of the experimental Ss. without inducing hypnosis might not have· achieved the same results. In such studies one could not be sure that presenting the suggestion. Sensory Deprivation Studies Corollary 9 following Hypothesis V of the theory states that 'suggestibility should be increased if sensory stimulation is curtailed'. these Ss could ensure a worse performance in the control state.) In the present study not only was there a non-hypnosis group. in addition. According to Orne (1959). (Shortcomings 1-4 will be familiar to most readers as those expounded upon recently by Barber [1969b] and Barber and Calverley [1966a]. the experimental Ss were usually pre-selected for their high hypnotic susceptibility. When control Ss were used.22 Alfred Barrios increase in response to suggestions of heart rate increase ('as if you were in an athletic competition').) 1. that produced the difference in effect. It should be mentioned that still another often referred to shortcoming was eliminated by the design . In many cases there was no comparison with a non-hypnotic control group. Further support of this corollary was provided by a number of different studies: Sanders and Rehyer (1969) using the Stanford Hypnotic Susceptibility Scale (SHSS) forms A and B and working with ten subjects initially resistant to hypnosis and an equivalent control group found sensory deprivation did significantly increase enhancement of hypnotic susceptibility. thus. 1969) and very possibly afterwards as well lies in their methodological shortcomings. the controls were sometimes selected for their poor hypnotic susceptibility. As Barber (1962) points out. directly or indirectly. This point was also brought out in the study by Scharf and Zamansky (1963). Wickramasekera in two separate studies (1969. PREVENTING METHODOLOGICAL SHORTCOMINGS IN HYPNOSIS EXPERIMENTS The main problem in many hypnosis experiments prior to the publication of the theory (Barrios.there was no more time or special attention spent on the hypnotic Ss than on control Ss. 2. In such cases one could not be sure that it was the actual hypnotic induction. we might also anticipate they are more likely to do poorer during the control phase . 1973a): Several such shortcomings are reviewed below with reference to the way in ' which the present study attempts to eliminate them. In the present study there was no pre-selection of Ss for hypnotic susceptibility. even worse. As can be seen by the results. and a considerable number of studies indicate that responsiveness can be increased with improved methods of hypnotic induction (Barber. 1967).g. 1969. 5. Klinger. both subject to questioning. For example. This shortcoming was taken care of in the current experiment by the extensive use of tapes. of the shortcomings is that the usual indicants of hypnosis are misleading. for many have mistakenly interpreted Barber as implying that hypnosis is not as effective as had previously been thought. . The use of such an antecedent indicant is quite acceptable as long as E makes it clear that any conclusions regarding hypnosis refer only to this narrow. Most of the responses used as the dependent variable in PHS experiments are highly subject to voluntary control. Such use of voluntary responses are more apt to lead to the criticism that S was faking . and before they even knew hypnosis was to be involved. Recent studies (e. In the current experiment the own-control" session was run first for all Ss. First. a response that is considerably less subject to voluntary control than most responses previously used in PHS experiments. In the current experiment use was made of the salivary response. 1959. 1968. E has not usually controlled for difference in tone of voice or other subconscious differences in treatment of the groups. Dorcus. rather than any specific suggestion. Barber. Controls have usually not been run for the effect of the hypnotic state. thus possibly biasing the results in favor of his hypothesis. (a) The basic problem with the antecedent indicant is that it usually leads one to the incorrect conclusion that the results of the experiment hold for hypnosis in general. 7. If the salivary responses obtained were due solely to the effects of having been hypnotized. 1963. This shortcoming was taken care of in the design by means of a neutral stimulus. operationally-defined band on the hypnosis continuum. when actually they hold only for the particular hypnotic induction used. Wilson. heretofore accepted as fact. 1969a. there is the assumption that hypnotic responsiveness is a fixed charactertrait..just performing the response to please the hypnotist. In experiments where controls have been used.A New Theory for Understanding and Appreciating the Power of Hypnosis 23 (see also Barber. Baykushev. Perhaps the most prevalent. 1964) seem to indicate that such an assumption is not justified. 1967. Underlying such overgeneralizations are two basic assumptions. Sachs & Anderson. This includes both (a) the "antecedent" type of indicant where E assumes that hypnosis has been induced because Ss have been put through a standard hypnotic induction. and (b) the "consequent" type of indicant where E concludes that hypnosis has been induced because of S's responsiveness to a set of test suggestions given after S is hypnotized. Pascal & Salzberg. 6. we should find no difference between the response to the conditioned stimulus and the response to the neutral stimulus. Apparently this has not been done sufficiently. That differences in tone of voice can have an effect was shown in a study by Barber and Calverley (1964). 4. 1969b). many people seem to commit this error with regard to many of Barber's (1969b) experiments where he appears to operationally define hypnosis as a “standard 15 minute induction. as well as the most insidious." and where he concludes that task motivating instructions (TMI) can produce hypnotic phenomena as effectively as a hypnotic induction. Some might feel that the posthypnotic changes can be produced by just the state itself. per se. In most hypnosis experiments this may very well be the case since the "own-control" session is run after the hypnosis session. this was not the case. hypersuggestible state produced by the inhibitory aspects of the hallucinogens in the same way as the hypersuggestible state of hypnosis is produced by the inhibitory set aspect of hypnosis." (b) The trouble with the consequent type of indicant is that it is merely a measure of responsiveness. 1969). a hypnotic induction could be ineffective and we could still get a high T2 score if Ss were high responders to begin with. These effects are seen as resulting from the hyper-responsive. Thus. drowsiness. and sleep (after S has been properly motivated and a positive attitude and expectancy toward hypnosis established). it is incumbent upon any E "testing the effectiveness of hypnosis" that he make it very clear that his experiment is merely testing the effectiveness of a particular hypnotic induction procedure and not hypnosis in general. A truer indicant of how effective a hypnotic induction is (and the one used in the present study) would be the difference in response to test suggestions given both after and before S is hypnotized (T2 .24 Alfred Barrios Thus. not increase in responsiveness. The second assumption open to questioning is that hypnotic induction primarily involves the giving of suggestions of relaxation. If uncontrolled. when Barber states that his TMI are just as effective as hypnotic induction. the relative effectiveness of two forms of hypnotic induction. The same principles of inhibition and conditioning used to explain the behavioral and therapeutic effect of hypnosis presented in the hypnosis theory including the Stimulus Dominance Hierarchy concept were used to explain the behavioral and therapeutic effects of the hallucinogens. One important point that needs to be made is that for one to achieve therapeutic effects from use of the hallucinogens’ hypersuggestible state. it is most productive if it is a controlled state. Barber's TMI followed by his test suggestions in ascending order of difficulty would also classify as a hypnotic induction. Using T2 alone as the indicant can be misleading in a number of ways. Conversely.Tl). Thus. a hypnotic induction could be effective but not show up as such if Ss were very low responders to begin with. According to the definition of hypnotic induction (discussed later in the paper) given in the theory proposed by the author (Barrios. the hypersuggestible. It can lead to uncalled for hallucinations and delusions which to someone not fully understanding what is going on. It is felt that the many cases of psychotic breakdowns reported as resulting from unsupervised ingestion of hallucinogenic drugs could very well have been due to this uncontrolled state of hypersuggestibility with resultant frightening hallucinations and . one should realize that he is merely comparing. hyper-responsive state can lead to a number of problems. it is also incumbent on E to let the reader know how he defines hypnosis and that results refer primarily to this definition and not "hypnosis in general. BENEFITS OF THE THEORY Explaining the Effects of Hallucinogens One of the benefits of the theory is that it led to my theory on the hallucinogens (Barrios. not in control. this is just one form of hypnotic induction. 1965). In the controlled state positive suggestions can be properly directed at whatever positive therapeutic changes are needed. For example. can become quite frightening. ) One of the most phenomenal hypnotherapy cases I have worked on was that of a paranoid schizophrenic whom I cured in one three-hour session by making use of the hypnotic state of heightened belief to reverse the negative thinking. The woman had been suffering from paranoid schizophrenia for the past three years and she was getting worse. Her subsequent life experience only served to add to this low self-image. was brought to me by her sister out of desperation. i. she had stopped taking the drugs. the latter being possibly the main reason for the psychotic state continuing long after the drug effects wore off. When I saw her. (Could this possibility be because some individuals have a higher concentration of hallucinogenic-type chemicals in their bloodstream than others? If so. the negative beliefs underlying her paranoia: “Maria. incidentally. cure the psychosis? Could it be used to reverse the belief that the psychotic symptoms would be permanent? We know hypnosis could be used to remove the causes of any precipitating high stress. She had been a heroin addict for a good part of her life and had resorted to prostitution as well as dealing in . a woman in her late thirties. Coming from a minority background. such as schizophrenia..A New Theory for Understanding and Appreciating the Power of Hypnosis 25 delusions and the (heightened) belief that they would be permanently occurring.) Is it possible that a state of high stress or anxiety or certain negative thinking could cause this suggestibility to get out of control? And if uncontrolled heightened suggestibility does play a part leading to psychoses. Her primary symptom was the delusion that people were ‘out to get her’. One question that would need to be answered here of course is what could have led to this state of uncontrolled hypersuggestibility. (See the above mentioned studies by Abrams. There are some interesting possibilities here. and little had been done about getting rid of the root cause of her problem. She had also recently shown signs of being homicidal .in a total of only three sessions. As with many psychotics. even though not cured. I could see why she might have thought this. Judging from her background. could a form of controlled hypersuggestibility (such as hypnosis) be used to somehow reverse the psychosis. in the first place? We know that a certain percentage of the population is highly suggestible to begin with. An Explanation and Possible Cure for Schizophrenia One may wonder if something very similar to this frightening state of uncontrolled hypersuggestibility isn’t at the bottom of non-drug induced psychotic-breakdowns. Maria had been put on a drug treatment program and sent home. without approval. anxiety or negative thinking. 1967 on the successful use of hypnosis in the treatment of psychoses. The all important belief or prestige factor was thus quite high from the beginning. One advantage I had was the fact that I had cured her 27-year-old nephew of heroin addiction . The first half of the three-hour session was devoted to getting some idea of the root causes of her problem. The drugs had only served to mask the symptoms. she had been conditioned to think of herself as inferior from an early age. 1963 & 1964 and Biddle. this would fit in with the idea that schizophrenia is caused by a “chemical imbalance”.e.having so scared her husband with very real threats on his life that he moved out. hyper-responsiveness. It wasn't too long before I saw that she had deep-seated feelings of inferiority and as a result she felt that no one could possibly love her. in a fit of temper. the words had gone in one ear and out the other. It usually takes months. cognitive stimuli can be amplified to cause psychotic delusions and hallucinations.26 Alfred Barrios heroin to support her habit. I pointed out all her good points and assured her that her family. She had gotten back with her husband and was happily looking forward to a trip to San Francisco with him. Once she was in this state. one day threw all this in her face. I was able to convince her that she was indeed capable of being loved. why not the possibility of manic and depressive thoughts or behavior also being magnified in a similar uncontrolled hyper-responsive state leading to a state of hypermania or hyper-depression? And if so. and especially her husband. the reason biofeedback has proven to be so effective for gaining control of involuntary behavior is that in actuality subjects being put through a biofeedback procedure are being put through a form of hypnotic induction. pp. So to say that I cured such a case in one session is almost like someone claiming to have cured a case of cancer by "laying on of the hands". etc. that all such problems can be cleared up in just one SPC session. But still. I was now more able to get through. Six months later when I called to see how she was doing. her sister informed me that she continued to be fine and free of symptoms. even years and many are never cured. then one can see the possible use of hypnosis to also helping one regain control and toning down or reversing these hyper states as well as getting rid of any underlying negative states of mind adding to the problem. so she was an ex-con as well. The breakdown had been triggered by a younger sister who. Within a week every one of her symptoms – hallucinations. Explaining the Effectiveness of Biofeedback As pointed out in Part I. 23 & 24) A Possible Explanation and Cure for Bipolar Disorder Could it be that an explanation for bipolar disorder (once referred to as manic – depressive disorder) lies along similar lines? If in a state of hypersuggestibility. hyperresponsiveness. did love her. delusions. but which I prefer to think of as a state of increased responsiveness to words. . How did I cure her in just one session? Using the Pendulum technique (p.were gone. The most amazing thing about this case was that I had been able to cure this woman of paranoid schizophrenia in just one three hour session. but to no avail. But in this state of increased responsiveness to words. of course. Such a feat is considered so extraordinary that I hesitated mentioning it lest I be labeled a charlatan by my fellow professionals . The latter had resulted in her spending five years in prison. Others before me had tried to convince her of this. .for paranoid schizophrenia is a most difficult mental illness to cure.” (Barrios. This is not to say. it should take a lot less time and be more effective than if a standard approach were taken. 36) I put her into a state some people refer to as hypnosis. I have included it because I want the reader to see the real potential of an approach that allows the power of the word to really get through. 1985. another incompatible response must become conditioned to the CS..A New Theory for Understanding and Appreciating the Power of Hypnosis 27 Helping Towards a More Comprehensive Theory of Learning We know that dramatic.. 'Understandably. we would have to establish that. One-trial conditioning and functional autonomy are not commonly encountered in the laboratory' (Barrios. it is felt. 2001: 195) . And this inhibitory set can be so efficient as to have the conditioning take place in only one trial. Regarding the functionally autonomous nature of the posthypnotic response: It is felt that the functionally autonomous nature of the post-hypnotic conditioned response can best be explained if an interference theory explanation of extinction is assumed. it can keep itself from being extinguished. Hypnosis. (Barrios.. 1960: 141-2. This leads to the part played by hypnosis in the facilitation of conditioning. 2001: 196). as stated in Hypothesis VI of the theory: 'Suggestion leads to behavior change by a form of higher-order conditioning called C-C conditioning. it will tend to be suppressed . According to Osgood (1963). that sentence conditioning does not always take place. a case of paranoid schizophrenia). An implication from this interference theory would be that if the CR is stronger than a potentially interfering response. But we would still have to explain the fact that suggestions are not always readily accepted. attitudes and beliefs associated with a patient's negative behavior can be transformed even after just one hypnotic session (see pages 23 and 24 of Barrios. sometimes overnight. This theory states that in order for a response to become extinguished.' This hypothesis is given considerable support by Mowrer's theoretical formulations on the sentence (a form of suggestion) as a conditioning device (Mowrer. 1985. perceptions. Therefore. provides an especially effective means (the inhibitory set) whereby interfering stimuli can be readily inhibited. as long as there is a strong enough CR to begin with. Thus. How is this possible and yet explainable in terms of principles of conditioning? First of all. Osgood perhaps best answered this question in his presidential address to the American Psychological Association when discussing Mowrer's concept of the sentence as a conditioning device. they thus interfere with the conditioning. attitudes. 147).. we hypothesize that anything that would eliminate such interfering stimuli should facilitate C-C conditioning . the latter will be the one inhibited. tend to suppress the cognitive stimuli to be paired.. etc. if the assertion made by the sentence (the suggestion) is incongruent with subject's previously held beliefs and attitudes (the cognitive environment) or their present perceptions (the sensory environment). 2001: 194 and 195): We will find that the answer to this question will begin to throw some light on the part played by hypnosis in facilitating C-C conditioning. all-encompassing changes can take place in hypnotherapy. As pointed out in the theory (Barrios. a learning theorist might hesitate before accepting the possibility that it is a process of conditioning which underlies the dramatic changes produced in hypnotherapy. This often means that all the negative habits. Since incongruent or incompatible beliefs. For example. the cognitive stimulus 'healing' is evoked with its attendant immune associated response (e. is connected up with all the internal and external stimuli which can reach the cortex. Explaining the Placebo Effect In discussing the broad implications of the definition of hypnotic induction. and replacing the state of hopelessness with one of hopefulness can help revive the immune system (see discussion on faith healing in the next section). First. people have previously been conditioned to accept at face value the statements of someone who is an authority in his field. for the person is in a heightened state of belief. The question is how? The section of the theory on prestige helps throw some light on this question: [T]he statements. macrophages. that is. 2001: 181) The placebo when given by a doctor or person of authority works in the same way as hypnotic suggestion. And second. As Pavlov (1960: 407) so aptly put it: 'Speech. referred to in the theory as competing stimuli (Barrios. In general. he is essentially giving the suggestion 'this is going to ease your pain'.e. or doubts about the painkiller's effectiveness. it was stated that the theory could also be used to explain 'the hypnotic effects (placebo effect) of psychotherapists and doctors of medicine' (Barrios. 2001: 195). That is. on account of the whole preceding life of the adult.g. an inhibitory set which inhibits contradictory stimuli has been previously conditioned (in much the same way as in the hypnotic induction process). commands or suggestions of a person with prestige tend to be questioned less. (Barrios. When a patient strongly believes he is being healed you can say a state of hopefulness has been created. And studies have shown that a mental state of hopelessness can suppress the immune system. This is so because what the authority says has usually turned out to be true.∗ The next question that needs to be answered is from whence do the cognitive stimuli 'pain relief' or 'healing' derive their meaning: i. the cognitive stimulus 'pain relief' with its associated endorphin (the body's natural pain killing substance) release into the bloodstream. The actual pain relief occurs even if the injection is an inert saline solution because of two factors associated with suggestion.28 Alfred Barrios As implied above in pointing out how the strong inhibitory set aspect of hypnosis can lead to strong one trial conditioning.). The large part played by the inhibitory set in facilitating conditioning and leading to strong conditioned responses is supported by the work of Harry Harlow (1959) and his errorfactor theory. As another example. such as any doubts about the doctor's skills. we can see how this strong inhibitory set can also lead to functionally autonomous posthypnotic responses. when the doctor gives a patient an injection 'to kill the pain'. He considered much of learning to involve the inhibition of what he referred to as error-producing factors. the inhibitory set of the suggestion is evoked that would inhibit anything that might interfere with the cognitive stimulus. release of t-cells. and therefore can ∗ One can also tie in this placebo healing effect with the idea of creating a state of hopefulness through the power of belief. signaling all of them and replacing all of them. 2001: 171). or even the sensory pain stimulus itself. such a person evokes a greater inhibitory set to begin with. etc. . how did the words or thought 'pain relief' come to be associated with endorphin secretion or how did the word or thought 'healing' come to be associated with the immune response? I would say the answer is: through a process of higherorder classical conditioning. when the doctor gives the patient any medicine or treatment that he says will cure the patient. There. This would be more from a form of first-order classical conditioning. Just as one can produce positive health or bodily effects through th power of the placebo where positive expectations are created. let's say morphine (the UCS). via similar mechanisms as presented above) negative effects are possible when negative expectations or beliefs are created via the nocebo or voodoo. is another way that a placebo response can occur. The Nocebo and Voodoo Related to the placebo effect are the nocebo and voodoo effects. (Kirsch. Knowles. at some point in a person's life. and see that conditioning is also a factor in the 'expectancy' placebo. 1957. I believe the above two-fold (first-order and higher-order conditioning) explanation may help throw some light on the questions raised in the section on placebos in Kirsch's 1985 paper on response expectancies. but is consistent with clinical data indicating that placebo effects can be remarkably persistent. and the word or thought 'healing' was associated with the body's own natural healing response while the person was experiencing the same.' In other words. I believe this is what is behind the conditioning explanation of the placebo response of such researchers as Gliedman. of course. 1997: p 75) However. although higher-order as opposed to first-order.. the words or thought 'pain relief' were associated with the body's own natural pain relieving endorphin secretion response. the syringe. The pain relief (the UCR) produced by the actual painkiller. etc. This should help eliminate the apparent clash between the 'conditioning' and the 'response expectancy' explanation of placebos if we can look upon the terms 'response expectancy' and 'belief' as being similar as 1 have previously discussed. becomes associated with the CS such that the CS can eventually produce a conditioned response (CR) of pain relief. For instance. in the same way (i. the stimuli associated with the injection (e.g. This CR can then also be looked upon as a placebo . One other area that should also be cleared up by the above higher-order conditioning explanation of placebos is the question raised by Kirsch: how can one explain placebos in terms of conditioning when placebos often exhibit functional autonomy? As put by Kirsch: A second interesting finding of the Montgomery (1995) study is that instead of extinguishing. when a person or animal is injected a number of different times with a pain killing medication. Gantt and Teitelbaum.e. how one can establish some fairly strong functionally autonomous responses via the conditioning power of the belief or response expectancy aspect of placebos.in this case produced via first order conditioning. 1980.) are the conditioned stimuli (the CS). and Wickramasekera. 1962. . 1963. Hernstein. models of placebo-effects. This is inconsistent with classical conditioning. the placebo effect increased over the course of 10 extinction trials. the person giving the injection. one can see from the previous section 'Helping towards a more comprehensive theory of learning'.A New Theory for Understanding and Appreciating the Power of Hypnosis 29 call forth all those reactions of the organism which are normally determined by the actual stimuli themselves. . Not all people have developed the ability to focus on the appropriate thought when they wish to. is built up if you have a positive response to a previous suggestion. 'Science in support of religion: from the perspective of a behavioral scientist' (Barrios. Very often. The following are four key examples of such predicted or suggested outcomes in religion: (1) the fulfillment of religious prophecies. expectations or prophecies. again we need to define our terms. As put in the article. But then the realists point to all the miserable people in the world and say: 'Are we to believe that all these people have freely chosen to be miserable?' Is there free will or not? In order to answer this question. 1985: 16) free will is defined as the ability to transcend one's automatic side. The key words here are 'by focusing sufficiently on the appropriate thought'. This also helps us to more fully understand the far-reaching and in depth changes that can often be produced (almost instantaneously) by a 'religious experience'. between happiness and misery. conflicting and opposite thoughts interfere and do not . Understanding how this power can affect human behavior can help provide natural (as opposed to supernatural) explanations for various religious phenomena. or response to a suggestion. The Phenomenon of Free Will Religious practitioners tell us that of course we have free will. As presented in Towards Greater Freedom and Happiness (Barrios. by means of inner speech or thought . one's subconscious.. 2002: 6): Looking at belief in this new light can also help us better understand the concept of exorcising (blocking out) of demons or the devil (negative programming) within us and the role belief can play . how it can indeed be possible to be reborn or born again as a result of such an intense heightened belief experience. Demons. the theory also provides a natural (as opposed to supernatural) explanation for how the power of religious faith (belief) is developed. the statement was made that the theory can also be used to explain 'hypnotic effects (faith) of ministers and faith healers' or to put it more broadly. The following are examples of religious phenomena that the theory helps provide a natural explanation for.30 Alfred Barrios Providing a Natural Explanation for Faith-based Phenomena In the theory. (2) miracles produced through the powers of the religion's prophet.. (3) positive responses to one's prayers to God.. This would fit right in with Hypothesis III of the theory that states that belief. that God gives us a choice in life. How the Power of Religious Faith (Belief) is Developed In many religions the foundations of belief can be traced to the fulfillment of certain predictions. gives us the power to choose between good and evil. Exorcism and Born again Transformations The above section on how hypnosis can lead to one trial conditioning and functionally autonomous responses as a result of the heightened state of belief under hypnosis also helps to explain the overnight and long lasting changes that can occur as a result of the heightened state of religious belief. by focusing sufficiently on the appropriate thought. and (4) the positive occurrences in one's life resulting from following the religion's guidelines. . pp 124. Temoshok and Dreher. This includes. 1989) ..A New Theory for Understanding and Appreciating the Power of Hypnosis 31 allow the full positive response . 1989.. in order for this temporary improvement to remain permanent. 1974) as well as the effect of the mental state of hopelessness on the immune system and resultant diseases such as cancer (Cousins. 1985. the definition of belief used herein is: concentration on a thought to the exclusion of anything that would contradict that thought' (Barrios. Although strong belief of being healed can be very effective in producing at least temporary improvement in one's health (by allowing for a stronger immune response and creating greater peace of mind at least for the moment). However. for example.. Thus we can see that one way of differentiating between the concept of belief and the concept of faith is to point out that faith usually means 'guided' belief or belief in a certain way of life.. One way of determining how much more effective faith is than belief alone in affecting permanent healing would be to do a thorough search of the placebo literature or to do further studies on the placebo to determine whether the positive effects of the placebo (or belief alone) are long lasting if there were no significant lifestyle changes also taking place. I worked with . The Phenomenon of Faith Healing Many studies in recent years have shown that a person's state of mind and lifestyle can definitely play a key role in determining their state of health. and the section on placebos in Cousins' book Head First. 2002: 7 & 8). This is why the belief factor is so important . Evidence of the power of belief to affect the body health-wise can be found in many studies on the power of the placebo (see for instance the book Timeless Healing: The Power and Biology of Belief. the belief factor must also be used to help fully absorb the guidance factor [see subsequent section on making posthypnotic suggestion more effective by adding a guidance factor] so that the immuno-suppressive psychological factors can be more likely to be permanently removed (see Barrios. The following excerpts from Barrios (2002: 11-16) help present the case for the power of belief and faith to heal the body: If we accept the fact that a person's state of mind and lifestyle can play a significant role in affecting the body. Belief is the key to allowing an individual to tap into his free will potential. then it should be obvious that anything that can playa major role in affecting the mind. the effect of stress on diseases such as stroke and heart disease (Friedman and Rosenman.. So we see that the answer to the question 'does man have free will?' is that all humans have the potential for free will because they have the potential to build up belief in their ability to control their automatic behavior via a form of self-hypnosis over time (as discussed in Part I in the section comparing the theory to Hilgard's) and this is why we find that people differ from one another in their level of free will. Remember. there is something that needs to be made clear.. such as belief and faith.125 & 154).. 1996 by Herbert Benson. 1993). could be a major factor affecting health and well being. This basic idea that belief alone is not as effective for insuring permanent healing to take place as when the belief is also used to bring about positive lifestyle changes is illustrated when the case of Jolee Marshall is contrasted with some of the other cancer patients I have worked with: Jolee Marshall: After a very strong emotional upheaval Jolee had developed an inoperable cancerous tumor of the intestines and had been given two weeks to live. She was now able to stand up to her very dominating and controlling husband.): Adele Bucanan: As opposed to just one session with Jolee. However. At this point he discovered SPC. They said we now have to do surgery. I received 35 massive radiation treatments in the neck. there had been no real follow-through for making the necessary changes in her way of life that could have helped her more effectively prevent the second. I saw Adele once a week for eight weeks. the complete SPC-PNI approach (which now also includes helping the patient make certain necessary lifestyle changes) had not been followed. Knew nothing of God or Jesus. was suffering from a fast moving cancer of the spine. lymph glands. The tumor did disappear (in fact overnight) much to the astonishment of her doctor and Jolee did live cancer-free for one more year. Adele. when last contacted. The strong belief that she would be cured was apparently sufficient to heal her for one year.) Because of this. never read the Bible. Six months later the cancer had disappeared in all four areas and three years after that. in the case of Jolee. The following synopses of the approach taken and results achieved with a number of these patients will give you some idea of the different outcomes that can be expected when a more complete “faith healing” approach is taken towards eliminating the contributing psychological factors (hopelessness. This allowed her to break out of the hopeless life situation that had most likely played a key role in making her more susceptible to cancer in the first place. she was able to develop a more assertive personality. I said.32 Alfred Barrios her for a period of four hours [with the hypnotic belief-building and imaging techniques section of the self-programmed control-psychoneuroimmunological (SPC. emotional upheaval that occurred a year later. In particular. the rib cage and the base of the brain . age 45. August 5. John Roswick: John had been given radiation treatment for cancer of the tongue. the cancer returned and this time Jolee soon succumbed to it. 1985)] and left her with a very strong belief that her body's natural defenses would clear away the tumor. as she had had a strong negative reaction to the standard dosage. However. but I started. At the time I first saw her. Barrios. at this point in time I had not fully realized that belief alone was not enough. The following letter was written in August of 1985 upon my request for him to summarize for me what had happened: Dear Dr. 1979 1 was told I had cancer of the tongue and had a year or less to live. I was not only able to build up a strong belief in her body's ability to cure itself of the cancers but through this heightened state of belief I was also able to bring about some major changes in her way of life. he refused the recommended follow up radical surgery.) Because of the extended amount of time with Adele. I hit the bottom of the pit. What surgery? . I started praying. Adele was still very much alive. 1985 Almost 6 years ago on Oct 19. (Unfortunately. I said to the doctors “am I healed”. and this time fatal. However. upon experiencing another similar emotional upheaval one year after my first and only session with Jolee. (At this point in time the only treatment she was undergoing was a very low dosage chemotherapy.PN1) approach presented in the chapter on cancer in Towards Greater Freedom & Happiness (Barrios. etc. This is in stark contrast to other cancer patients I have worked with where the more complete SPC-PNI approach was followed.a metastasis from an original cancer of the breast. I would urge anyone who has an illness of any nature to seek out the SPC program. I have had the honor of knowing Dr. and his enormous influence on the American public. My saliva returned to me during my sessions with you. I observed the extraordinary development of the clinical applications of his pioneering theories. confused. you strengthened my belief in what Jesus said in Mark ll:23 ['Believe and all things are possible'] Dr. Barrios has developed a program that has allowed people worldwide to tap into their own personal power to change their health. It puts you in tune with the real you.' You said: you now have two good books (meaning yours and the Bible) and told me to read them both. During my first visit with you. guilt. ridding myself of all pent up fear. Barrios and observing his work since 1983. And I thank him for you. that my taster. doubts. It has for me and I know it will for others. anger. unforgivness. oh yes confused! My condition is healed. and I forgot to mention. At the same time. Through his SPC approach. 1996 “As CEO of P. Your holistic approach is a blessing. especially fear. taste buds. their happiness and their lives for the better! He has made the mind/body link accessible and understandable to the world. frightened. I could not summon up the resources to make necessary changes in my personal lifestyle. reinforcing my belief in Jesus teachings. which I did. It works. I firmly believe you are an instrument of God's.A New Theory for Understanding and Appreciating the Power of Hypnosis 33 They were going to take out half my neck. I am not the same person you first met. I said no. Well today I enjoy full saliva. the spirit. In many ways this was not . I thank God for you and your book. It is sad to note that medical doctors don’t. my voice. Over the years. would be about 50 to 75% returned.J. Your program SPC was the beginning in my healing. The doctors said my saliva would never be the same. instructed me on SPC techniques and other counseling on belief and visualization. in my opinion your program is bridging the gap between the mind. It was then that Dr." Pam Roth: When I first started working on Pam’s case. Barrios made the mind/body link accessible and understandable to me in the most profound way possible! In light of my particular case and my prognosis. I felt it had little to do with me on a personal level. and the spirit then the body. [After radiation] I couldn't taste anything. or won’t advise patients on positive principles laid down in your book or the bible. At the same time. I contacted you in the summer of 1980. my physicians encouraged me to undergo the most strenuous chemotherapy and radiation. Dr. and full tasting abilities I had before radiation. and a bringing together of the Mind. Barrios. I used your garden technique and visualized myself 'well' on a mountain top. even faced with my own mortality. Spirit and Body. MY TASTER. when I was diagnosed with metastasic breast cancer. You agreed to see me once a week for 8 or 9 weeks. you gave me your book 'Towards Greater Freedom and Happiness. she had just gone through chemotherapy and radiation for metastatic breast cancer. The following letter (which she wrote on my behalf when I was nominated in 1996 for the Norman Cousins Award in mindbody health) tells her story: To Whom It May Concern June 14. That is until 1992. Roth & Associates and President of The Public Service News Bureau. She was also having great difficulty breaking free of a 30 year two pack a day cigarette habit. thirty three years later. the cancer had eventually spread to his lymph nodes. His doctors told him that even with the best treatment at the time (a combination of surgery. Under hypnosis he was much more open to healing suggestions aimed at opening up blocks in his capacity to love and be loved and to work on achieving his long term life goals.. debilitated by my treatment and more out of touch than ever with the body that had betrayed me. In such studies. Years of therapy. among other things. . through applying these powerful hypnotic and visualization techniques to my cancer and my personal “mind/body” split – I not only stopped smoking once and for all.a lifelong goal. I am a committed ex-smoker. well and cancer-free. I had tried everything including traditional hypnosis but nothing seemed to work. Within two sessions. controlled studies. On the very day he was ordained “he got the news that his follow-up x-rays showed no more evidence of cancer. who exercises. His lymph nodes and lungs were completely clear. In her book..34 Alfred Barrios surprising. I had previously spent years of therapy unsuccessfully attempting to deal with the underlying lack of self worth that showed itself in an aggressive disregard of and for my own physical and emotional well being. Barrios stepped back into my life bringing all the benefits of his years of clinical experience in mind-body health. I was transformed into a person in touch with and caring for her own physical and emotional needs. I made the remarkable breakthroughs that years of therapy and prior hypnosis were unable to achieve! And it was all so easy. rather than definitive proof of the ability to cure cancer by using a mental/spiritual. which he did undergo) he had only three to four months to live and that he had zero chance of survival. cobalt and nitrogen mustard. Within weeks. eats well and takes care of herself in every way possible. I intend to give myself every opportunity to stay that way by continuing to practice the SPC techniques that have made the difference in my recovery!” It should be pointed out that I am not the only one to report such long lasting recoveries from cancer when a more complete “faith healing” approach is taken.” (Temoshok. 2007]. “faith healing”. This seeming miracle occurred six months after his original diagnosis. 320 italics added). It should be pointed out that my presentation of the above anecdotal evidence of cancer cures through a form of faith healing is done more as support for. will power and even cancer seemed to make little difference to ending my two pack a day habit and a 30 year addiction to nicotine. I was depressed. Temoshok cites numerous cases of successful cancer cures brought about by her and other researchers in the field using the more complete healing approach. Take for instance the story of Irwin: Diagnosed initially with testicular cancer. approach. Barrios’ approach not only convinced me that I had the power to tap into my own subconscious – it showed me how to use and apply that power to achieve deep seated change. For this definitive proof we will need larger. It was then that Dr. At this point he sought the help of a psychotherapist who used hypnosis along with traditional psychoanalysis. after all. p.. More importantly. according to all tests. Today.Today. he had resolved his love problems and gotten married and was ordained as an Episcopal priest . Within six months. 1993. anxious about the cancer that I was sure was still with me. “cancer free” [still “free” as of October. radiation. Irwin is alive. Dr. None of these could change the stress attached to my particular career choice or the fact that I had never developed necessary care and consideration for my physical “self”. chest and lungs. I was in trouble and I knew it. One tumor on his neck had grown so large he was forced to keep his head at an odd tilt. I am also. (2) eliminating the fear of losing control. The demonstration of salivating to the thought of biting into a sour lemon is one way to help get across this point. and therefore it should not bother them if they do not respond to a suggestion.' As for providing for more effective hypnotic induction techniques. 1973b). as suggested by the theory. Several ways of doing this are recommended by the theory: the use of easy to respond to suggestions to begin with (see Corollary 5. Misconceptions can be eliminated by defining hypnosis as a state of heightened belief produced by responding positively to a series of suggestions (as per the theory) and not a state of sleep or unconsciousness. 1973 in Upsala Sweden (Barrios. For instance.A New Theory for Understanding and Appreciating the Power of Hypnosis 35 all the important variables can be studied systematically and under scientifically controlled conditions. In fact. several basic areas that need to be addressed according to the theory are: (1) eliminating misconceptions regarding hypnosis. the power of thoughts and the power of belief to control automatic responses. With regards to a proper pre-induction talk. such studies would include accurate and more complete measurements of how strong the belief factor was and how complete were the necessary lifestyle changes for each individual case. anything that would ensure a positive response to suggestion would help heighten the belief factor and thus increase the effectiveness of the hypnotic induction. In such a case they should just wait for the next one. and the use of biofeedback devices. The ideas to be discussed were first presented in a paper delivered at the 6th International Congress for Hypnosis on 3 July. As for eliminating the fear of losing control. you help the individual see that they will in fact be gaining greater control rather than losing control. . it is recommended that the hypnotic induction be referred to as inducing a state of 'self-programmed control' (SPC) and to define SPC as a method for giving an individual greater control over his automatic behavior. and (4) minimizing the negative effect of failure. following Hypothesis III). one can see that by referring to the induction as a means of developing selfprogrammed control. (3) eliminating fear of the unknown. Fear of the unknown is eliminated in the pre-induction talk by providing a rational explanation for how this state of greater control is developed as the result of the power of words. The negative effects of failure are minimized by telling subjects that 'because of individual differences there may be some suggestions that work very well for some people but not for others. the use of naturally-occurring responses and the use of subtle reinforcement of suggested stimuli or responses (see Corollary 6). The latter would I feel help throw light on the question often posed: “How do you explain counter anecdotal cases whereby terminally ill patients have tried to pray for their recovery substantially but to no avail?” One answer to such a question might be that the degree and length of healing would be directly correlated to strength of belief and depth of relevant life changes that took place. Developing More Effective Methods of Hypnotic Induction There are a number of ways the theory has helped increase the effectiveness of hypnotic induction both in terms of providing a proper pre-induction talk as well as providing more effective hypnotic induction techniques. is a naturally-occurring effect as a result of looking at the spiral spinning in a clockwise direction. This technique involves having the subjects looking at a spinning spiral. Of course. etc. Throughout. there is a natural tendency of the head to sink with each breath let out so one can reinforce suggestions of head sinking in a similar way. This very dramatic effect. suggestions that the spiral is concentrating the power of the mind continue to be given. Then. as per the theory. everything will be seen that much more clearly and strongly (which is true). In the initial steps the subject is told they will see a yellow colored balloon after they close their eyes and that it will be changing in color from yellow to red to magenta to blue (which would be the natural color changes the after image would go through). I lead them through a series of suggestions of visual phenomena which I devised by mirroring the subtle visual effects I experienced myself as I visualized the spinning spiral. light-headedness. the rapid deep breathing. by having responded positively to the series of previous suggestions. The following suggestions are given: as your mind becomes more and more concentrated. Then there are a series of other naturally reinforced suggestions starting with the suggestion that the fingers will automatically begin to creep open and as a result the pendulum will soon be dropped. In the light bulb technique. . you will feel as if you are riding backwards on a train in a spiral tunnel looking out the rear window. 2006) also takes advantage of naturally occurring phenomena. I even tell the subjects afterwards that some people do not experience any of these effects (which is also true for those not paying attention). Suggestions are also given that the balloon will begin to float up and the head will also begin to float up. and the hand levitation techniques. to emphasize this point. The subject is told that the latter will occur with each breath they take in. This is followed by suggestions that the hand and arm will be floating down as the state of relaxation continues to deepen (another natural response). there is a natural tendency of the head to rise with each breath taken in. Other SPC techniques making use of naturally-occurring phenomena are the light bulb. In this technique there is first the biofeedback amplification provided by the length of the pendulum to amplify the minute automatic movements of the hand. you will see a yellowish fluorescent-like fringe to the black lines.) The rapid deep breathing technique (an adaptation of the hyperventilation method discussed by Kroger. then swinging in a circle. This response occurs naturally as the hand slowly begins to bend at the wrist as suggestions are given that the hand will relax. dark rays will appear to spin off the edge of the disk. The concentration spiral technique (Barrios. swinging from left to right is suggested.36 Alfred Barrios The following are some of the SPC techniques I developed as a result (see Barrios. (Conversely. the effect is magnified that much more. Unbeknownst to the subject. use is made of the after-image produced after staring into a 40-watt light bulb for a short while. unbeknownst to the subject. greater awareness of heart beating. To minimize any feelings of deception for the few that may think of the spiral technique as pure illusion. you will begin to see a fuzziness or waviness in the lines of the spiral. First. prior to going through the technique I first point out that everything the subjects are going to see is naturally there but as a result of the concentrating effect of the procedure. the suggestion is made that upon looking away from the spiral at the clock on the wall (or some other object like a plant in the room) the clock (or plant) will be magnified and appear to grow larger. 1985: 36-42): One of the techniques developed by following these guidelines was the already mentioned pendulum technique. 1977: 77-8) takes advantage of such naturallyoccurring responses to hyperventilation as tingling. More Effective Methods for Giving Posthypnotic Suggestion How does the theory lead to ideas for increasing the probability of producing positive behavioral changes via posthypnotic suggestion? The answer to this question comes from Corollary 8 (following Hypothesis IV) of the theory. and (5) the success technique (see Barrios. it's another to get him to change in this direction. Following along the lines of enhancing posthypnotic suggestion with positive guidance. These basic principles for increasing the effectiveness of hypnotic inductions derived from the theory have been presented in such a way that one should be able to extrapolate from them and develop other similar naturally reinforced techniques. I feel the SPC program by facilitating change provides this missing link to achieving self-actualization. This basic concept underlies the value of using imagery (visualization) to ensure the suggestion would hold in a variety of situations and guidance to give the suggestion depth. For example. (2) the approximation version. The Development of Self-programmed Control and its Positive Applications This combining of effective hypnosis (and self-hypnosis) techniques with more effective methods of giving posthypnotic suggestions. I have developed five variations of visualization for effectively programming in one's goals. emotions. . Although Maslow. 1985: 43-50). including a comprehensive guidance component. in defining self-actualization. the second part of the book Towards Greater Freedom and Happiness (Barrios. These include: (1) the simple projection method. the stronger the response to the suggestion'. This includes positive guidance in the following areas: mental attitudes. 1971). I have the subjects begin by first pressing the hand as flat as possible against the surface. let's say a patient was suffering from a deep depression due to a poor selfimage and a sense of being a failure in life. led to the development of a general program for helping people achieve self-actualization which was christened self-programmed control or SPC. 1985: 57196) offers a wide range of positive guidelines to choose from. Compare the effectiveness of (1) just giving the simple. Thus. health and education. more positive about oneself. and then having the patients visualize themselves in a number of different typical situations responding in these more positive ways. 'The more compatible cognitive stimuli associated with the response evoked by the suggestion. had done a magnificent job of outlining the ultimate high goals one should strive for in life (Maslow. with the fingers spread as far apart as possible. thus reinforcing the suggestions. (4) the punishment reward method. Along the lines of enhancing posthypnotic suggestion with imagery. (3) the negative positive method. suggestion 'You will no longer feel depressed' to (2) giving this general positive suggestion followed by a series of more in-depth suggestions that included proper guidance on how to become more successful in life. I tell them to push down as hard as they can initially. when suggestions are given that the hand will start to rise and the fingers will start to come together as the hand relaxes this is what would naturally occur as they stop pushing down and relax.A New Theory for Understanding and Appreciating the Power of Hypnosis 37 In my adaptation of the hand levitation hypnotic technique. It is one thing to tell a person what he needs to strive for to feel more fulfilled in life. general. I feel he never really outlined an effective systematic method of achieving these goals. This combined with the other two parts of the program leads to a greater belief in their capabilities. Soon after the school administration asked me if I could avoid using the term hypnosis because of all the associated misconceptions. a basic theme underlying this three pronged approach was to provide as much immediate positive feedback as possible to increase the belief factor that much more. Or as he put it. medicine.) In later years the term 'emotional intelligence' was coined to describe the importance of learning to deal effectively with anxiety and emotional problems in order to succeed in life (Goleman. 1977: 191). problem solving. without such a belief. As previously indicated. and test-taking techniques many of which were taken from Studying Effectively (Wrenn and Larsen. I started with two memory techniques that provided immediate feedback: (a) the 'numbers' technique where the students were amazed to see how quickly they could memorize a 23 digit number using grouping and association techniques. As he at the time so correctly pointed out. And with regards to the learning skills section. the SPC techniques had built-in immediate positive feedback as recommended from the theory and this same immediate feedback approached was followed with the other two components of the program thus further adding to the overall positive belief factor. I developed a program to help college students (primarily Mexican American) on scholastic probation avoid dropping out. In a prior study by Losak (1972). 'It is hypothesized that expectations [belief] of personal efficacy determine whether coping behavior will be initiated. 1955). 1969).or outside-of-school-related stress/anxiety problems that can also often interfere with learning and test-taking capabilities. the lack of belief in their capabilities was felt to be the reason why remedial programs alone were found to be of no help for students at risk of failing. I used a three-pronged approach (see Barrios. the part especially geared for improving students' scholastic abilities. The SPC techniques played a part here also by helping to program in an automatic relaxation response in times of stress as well as stress-reducing positive attitudes.38 Alfred Barrios This section of the paper will further describe the essence of SPC and will present some of the positive results achieved in its application in a number of different areas: education. Albert Bandura would coin the term 'selfefficacy' for such belief in one's capabilities. and (b) the 'names' technique where the students were equally amazed to find out how easy it was to memorize the first names of all the students in the class using . the stress control biofeedback card (originally called the 'Colorimeter') was used to immediately reinforce the relaxation response. The main purpose of the SPC techniques was to help the students develop a greater belief in the power of their minds. people would not even make the effort to help themselves. 1973b). Following from the theory. Education After my PhD dissertation (Barrios. (The book Psycho-Cybernetics [Maltz. and drug rehabilitation. The third part of the program. The second part of the three pronged approach was aimed at helping eliminate any school. Eight years later. and how long it will be sustained in the face of obstacles and aversive experience' (Bandura. 1960] was used initially to introduce the students to these positive attitudes towards life. It was at this point that I came up with the term “self-programmed control” (SPC) techniques in place of “self-hypnosis techniques”. The SPC program eventually came to refer to the entire program of SPC techniques plus guidance. how much effort will be expended. industry. 1995). The first part consisted of the set of self-hypnosis techniques I had developed from the theory (see the techniques mentioned above). was made up of study. For instance my invention. welfare. .. As Bandura puts it 'Seeing others perform threatening [difficult] activities without adverse consequences can generate expectations in observance that they too will improve if they intensify and persist in their efforts. Verbal persuasion: SPC is of course to a great extent founded on the potential power of verbal persuasion (in the form of hypnosis).A New Theory for Understanding and Appreciating the Power of Hypnosis 39 association techniques. At the beginning of each class meeting I would ask for people to stand up and share any successes they had already achieved. Efficacy expectations induced in this manner are also likely to be weaker than those arising from one's own accomplishments . They persuade themselves that if others can do it. to build self-efficacy.) Similarities between SPC and Bandura's Self-efficacy What amazes me is how many similarities there are between the SPC approach to helping these students and Bandura's overall approach to building self efficacy. However. include: (1) the use of the stress control biofeedback card to reinforce the effectiveness of relaxation techniques in a stressful/anxious situation. These techniques in turn whetted the students' appetites for other even more practical techniques such as the 'SQ3R' study technique which itself produced immediate positive results in the quizzes which quickly followed. vicarious experience. although Bandura does acknowledge that suggestion can influence one's level of efficacy. On the first page of the progress report they were to make a list of the goals they wanted to achieve and at the end of each week they were to look back and note down any positive results they had already achieved regarding these goals. Vicarious experience: Bandura's discussion of the use of modeled successful behavior to build self efficacy is similar to my having the students get up at the beginning of each SPC session and share their successes with the class.. Bandura then goes on to say. whatever mastery expectations are induced by suggestion can be readily extinguished by disconfirming experiences . (See pages 2007 in Barrios. 1985 for examples of these student progress reports. Simply informing participants that they . through suggestion into believing they can cope successfully with what has overwhelmed them in the past. Let's look at each of these areas as it relates to some of the methods used in building the belief factor in the SPC program: Performance accomplishments: Examples of the use of positive performance accomplishments in the SPC program to build belief in oneself. In the face of distressing threats and a long history of failure in coping with them. One difference here is that Bandura is referring to actually seeing the other person perform the threatening or difficult task as what is helpful whereas I am saying that hearing the person relating that he has successfully performed the task is also reinforcing. Another source of immediate feedback was the progress reports..' However. a form of journal I asked the students to keep. As Bandura puts it: 'People are led. Bandura (1977: 195200) refers to four basic ways in which self-efficacy can be built: performance accomplishments. verbal persuasion and physiological states. (2) the demonstration of the 'numbers' and 'names' memory techniques as well as the SQ3R studying techniques to instill belief in one's learning capabilities. he tends to downplay it a bit. This was especially helpful in getting through to those in the group who for whatever reason still found it hard to believe that SPC could produce results. they should be able to achieve at least some improvement in performance' (Bandura 1977: 199). g. The total difference of 9. it would appear that he should agree that heightening the state of belief(e. 'Because high arousal usually debilitates performance. assuredness. 1973c) There was also an interesting side benefit to the program in terms of reduced substance abuse and addictions (reduced habits of excess) amongst the students in the SPC classes. 1960). (Bandura. The two main dependent variables compared between the two groups were dropout rates and grade points (GPA x units completed) over a one and a half year period. problem solving and test-taking techniques (with lots of immediate positive feedback) as well as a set of positive guidelines to life (originally supplied via the book Psycho-Cybernetics. Emotional arousal: Bandura definitely agrees with the need of the students to effectively deal with anxiety and emotional problems if they are to succeed in school. there was an average increase of 3. the more likely are efficacy expectations to change' (Bandura 1977: 202). But judging from the following statement of his.40 Alfred Barrios will or will not benefit from treatment does not mean that they necessarily believe what they are told. Maltz. their prestige. individuals are more likely to expect success when they are not beset by aversive arousal than if they are tense and viscerally agitated' (Bandura 1977: 198). During this period the dropout rate for the study skills only (control) group was 56% (not surprising considering Losak's 1972 finding). There were 105 enrolled in my (SPC) Psychology 22 class (the experimental group) and 89 students taking the regular Psychology 22 class (the control group) where only study skills were taught and by instructors other than myself.80 grade points for the experimental group and an actual average 5.45 grade points decrease in the control group (also not surprising to Losak). trustworthiness. Results of the Application of SPC in Education for Reducing Dropout A total of 194 students took part in the study at East Los Angeles Community College (ELAC). There is one more important point that Bandura makes regarding the overall effectiveness of verbal persuasion at building self-efficacy: 'However. This is of course why the SPC program for students also included giving them effective study. especially when it contradicts their other personal experiences. to raise by persuasion expectations of personal competence without arranging conditions to facilitate effective performance will more likely lead to failures that discredit the persuaders and further undermine the recipients' perceived self-efficacy' (1977: 198).02 level (Barrios. 1977: 198) Nowhere in his section on verbal persuasion does Bandura bring in the potential usefulness of hypnosis in making verbal persuasion more effective. As for the grade points. In those students indicating excess in the following areas these percentages cut down: . The dropout rate for the SPC class (the experimental group) was 16%. The way he puts it is to say that self-efficacy level will definitely be affected by emotional or anxiety problems. The more believable the source of information.25 grade points between the two groups was statistically significant at the 0. The following results were obtained from an anonymous questionnaire given to a total of 236 students at the end of the class (the above original 105 SPC students plus an additional 131 that took subsequent SPC classes). expertise. via an effective hypnotic induction) would most likely make verbal persuasion more effective in building self-efficacy: 'The impact of verbal persuasion on self-efficacy may vary substantially depending on perceived credibility of the persuaders. recently became Mayor of Los Angeles and having seen first hand the benefits of the program has indicated plans to introduce it to the Los Angeles School District as a means of reducing the current high dropout rate of Hispanics and African Americans in the Los Angeles schools (55%). First the comments of Maria-Luisa Lopez. one of the students benefiting from this 1972 UCLA class. I don't believe this. self-confident attitude which has helped them during the interviews and subsequently while learning their duties as new employees. She stated that after much searching. all have found jobs.A New Theory for Understanding and Appreciating the Power of Hypnosis food cigarettes alcohol TV gambling 72% 70% 91% 82% 75% (65 of 90) (37 of 53) (48 of 53) (84 of 102) (9 of 12) marijuana pills (‘uppers & downers’) LSD heroin 41 69% (22 of 32) 83% (10 of 12) 100% (7 of 7) 100% (1 of 1) The interesting thing about this curtailment of excesses is that it occurred primarily as a side benefit of the program. Most excesses or addictions can usually be traced to a deficit in one or more of these areas. In her own words: n the past (prior to SPC exposure) many of our trainees who were sent out on interviews by the staff Job Developer would not even show up. 209) tend to support a hypothesis I have regarding welfare recipients: Many feel that people on welfare are just plain lazy malingerers and don't real1y want to work. 1985: 32) . 1985: 32. or if they did they projected a negative or insecure attitude and were rejected in many instances. It is felt to have occurred mainly because of three major changes resulting from the program: the general increase in the ability to relax. 208. (Barrios. she had at last found (in SPC) a means of dealing with the all-important attitudes and fears of her students that had continued to plague her ability to get through to them. and the greater amount of self control. Welfare and Work Incentive Programs The positive results achieved with incorporating SPC into work incentive programs to help get people off welfare (see Barrios. Since SPC exposure. Needless to say. Interestingly enough. (Barrios 1985: 208) The essence of what the program can do for these people was captured by the comments of two CETA (Comprehensive Employment and Training Act) instructors who saw the results of what SPC was able to do for their students. I am completely sold on the SPC concept.something unheard of before as in the past those who had found work found it as a result of the Job Developer's efforts. Of the 18 trainees I had in my class when I started using SPC. Corroborating the results achieved at ELAC were those achieved at UCLA in 1972 with 362 freshmen where the SPC program was introduced as part of an overall program to help minority students survive at UCLA. a former high school dropout prior to taking the class. the greater enjoyment of other areas of life. No concentrated attack had been made on curtailing excesses. al1 have acquired a more positive. CETA instructor in East Los Angeles. ten of them completely on their own . It's my theory that these people remain on welfare not because they want to but because their low self-image [low self-efficacy] makes them feel incapable of anything else. there would be considerably fewer stress problems. absenteeism due to illness would be much less.) J. All these would result in increased productivity. Inefficiency and absenteeism would be diminished. and met once a week for two hours for a total of six weeks.36 to 6. 1985: 209-13): The SPC class at Rockwell had a total of 11 participants . there would be a definite lessening of friction among personnel. 1985: 209) Industry One can also see that there could also be a positive use for SPC in industry. see also Barrios. A-53 Procrastination . Barrios' concepts and techniques. Three simple measures were used to get some idea of the effectiveness of the program: (1) The Willoughby test (p. B-62. after the initials of the participant. That such results are possible with SPC was borne out in a study done at Rockwell International and reported in the Journal of Employee Recreation. In each case. no sense of control over his own destiny. . I feel strongly that this is an important part of job training that has never been previously recognized. This includes paying bills.B. 1975. I have included the before (B) and after (A) Willoughby percentile. using a scale of 0 to 10. no previous pattern of success. (2) A before and after selfrating of the goals chosen to be worked on by each participant.from all levels. the average self rating went up from 3. work morale would be higher. and (3) Each participant's own summary of his progress written at the end of the class. (The lower the percentile the better. Barrios' course which applies so directly to our CETA trainees. including management. letters. 52-53) with each person working on an average of five to six of the following goals (self-confidence being the most common one chosen): Positive Thinking Self-Confidence Learning Ability Creativity Weight Control Tension Control Excessive Drinking Smoking Health Fears Emotions Sex Exercise Eternal Youth Headaches Physical Attractiveness Leadership Ability Procrastination Reading through the following summaries of progress (all 11 are included. 224) before and after. Health and Education (Barrios. It is this strategic area of Dr. he has great difficulty getting and holding down a job. including the one failure) will give you a better feel for the type of results achieved.Have done one or two extra chores every night instead of putting it off until there is no time left.80. The results of the Willoughby test indicated an overall improvement of from the 75th to the 47th percentile. With regards to the changes in rating of goal-reachability. (Barrios. (see p.42 Alfred Barrios And in the words of CETA counselor Suzanne Bourg in Pasadena California: After seeing the response of the students and hearing examples of their applications of Dr. etc. CETA can train a person to obtain job skil1s but if he has no self-confidence.3 women and 8 men . I find that I like myself even more and am able to do much more than I've done in the past. I just changed my attitude (after I started the class and started reading “Psycho-Cybernetics”) and everything just seemed to shape up. I will have to say the class has been a success for me.Work running more smoothly now.Started doing exercises at home. A. And I am able to shut out outside interference when thinking. no longer pose a threat of failure because I am assured I can solve any. My memory and reading comprehension have improved. Not as many redo's from frustration or aggravation and the time element is no longer creating excessive tension. Have already lost a few pounds.absolutely no sweets and sweets were my weakness.A New Theory for Understanding and Appreciating the Power of Hypnosis 43 Diet & Health .B. A-12 I have greatly reduced tension. I have the tools . Also. For instance. E. I know I will be successful most of the time. So. I have something light at dinner . I wonder where would I be today? R. Now. A-5 This course has been helpful in many ways toward improving my self-image. . I am convinced the program works. Have gone without one as much as four hours at a time at work where the pressure is the greatest. B-89.I don't mind getting up and going to work. Since my self-image has improved. The class has definitely helped me. no one could have hated a job more than I did.P. A-57 I have learned the techniques. I can see where everyone could benefit from this course. Problems. I really like the people I work with now. I really enjoy my job . Without this course. My life is a much happier one which gives off a glow of warm vibrations to others around me. I am confident I will accomplish my goals. both short and long range. I'm able to concentrate on a positive thought whenever I desire.now the rest is up to me. Smoking . For years I've read books oriented along these lines. My weight and work problems seem to be going okay now so I think I'll start trying for self-confidence (that will be a tough one but I know I’ll be able to make it).Have cut down considerably. I have lost 7 lbs. B-60.O B-30. at work or at home. I have started and am continuing an exercise program every day at noon. I feel it was worth the time and money. but this course seemed to show how to accomplish your goals. Have also done pretty well with my meals. My confidence and positive thoughts have strengthened a great amount. My sex life has improved considerably and I feel I have a more positive attitude toward the future. Work . While my problems were not as great as many people. large or small. Now that I realize I have the ability. I despised going to work in the mornings. Have been running a mile at noon instead of eating lunch. B. I think an SPC program is absolutely essential in a corporate organization in order to develop maximum performance and output among its members. I find that I'm now able to get vivid blue on the Stress Card more and more frequently. Now I don't. B-85. At work SPC has helped by teaching me to take a more deliberate and analytical approach and therefore achieve more reasonable solutions to my problems. A-41 I am convinced now I have made relaxation a habit. Example . with the countdown. A-96 (The one apparent failure) I do not feel that SPC has helped me a great deal.P. keep my feelings in control so as not to upset the entire office. Before I would easily become discouraged and be quick to give up and drop the class.P. B-88. A-93 In the past. Find myself thinking clearly again and normal. I'd run. too.R. Previously I would be so upset during the learning period it took twice as long. there is an annoying person whom I work with . This is true even though my age [around 65] is such that it is easy to have serious doubts if I were to allow them to develop. . I'm definitely going to continue working with this program. I am confident.44 Alfred Barrios D. Also. Corporation work programs such as North American Rockwell have impossible schedules. under pressure. B-98. B-81. I've noticed that more done lately in shorter time and with less effort.P. almost impossible goal requirements and a need for maximum cooperation between all members. L. R.I can for the most part. SPC will develop a calmness in these individuals so that their efficiency is increased tremendously and their awareness of the other person's point of view and his requirements are greatly enhanced to the point where cooperation and efficiency of the overall program results in a much better end result. but who knows what seeds have been planted.because I can keep calm long enough to learn it. I find that SPC has also helped with my job .In a night class I am taking I have noticed a complete change of attitude. A-52 This has opened my eyes to a lot of little things that are really big. Now I find myself sticking to it and no longer so afraid of the teacher. that my new positive. winning attitude can accomplish the results I need to meet all my realistic goals. Almost all workers in such a situation will develop an extremely tense personality where their creative output reaches minimum because of the impossible schedules and goals. I use the quick count-down when I get in a tight spot and it seems to help quite a bit. Also. Although no study has been done with the specific purpose of testing the effectiveness of SPC for improving health. This has helped my ego and my confidence to a great degree. I recently have had success in controlling this habit for the first time in approximately 30 years . I really "dig" the "positive thought" technique. B-68. I am working on one that has grown since childhood. I use this every day. I have also made some slight progress in my weight reduction goal. A-12 Have achieved positive results from the 6 week program. Medicine One can also see the possibilities of SPC in the area of medicine. now I must continue to use them to continue the progress. I probably would not have read Psycho-Cybernetics at all. I was quite pleased with the "before" and "after" results of the Willoughby test. When I think negatively I immediately disregard the thought and think of a positive thought. Now I find myself catching myself as soon as I become aware of the situation and program in that I am confident in my abilities. I was particularly impressed with my ability to remember names. This is the basis of Maltz' book [Psycho-Cybernetics] but I didn't really get it until this class. Therefore I am able to get more work accomplished. I find that I am also starting to gain confidence in my handling of situations at work that bugged me before and am much more relaxed when making presentations to a group of people.three successes in a row. A. B-82.S. A-63 I feel that I have learned the tools to help myself over the past six weeks. I think I have reversed my negative pattern. B-86. I have obtained positive results in my blood pressure reduction goal and find I am more relaxed now. feel that this is only the beginning. Before the course I rated myself low in self-confidence and positive thinking. A-40 I thought the course was well presented. As far as habits are concerned. I look forward to working hard on all areas with the tools learned in the class. Now when I go to bed I go through a complete programming input and relax much more than before. This was always a weak point with me. P. I now try to concentrate on my successes as much as possible. This course gave me the tools. Also. thereby getting to sleep earlier and more relaxed. one can see from many of the above reports as well as others scattered throughout the book . This is the biggest thing I have learned to date. Thanks to the short-cut techniques I can automatically relax when problems come up at work and find I can deal with others more easily. And my mind is not as cluttered up with negative thoughts and fears during the day.R.A New Theory for Understanding and Appreciating the Power of Hypnosis 45 R. I had trouble sleeping at times. As a result I am on time for work and more relaxed during the day.S. Now that I started the book I feel I will complete the book within the month. She was like me at first. Then it started taking effect. I let this saying make a nest in my subconscious.A. one of the side benefits of the SPC program for students was considerable reduction in a number of habits of excess or addictions including a number of different drug addictions. it was as if I had taken it before. now she's getting involved and she's really doing fine now. My application was accepted. I signed up for the Bridgeback Drug Program. I'm going to close with these last few words. I started out by using the Spiral Mind Technique. So I programmed in that I would complete the Mural. I applied for a job for the State of California as a claim's examiner's assistant. Upon completion. 1985: 213) Drug Rehabilitation As has already been reported. A. depression. pain. as far as a future. and I'm always getting recognition for it. skeptical. Both are rehabilitative centers for hard-core drug and alcoholic offenders many of whom had been sent to prison for drug-related crimes. anxiety. Oh yes. I finally gave up and said it's time to get help. The types of results achieved are illustrated in the two letters presented on pages 214-16 of Barrios. I began getting so involved. obesity. I just know I did well on it because I got under the Spiral that morning.46 Alfred Barrios [Towards Greater Freedom and Happiness] that SPC can be considerably effective with such health problems as: high blood pressure. Now. Then I had this Mural to paint. Every morning I would use it. He said he could change a person's entire life if they got involved. smoking. I'm enjoying life in a much more rewarding way. A. Through the years I tried several times to break the habit but each time would go back. heart disease and cancer. I just knew I wouldn't finish it. I took the test and I found it was so easy. Not having too much on the ball. now they are.A. My grades in high school were C's and D's. A more direct use of SPC with drug addicts and alcoholics was its application at Bridgeback and the House of Uhuru in the predominately Black area of Los Angeles. Now I'm a resident at Bridgeback. ulcers. arthritis. The first was written by a resident at Bridgeback and addressed to-whom-it-may-concern: For many years (since 1959) I had been a drug-addict. asthma. I hope to become an accounting clerk. I had been told that once a dope-fiend always a dope-fiend. diabetes. believe it or not. insomnia.A. I said what can I lose. There I thought that I could get help by just grouping [note: this is a form of encounter group therapy and has been the main form of therapy currently used by many drug rehabilitative programs] but I couldn't. Next. For a long time I thought there was no hope. still using Dr. So. It's really something to see how these techniques work. Because of this I would not deal with anything. There was this young lady that came to the program. Well. 75 feet long and 25 feet high. So along came Dr. headaches. Barrios' SPC program. (Barrios. A. A's and B's. Business College where I'm studying accounting. alcoholism. I saw where I could help her with this new program. and now it's one of the best in the city of L. 1985. Barrios. I didn't believe it at first. He had a very unique program called SPC (selfprogram control). then he started saying things that sounded good. The next thing I know I had no desire whatsoever to use or even be around dope. I purchased a kit. . I attend L. let me include this in this short story of my changed life-style. At first I just sat in class and didn't get involved. the class.A New Theory for Understanding and Appreciating the Power of Hypnosis 47 The following letter was written to the Director of the House of Uhuru by one of the peer-counselors who had taken part in the pilot SPC study there: I am writing concerning a program I feel would be of great interest to you and which I highly recommend for incorporation into the House of Uhuru. I became more confident and aware of my abilities to change and control my life as I deem fit. but I have also seen that we ourselves could very easily teach it to others in turn. stop at a liquor store and after getting home. a tranquilizing medication. At the conclusion of the fourth session. such as over-eating. I know this is possible because I've seen the program work not only with me but many others as well. Anderson. I am strongly in favor of the idea. In March of this year my husband was incarcerated. allow me to state that this program. One client especially stated she had gotten so upset one day that . These ten clients were taught SPC by us without Dr. Not only have I seen the positive effects of the class on myself and the others taking it. During the last four classes ten clients participated who were from the residential component. my temper and mood variations have displayed positive movement toward a more balanced equilibrium. I started drinking alcohol everyday. As a result of this occurrence. Before utilizing the SPC techniques I experienced headaches often. would drink myself into a stupor. despondency. At the beginning of the class we were asked if there was anything that we wanted to focus upon within ourselves.). etc. thanks to being in the SPC class Dr. as I'm sure you are aware of. and reading excerpts from the book Psycho-Cybernetics by Maxwell Maltz. introduced to them a few of the SPC techniques that were ideal for tension control and relaxation. and would be away for 18 months. lost my temper at the drop of a hat. by using the 20 to 10 Countdown Technique the clients were able to control their tempers and display a more positive attitude and behavior pattern. programmed in the goal of not having to drink to deal with my fears. I'd get off from work. I felt and continue to feel good about myself! With the continued usage of the techniques learned through SPC. First of all Mr. Barrios. One of the goals I set was to become adept at tension control. During this time I had forgotten about SPC and just about everything else. I went through the technique twice. and underwent mood changes quite frequently (depression. clients were relating to me how they had used the Deep Breathing Technique to relax and had as a result stopped taking sinnequans. Self-Program Control (SPC). Many of the clients also reported that they were now able to go to sleep at night without the aid of medication simply by using the techniques learned in SPC. I remembered the SPC 20 to 10 Countdown Technique for relaxation. all of the residential clients were very enthused and expressed a desire to attend and learn more from additional sessions. and my headaches are almost nonexistent. drug taking and abuse and countless others can be minimized and eventually alleviated by applying the techniques acquired and practiced until they become second nature by believing you can do it. and poured the pint of bourbon down the kitchen drain. Barrios taught here this past semester. Unhealthy habits. Now. Also while participating in the regular intensive grouping sessions. in that by means of it one can be in control of his life and destiny. In regards to Self-Program Control being incorporated and implemented as an on-going therapeutic phase of the Uhuru's philosophy. insecurities. self-pity. We. At the end of the very first session. works! It is a truth. Then one evening after I had taken my first drink. I felt afraid and completely alone. excessive smoking and drinking. for at the phenomenally fast rate at which technology has advanced during the past century. I believe strongly that we need this chain reaction effect if we are going to help turn this world around in time. Again this is all in keeping with the "demystification" approach of Ivey and Alshuler (1973) that says we don't have to be Ph. Please also note the chain reaction effect. 1985:217) CONCLUSIONS A significant number of benefits were derived from the theory. Each day SPC is being heralded by these ten residents who were fortunate enough to be included in the SPC class. . schizophrenia & bipolar disorder. Key factors in achieving self-actualization in the SPC program are the greater levels of self-efficacy (Bandura.. we are currently in a life or death race. At this time the client went through the techniques learned in SPC. placebos and faith-based phenomena including free will and faith healing. industry. and as a result her blood pressure returned to normal without her having to be administered medication. REFERENCES Bandura A (1977) Self-Efficacy: Toward a unifying theory of behavioral change. and they themselves are now teaching the techniques of SPC to new residents.48 Alfred Barrios her blood pressure went up high enough for our doctor to feel medication was necessary to restore it to normal.how easy it is to teach. These include: (1) a further understanding of the hallucinogens. medicine. The students I taught in turn taught the program to ten other residents who in turn started teaching the program to others. The above letter illustrates once again a major advantage of the SPC program . 1977) and emotional intelligence (Goleman. 1995) achieved. biofeedback. higher–order conditioning. Although Maslow (1971) did an excellent job of introducing the concept. he never really developed a systematic approach to achieving self-actualization. man now has the means to totally destroy himself. 2005). Positive results of SPC’s application in a number of important areas were presented: education. a positive-oriented behavioral improvement program which provides a systematic means of achieving self-actualization. “. Barber TX (1969) Hypnosis: A Scientific Approach. welfare. New York: Van Nostrand Reinhold. (Barrios. and will unless we can get to him first”.. and drug rehabilitation. These are some of the incidents that lend credence to the benefits that can be acquired through SPC. This emphasis on a positive psychological approach to behavioral improvement fits right in with the current positive Psychology movement (Seligman. (2) development of more effective methods of hypnotic induction. (3) development of more effective methods of giving post-hypnotic suggestions. and (4) development of SelfProgrammed Control (SPC).Ds or so called experts in order to help others. As I alluded to in the beginning of this book. Psychological Review 84: 191-215. stresscards. Barrios AA (2002) Science in Support of Religion: From the Perspective of a Behavioral Scientist. Doctoral dissertation. Barrios AA (1973a) Posthypnotic suggestion as higher-order conditioning: a methodological and experimental analysis. Banning. Friedman M. Journal of Abnormal and Social Psychology 68: 585. July 3 rd. Theoretical and Experimental Approach. Los Angeles. (This article can also be found in the articles section of www. 18-21. Contemporary Hypnosis 24: 123-138. Barrios AA (1970) Hypnotherapy: A Reappraisal.stresscards. 1973. SPC Press. Barrios AA (1973b) Increasing the effectiveness of hypnotic induction. University of California at Los Angeles. Barrios AA (2007a) Commentary on a theory of hypnosis based on principles of conditioning and inhibition Part I: Contrasts with other perspectives and supporting evidence. International Journal of Neuropsychiatry 1: 574-92. and Human Potentialities. 7: 2-7. Barrios AA (2007b) Commentary on a theory of hypnosis based on principles of conditioning and inhibition Part II: Benefits of the theory.) Barrios AA (1975) Self Programmed Control: Towards Greater health happiness and productivity. Imagination. . Contemporary Hypnosis 18: 163-203. Contemporary Hypnosis 24: 109-122.stresscards. Research and Practice. American Journal of Clinical Hypnosis 5: 163-70. Rossi EL. Cousins N (1989) Head First: The biology of Hope.com. (See also articles section of www.Barrios AA (1985) Towards Greater Freedom & Happiness. Calverley DS (1969) Multidimensional analysis of “hypnotic” behavior. Erickson MH. Barrios AA (1965) an explanation of the behavioral and therapeutic effects of the hallucinogens. Rossi SI. Recreation Management: The Journal of Employee Recreation. Cancer Federation Press. New York: Pergamon.A New Theory for Understanding and Appreciating the Power of Hypnosis 49 Barber TX. Barrios AA (1973c) Self Programmed Control: A new approach to learning. Proceedings of the Sixth Annual Conference of the Western College Reading Association. Chavez JF (1974) Hypnosis. Dorcus RM (1963). Dutton. pp. California. Health and Education. Paper presented at the VIth International Congress for Hypnosis. The International Journal of Clinical and Experimental Hypnosis 21: 32-50. Barber TX. New York: E. Barber TX. Spanos NP. See additional products section. Barrios AA (1969) Toward Understanding the Effectiveness of Hypnotherapy: A Combined Clinical.com) Barrios AA (2006) The Concentration Spiral on DVD. New York: Fawcet Columbine Books.com. www. Barrios AA (2001) A theory of hypnosis based on principles of conditioning and inhibition. Rosenman RH (1974) Type A Behavior and Your Heart. Journal of Abnormal Behavior 74: 209-220.592. (1976) Hypnotic Realities: The Induction of Clinical Hypnosis and Forms of Indirect Suggestion. New York: Irvington. Calverley DS (1964) Toward a Theory of “hypnotic” behavior: Effects on suggestibility of defining suggestion as easy. Fallacies in predictions of susceptibility to hypnosis based on personality characteristics.P. Sweden. Psychotherapy: Theory. Upsala. Sherman SJ (2000) The clinical importance of sociocognitive models of hypnosis: Response set theory and Milton Erickson’s strategic interventions. American Journal of Clinical Hypnosis 42: 274-292. New York: Harcourt. Unpublished doctoral dissertation. Teitelbaum. Gantt. . Osgood CE (1963) On understanding and creating sentences.B. Kirsch I (1997a) Response expectancy theory and application: A decennial review. Kirsch I (1985) Response expectancy as a determinant of experience and behavior. S (Ed. Kirsch I. Goleman D (1995) Emotional Intelligence: Why It Can Matter More Than I. Kroger WS (1977) Clinical and Experimental Hypnosis. Losak J (1972) Do remedial programs really work? Personnel and Guidance Journal 50: 383386.Q. Wickless C. Brace & World. Kirsch I. Personnel and Guidance Journal 51: 591-597. Hilgard ER (1977) Divided Consciousness: Multiple Controls in Human Thought and Action. Storrs. Lippincott. HA (1957) Some implications of conditional reflex studies for placebo research. Psychology: A Study of a Science. Maltz M (1960) Psycho-Cybernetics. Inc. Behavior Research and Therapy 1: 151-7. American Journal of Clinical Hypnosis 43: 294-311.50 Alfred Barrios Gliedman LH. American Psychologist 18: 73551. New York. Hernstein R (1962) Placebo effect in the rat. Moffit K (1999) Expectancy and suggestibility: Are the effects of environmental enhancement due to detection? The International Journal of Clinical and Experimental Hypnosis 47: 40-45 Knowles JB (1963) Conditioning and the placebo effects of decaffeinated coffee on simple reaction time in habitual coffee drinkers. Englewood Cliffs. Harlow H (1959) Learning set and error factor theory.:Prentice Hall. In Koch. Montgomery GH (1995) Mechanisms of placebo analgesia: Expectancy theory and classical conditioning. Hilgard ER (1965) Hypnotic Susceptibility. New York. NY: McGraw-Hill. Kirsch I (1997b) Suggestibility or Hypnosis: What do our scales really measure? The International Journal of Clinical and Experimental Hypnosis 45: 212-225. Mowrer OH (1960) Learning Theory and the Symbolic Processes. WH.J. Pavlov I (1960) Conditioned Reflexes. Science 138: 677-8. New York: Viking. Alshuler AS (1973) An introduction to the field (Psychological Education). Journal of Abnormal Psychology 58: 277-99. Applied & Preventative Psychology 6: 69-79. Rehyer J (1969) Sensory deprivation and the enhancement of hypnotic susceptibility. Orne MT (1959) The nature of hypnosis: Artifact and essence. Maslow A (1971) The Farthest Reaches of Human Nature. Ivey AE. Kirsch I (2000) The response set theory of hypnosis. American Psychologist 40: 1189-1202. American Journal of Psychiatry 113: 1103-07. University of Connecticut. Lynn SJ (1998) Dissociation theories of hypnosis. Psychological Bulletin 123: 100115. New York: Wiley. Lynn ST.). Bantam Books. N. New York. NY: John Wiley and Sons. 492-537. NY: Dover. Philadelphia: J. Journal of Abnormal Psychology 74: 375-81. Sanders RS. (Ed. Journal of Abnormal Psychology 76: 69-75. New York. Biofeedback and Self-Regulation 5: 5-18. 66-6781) Wrenn CG. (Eds. Spanos NP. & Lopez. N. NY: Appleton-Century-Crofts. Dreher H (1993) The Type C Connection.). (University Microfilms No. Stanford University Press. Wickless C. . Snyder. Handbook of Positive Psychology.E. Wickramasekera I (1973) Effects of electromyographic feedback on hypnotic susceptibility. S. some preliminary data and theoretical speculation. and positive therapy. Rivers S (1977) Experienced involuntariness in response to hypnotic suggestions.A New Theory for Understanding and Appreciating the Power of Hypnosis 51 Seligman MEP (2005) Positive psychology. Edmonston. Kirsch I (1989) Effects of verbal and experiential expectancy manipulations of hypnotic susceptibility. Wickramasekera I (1969) The effects of sensory restriction on susceptibility to hypnosis: A hypothesis. New York.R. New York: Random House. Temoshok L. Wilson DL (1967) The role of confirmation of expectancies in hypnotic induction. Wickramasekera I (1980) A conditioned response model of the placebo effect: Predictions from the model. Conceptual and investigative approaches to hypnosis and hypnotic phenomena. Jr. Journal of Personality and Social Psychology 57: 762-768. Hypnotism: An Objective Study in Suggestibility. positive prevention. Weitzenhoffer AM (1953). In W. Dissertation Abstracts International 28: 4787-B. Annals of the New York Academy of Sciences 296: 208-216.: John Wiley and Sons. The International Journal of Clinical and Experimental Hypnosis 17: 217-24. Wickramasekera I (1970) Effects of sensory restriction on susceptibility to hypnosis. C. Larsen RP (1955) Studying Effectively.) Skinner BF (1957) Verbal Behavior.Y. Journal of Abnormal Psychology 82: 74-77. . Koester and P. Research and Applications Editors: G. Hungary ABSTRACT In this study we review the process of the formulation of our interactional approach to hypnosis together with the development of a new methodology through various experiments. Inc. D. Delisle ISBN 978-1-60456© 2009 Nova Science Publishers. Another possibility of the interactional analysis is the use of the same paper/pencil tests for the hypnotist and subject. and in several of our experiments we compared their subjective experiences along their scores on the PCI factors. Eötvös Loránd University. Éva I. PEAT is suitable for eliciting and simultaneously gathering free reports on the subjective experiences from both interactants that later can be parallelly processed. Emese Józsa.In: Hypnosis: Theories. The first interactional method developed to detect interactional synchrony between hypnotist and subject on the subjective level is the Parallel Experiential Analysis Technique (PEAT). Budapest. First we used the Phenomenology of Consciousness Inventory (PCI) for this purpose. Bányai and Anna C. R. characteristic data are shown as examples of the phenomenology of the subjective experiences of hypnotists and subjects. The free reports of hypnotists about their subjective experiences were analysed separately as well and yielded three common topics that are illustrated by verbatim quotations from the original reports. We exemplify the special possibilities of the interactional approach of phenomenological data by a recent empirical result: we . DIH was validated in a series of experiments and it is a promising measure for tapping the interactional aspects of a hypnotic relationship. Chapter 2 PATTERNS OF INTERACTIONAL HARMONY: THE PHENOMENOLOGY OF HYPNOSIS INTERACTION Katalin Varga. Later we developed a new paper/pencil test. the Dyadic Interactional Harmony (DIH) questionnaire. On the basis of four experimental series. Gősi-Greguss Center for Affective Psychology. for directly measuring the synchrony of an interaction. We used PCI and DIH from hypnotist and subject as means of interactional analysis of subjective data along with the concept of hypnosis styles (maternal/paternal scores) in a real-simulator design. Vágó. Emese Józsa. but the hypnotist as well. behavioral. 1983. Fourie. the chapters of Bányai. 1982. Gősi-Greguss. Experimental hypnosis has been approached by our laboratory from an interactional point of view for decades: we have been investigating both parties of a hypnosis interaction. Bányai. Varga. so the hypnotist is just a participant of the subject’s hypnotic dreams (Sheehan and Dolby. Nash and Lynn. 1991). psychophysiological and phenomenological investigation of the participants (for results on these levels see Bányai. even the very interactional approaches investigate the hypnotic process from the perspective of the subject. 1980. All of these empirical results seem to add special new possibilities to the understanding of hypnosis and we encourage every researcher to follow this interactional approach and methodology.. 1984 or Bányai. Nash and Sheehan in Lynn and Rhue.g. 1986. 1983. Levitt and Baker. 1. as a social encounter between hypnotist and subject (see. 1979) or just the target of the subject’s perceptions. 1991). the phenomenological level of hypnosis also must and can be investigated in an interactional way. however. as in the other measures. here providing an archival accounting of our research on interactional phenomenology. results showed that the phenomenological experience of hypnosis is not based on genetic determination. the special relationship between the two participants. 1984. and Horváth. but the way interactants evaluate the session (the interaction itself) seems to be closely related to the degree of kinship. 594). Nash and Spinler. Perry and Sheehan. serving those who would like to study the subtleties. deprived attachment needs. “the flesh and blood of hypnosis—its multidimensional clinical richness and variation—only appears when hypnosis is viewed in terms of the dynamic interrelationships between real people” (p. relational. 1983. INTRODUCTION Interactional Approach in Hypnosis Research As Shor noted in 1959. These theories place particular emphasis on “rapport”. 1989. 1987. etc. Levitt and Baker. First we introduce our data on . We think that. 1985. In our experiments. the social-psychobiological approach (Bányai.54 Katalin Varga. e.. Nash. we investigate both of them. Bányai. i. and more and more theories conceptualise hypnosis as an interactional process. in which standardised hypnosis interactions of subjects of various kinship had been analyzed. Éva I.e. we miss the real target. 1990). Bányai et al. At the same time. 1991) conceptualizes hypnosis as a unique reciprocal interaction between hypnotist and subject: instead of limiting our attention to only one of the participants of the hypnosis interaction. no matter how deeply the subject is investigated. Mészáros and Csókay. 1989. 1980). 1978. Lynn and Rhue. Interestingly. for a review see Diamond. emotions. transference. That is why we present our original research data in detail. demonstrate the very different pattern of heritability in the case of subjective data as opposed to the behavioral score of hypnosis. Our empirical research in hypnotic interaction includes the attitudinal. Sheehan. not only the subject. This implies that we cannot really understand hypnosis on an individual basis. 1991. 1985. Since the early 1980s more and more theoretical and empirical work emphasize the interactional nature of hypnosis (Diamond. (see Baker and Levitt. Sheehan. In this paper we summarize our steps. Bányai. 42 years old 2nd series) 1 male. GősiGreguss (2006) E2: WSGC 110 healthy volunteer Ss (79 (=71.Patterns of Interactional Harmony 55 hypnotists’ phenomenology. Bányai and GősiGreguss (1994) .8%) females. Fromm. Fromm. Hilgard. 1989 and so on). 4 high.2) males 18 hypnotists (in 25% of the sessions a male. The subject’s subjective experience of hypnosis is not discussed in detail here because the subject’s phenomenology is a classical topic in the literature described by several authors (Shor. DIH Varga. 1989. Hurt. Matheson. 64 (=27. as there is no other systematic study about experimental hypnotists’ involvement in the process. 31(=28. J. first with the HGSHS:A. The details of the studies summarized in this chapter are introduced in Table 1. Brown. Then we present our methodological development: specific techniques for gathering subjective data of both participants and specific methodology for comparing the subjective experiences of the hypnotist and that of the subject. Boxer and Pfeifer. Shue and Bart. Fromm. Lombard. Fromm. Lombard and Sossi. 4 medium and 4 low) 2nd series: 12 (6 males and 6 females. we will show the special possibilities of phenomenological analysis within interactional framework. 4 high. Oberlander. with the help of two examples. DIH Varga. in 75% female hypnotist) 3 female hypnotists PCI. 1962.5%) males PCI. Bányai. Field. Finally. written or audiotaped) Reference 103 experimental hypnosis sessions 7 hypnotists (4 female and 3 male) 1st series: 12 (5 males and 7 females. 1981. 33 years old) PEAT 5 different female experimenter hypnotists PCI after SHSS:C Varga. Józsa. E1: SHSS:A Subjects Hypnotists Phenomenological methods Free reports (PEAT. Kahn. Bányai. Skinner and Kahn. 1989. 1965. Table 1. Some details of the studies discussed in this paper Hypnosis scale(s) TRH (5 hypnotists) or AAH (2 hypnotists) 1st series: waking control and a hypnotic part (SHSS:B) in a counterbalanced order 2nd series: SHSS:A The participants were hypnotized twice. Bányai and GősiGreguss (1999) Varga. 1979. GősiGreguss (2006) Varga. 1983.4%) females. 1977. GősiGreguss and Kumar (2001) 232 healthy volunteer Ss (168 (=72. 1987–88. Józsa. Pekala and Kumar. and then later with the SHSS:C. 4 medium and 4 low) 104 students (52 men and 52 women) 2 hypnotists: 1st series) 1 female. Józsa. Eisen and Fromm. Standardized age regression and trance-logic suggestions. Orne (1959) stated that the real essence of hypnosis lies in the subjective alterations experienced by hypnotized individuals. Kahn. Lombard. GősiGreguss. one has to investigate both partners in the hypnosis session. and Fromm. Form A (Shor and Orne. Ss: subjects. AAH: active alert hypnosis. and Pfeifer.d. 2 mediums. But to be truly interactional. 1990). H: Hypnotist. Bányai et al. Emese Józsa. WSGC Waterloo-Stanford Group Scale of Hypnotic Susceptibility. S. 1981. free dehypnosis. Éva I. Table 1. Tauszik (n. Gősi-Greguss. they would give rich and meaningful phenomenological data about their experiences. Form C (Weitzenhoffer and Hilgard. 1991). Form A or B Weitzenhoffer and Hilgard. 2 males) SHSS:A 62 MZ twins. 2. Subjects Hypnotists 32 subjects: for each H 8 young. PEAT: Parallel Experiential Analysis Technique. 1962). 1987–88. That is why we wanted to first test whether. All of these papers obviously were speaking about the hypnotized subject. the hypnotist . Bányai. 60 DZ twins. Fromm. HYPNOTISTS’ PHENOMENOLOGY In his influential paper. DIH Varga. DIH. SHSS: A or B Stanford Hypnotic Susceptibility Scale. 1983. Kahn. Lombard. Brown. altogether 278 healthy volunteer Ss 10 hypnotists Phenomenological methods PCI. 32 subjects 4 hypnotists (2 females. tested by a standardized cold pressor test. and 94 parent child pairs. Józsa and Gősi-Greguss (2008) TRH: traditional relaxational hypnosis. Józsa. Form C (Bowers.) Varga. For a long time hypnotists have been almost completely neglected in hypnosis research. 1982. The question arises: why? At the beginning of the history of hypnosis. Field. Lombard and Sossi. 2 lows and 2 simulators). judgement of hypnosis styles Reference PCI. 62 siblings. K. Fromm. Stanford Hypnotic Susceptibility Scale. Fromm. Oberlander. 1959). Bányai. Continued Hypnosis scale(s) Free induction. 1965. PCI: Phenomenology Consciousness Inventory (Pekala. Boxer. Skinner and Kahn. if hypnotists are really involved in the process of experimental hypnosis. Fromm and her colleagues have stressed that controlled assessment and description of phenomenological aspects are crucial to the understanding of the nature of hypnotic phenomena (Eisen and Fromm. 1998). HGSHS: A Harvard Group Scale of Hypnotic Susceptibility. 4 males / 2 highs. healthy volunteer subjects (4 females. 2006). free analgesia suggestion.56 Katalin Varga. DIH: Dyadic Interactional Harmony Questionnaire (Varga. Hurt. 1962). SHSS: C. 1989. Bányai. 1991. Varga. 1986. later this approach was reversed. common breathing rhythm and heart rate concordance between hypnotist and subject (Bányai. Free reports from hypnotists. mirroring the posture of the subject. and Horváth. working alliance. 1987. Lazar and Dempster. (c) the therapist-patient relationship (Brown and Fromm. symbiotic/fusional alliance and realistic relationship) operate subjectively. Frankel. Varga. Here we summarize our experimental data about the first step of collecting and analysing subjective experiences of experimenter hypnotists (see Table 1. of the possibility of leaving the normal. Vas. it is quite rare. 1987. for further details Varga. Sheehan and McConkey. So. 1991. Tart. Scagnelli. empirical signs of their deep “tuning in” to the subject. Vágó. Gősi-Greguss. waking state of awareness. There is no mention about the possibility of their emotional involvement. Bányai. Lynn and Rhue. 1985). Gősi-Greguss. But we can find very limited information about the experimenter hypnotist: one cause of this can be their reluctance to be analysed. 1992). In spite of these there are excellent works regarding hypnotherapists that describe (a) their countertransference (Gill and Brenman. and Horváth. 1990). Some influential theoreticians even explicitly deny the possibility of the development of archaic involvement within an experimental context (Shor. This important limiting factor raises special methodological. and Horváth. 1991).To get a systematic view on the . 1984). Gősi-Greguss. 1980. Experimenter hypnotists are often regarded as immovable figures. Varga. Bányai. the subjective. inner feelings of the experimenter hypnotist are almost completely hidden. Gravitz. before attempting to interrelate the subjective feelings of both participants of the hypnosis interaction. Vágó. 1991. 1969. Early research data about the hypnotists from our Budapest Hypnosis Laboratory are very important objective. and the possibility of the therapists' trance state (Diamond. Bányai. 1959) and (d) the determinants of a successful hypnotherapist (Diamond. 1986. deviation from the standardised text (Bányai. 1987. 1984). It is all the more surprising if we consider that Diamond (1987) emphasised that the relational dimensions of hypnosis (transference. Lazar and Dempster. Gill and Brenman. (b) the phenomenon of mutual hypnosis. and to uncover their own regressive. Hilgard. 1990. 1984. 1984). Varga. Fromm. of real transference or countertransference. and Horváth. because in 1813 Abbe Faria concluded that the process was more due to the subjects. Bányai and Gősi-Greguss. Even those. synchronous electromyographic activity during hypnotic suggestions (Bányai. the signs of interactional synchrony: hemispheric prevalence influenced by the subject's susceptibility. Brown and Fromm. Unfortunately. we should know what are their experiences at all. Varga. changing the duration of the induction procedure (Bányai. 1993). 1991. 1982) restrict themselves to the subjects’ phenomenological data. swaying motion of the hypnotist’s body in synchrony with the subject's breathing. 1968. 1959. 1959. During the past decades both hypnosis research and clinical reports stressed the subjects’ skills rather than the hypnotists’ contribution to the process (see Baker. Lazar and Dempster. motivational and even ethical questions. 1962). 1987. Gősi-Greguss. etc. Bányai and Gősi-Greguss. 1999). functioning unflappably according to the protocol of the (standardised) experiment.Patterns of Interactional Harmony 57 (magnetiser) was considered central in the process. unconscious material in a professional setting (Gill and Brenman. Mészáros and Csókay 1985. who stress the importance of the investigation of subjective experiences (Hilgard. 1986). that the hypnotists’ experiences were explored in detail (Bányai. 1992). 6. In all of the sessions healthy young volunteers— mostly university students—of different hypnotizability participated as subjects. Seven hypnotists' free reports were collected regarding altogether 103 experimental hypnosis sessions in which they conducted hypnosis. hypnotists’ phenomenology. Weitzenhoffer and Hilgard. while hypnotists 6th and 7th were using active alert hypnosis. No. . The basic data of hypnotists involved in this experimental series are presented in Table 2. 1999. The sessions were video recorded in full length. In the cases of TRH.) Table 2. Éva I. Here we demonstrate and discuss three important topics that are common in the reports: (1) the way the hypnotist evaluated and reflected the context (situation) of the hypnosis session. B. Bányai. C. We were looking for the common topics in the independent reports of different hypnotists. 1976. Form B/ Shor and Orne. After the hypnotic sessions all of the hypnotists gave free reports: an encouraging instruction was given to them. and (3) the (counter)transference reactions of the hypnotist (for more detailed results see Varga. Sex F M F M M F F Age 42 33 25 30 32 49 41 Hypnotizability 0 (SHSS:B) 5 (SHSS:B) 6 (HGSHS) 1 (SHSS:B) 12 (SHSS:B) 0 (SHSS:B) 12 (SHSS:B) Background EE C CC EE EE CC E CC CC After the sex (F: female. stressing that all of their impressions. Emese Józsa. or using activealert induction (Bányai and Hilgard. No. The standardized procedures of AAH sessions applied the active-alert versions of the test-suggestions (Bányai and Hilgard.7. supposing that the common elements should reflect the most important points in the hypnotists' phenomenology in general. /SHSS:B Stanford Hypnotic Susceptibility Scale.4. either by TRH (5 hypnotists) or by AAH (2 hypnotists). No. Basic data of hypnotists No. and the hypnotist was blind to the subjects' susceptibility. free subjective reports have been gathered under controlled experimental setting regarding the most important contents of the subjective experiences of the experimenter-hypnotists. inducing hypnosis either in a traditional way. feelings. 1–5 are the ones who applied traditional relaxational hypnosis. 1976). No. 1980). The hypnotists No. 1959. the number of the letters roughly represents the ratio of the involvement in these fields). /HGSHS: Harvard Group Scale of Hypnotic Susceptibility/).3.2.58 Katalin Varga. 1962.5. remarks were important. then contentanalysed. GősiGreguss and Bányai.1. Bányai et al. Method. 1962) which were read verbatim. (2) the subjective feelings reflecting the hypnotist's trance-like state. No. Finally the orientation of the hypnotist is indicated (E: experimenter C: clinician. they were asked to relate anything regardless of its perceived importance. 1959. No. The subject and the hypnotist didn't know each other previously. the Ss were hypnotized by standardized relaxational hypnotic induction procedures and test suggestions of the Stanford Hypnotic Scales (SHSS: A. M: male) the age and the hypnotizability of the hypnotists are presented according to the standardised scales (Weitzenhoffer and Hilgard. These reports were video-recorded. . I mean “let's go together to this state. Spanos. searching for my eyes. The origin of the quotations is indicated by the number of the hypnotist (H) and the subject (S) of the given session.. regardless of the way the report is gathered. and stirred. Coe and Sarbin.. 1984. The Context of Hypnosis from the Viewpoint of Hypnotist The outcome of the session is determined by the expectations and beliefs regarding the nature of hypnosis... Kennedy. and kept scratching.” . Both the subject’s (patient’s) and hypnotist’s (therapist’s) faith in the process play a major role in facilitating success (Diamond. 2. 1986). and it disturbed me all along. it has destroyed our relationship. 1988. Togetherness. Jarrett and Gwynn. I just realized. that she was simply doing her job. that silence and all devout attention and relationship in which all tiny hair's breadth trembling has its own significance” AAH (H6 S8/1): “..” Interactional Aspects. 1977. that I had to look at the text. Gabora. whether they label it as “hypnosis” or as an “experiment on imagination”—has surprisingly strong influence on their (hypnotic) performance (deGroot.. It didn't disturb me. If we have a more detailed picture about the hypnotists’ attitude it may take us closer to answering the burning question: what is the mechanism of the subjects' processing of contextual information having an impact on their performance and involvement in the situation. and Gwynn. since the hypnotist directly or indirectly communicates his/her own attitude. S6) “…the way I say. Research shows that the way subjects conceptualize the situation of the hypnosis session—for instance. as well. 1941). White. and it was bad for me. compared to the feelings between me and the subject. Naturally the analysis of the same phenomenon on the part of hypnotists could be interesting: the way the hypnotist perceives the situation and interprets his/her own role may be influential on the subjects' perception. a completely equal relationship. 1989). the active alert hypnosis seems to change our energetic matters as well.” AAH (H1 S8/1) “she has turned to me many times.There is no doubt. This inevitably requires unique attitude and special mood in the hypnosis session. Mutual Involvement TRH (H1. a kind of holy.. Gwynn and Spanos. S2) “The presence of the observer was calming.Patterns of Interactional Harmony 59 Verbatim quotations will serve as examples for these features. this is “something”.. I think she experienced a kind of loneliness. having a special spirit and atmosphere (the observer’s behaviour) is so vulgar. While reading the quotations please note that the demonstrated phenomena occured independently from the hypnotizability of the hypnotist.. 1986. extreme energies are involved here. without the feeling.1. and regardless of the professional orientation of the hypnotist. The context-generated expectancies and the role demands of the situations labeled “hypnosis” are central elements in the socialpsychological account of hypnosis (Spanos. Spanos.. About Hypnosis TRH (H3. that . though at the beginning she was not noble enough and it didn't fit to the fineness of the situation as she turned her pages.. 1984.(. the spinning of the pedal.in rather . like this?” AAH (H6. 1986. 1987). but it didn’t went. 1976. 1983) can be documented in experimental hypnotists’ reports as well. 1977/79)...) this arose from her. because why would I relax in a situation. As “most hypnotherapist spontaneously experiences trance when hypnotizing their clients” (Diamond.60 Katalin Varga. But these studies present this issue as specific for therapeutic sessions and suppose that it is unlikely to occur in experimental hypnosis. I don’t know why... This subjective element is easily available for the person so s/he can identify this state without doubt. she will accept the situation!” AAH (H6. S10) “It is difficult to put my experience into words.. Haley.) I had an image of a man sitting cross-legged. 1969). we repeat the conditions: to co-operate.” TRH (H5.. Bányai et al. so I also do together with him up to the end... Many theories—in spite of the methodological controversies—postulate.. I was not aware of this at all... 1989. Diamond stresses the importance of systematic research studying the hypnotherapists' trance experiences in order to move from purely speculative analysis of the nature of these phenomena (Diamond.. 9. (. I felt that this is good. 1993).... 1984. 2. Among others Tart (1972) and Orne (1959) stress that the subjective conviction that somebody is in an altered state of consciousness (ASC) is a crucial factor in detecting the state. and just to listen to my voice…this is the repetition of the rapport. counter-trance (Vas.2. Éva I. 1958. because there are mostly pictures inside me. 1980) and related phenomena have both theoretical and practical significance. in the introduction as a matter of fact.) TRH (H1. Tart.).. S10) “The rumbling in my stomach was due to relaxation .and you can feel where we are...during hypnosis you get the feedback from the face. S2/1) “. S5) “I feel this is very important.” AAH (H7 S1/1) “(arm rigidity suggestion) I simply had to raise up my arm. it was extremely good. etc..If she stands this without uneasiness. S2/1) “When I hypnotize I am at least as hypnotized as the subject. that I could relax. the posture. the client as hypnotist hypnotizing the therapist (Diamond. Emese Józsa... or just characteristic of the hypnotized person... 1972. to concentrate. Signs of Alteration of State of Consciousness The concept of the hypnotized subjects’ trance state is fundamental in the neodissociation theory (Hilgard...... the hypnotist—may get into an altered state of awareness is well documented regarding clinical hypnosis sessions: mutual hypnosis (Tart.When I entered my first impression was that this man exists just inside of his skin (. Pekala.. The possibility that the other participant of the dyad—i.” TRH (H1. We think and support by quotations below that the characteristics of trance(like) states (Ludwig. and Kumar. S2) “Look. 1972. p. I say things like this completely out of my control. Professional Remarks TRH (H2.) meanwhile once I’ve tried to let it down.e. Steinberg. that the best index of an ASC is the person’s subjective experience of being in the state (Farthing. Pekala and Kumar. and an important element in the “state” or “special process” theories either as causal variable. 1992.... because the inside of him is lively.239. S9) “I definitely remember that I had something in my mind at this point.. because the message must have the form that would be most conductive to the subject's frame of reference or awareness (e. that the notion of “dissociation” had been “reserved” for the subjects so far. To reach this. Bányai. 1987). colourful.I have no idea. who felt it. 1986.feel together…maybe it was me. and “may evoke greater sensitivity to and feeling of intimacy” (Lazar and Dempster. Diamond.. S1) “At this moment I had a feeling in my body…it was a strange feeling: ‘don't go further!’. thought.. It is needless to stress.I had a completely pleasant feeling. 1986.. In his writings Diamond strongly stresses (1984. S2/1) “When I hypnotize. Vágó. my arm gets heavy first…at the arm rigidity I feel that my arm is rigid and stiff. what I wanted to get..32. the extremely detailed observation of the subject and absorbed attention are all factors that may lead to ASC. and I felt: ‘Backward! It is too quick for her!’” AAH Q (H7 S1/1) “. p. surely. 1984. it was comfortable for me. Usually deep. 32) or as the hidden wish to satisfy his regressive longings (Gill and Brenman.” TRH Q (H1.....” TRH Q (H5. which in turn facilitates the therapist’s ability to employ a “language” appropriate to the patient’s operative state of consciousness” (p. again. those kinds of effects of the suggestions that I myself felt.The hypnosis is difficult at these times.. and it is very difficult for me to remember what they say…the numbers.. 1959) and related dynamic/analytic concepts. 1990. This “facilitates the ability to be empathic with and receptive to the patient” (Diamond. but I don't remember what.it was very good for me…so it was enjoyable to read in this strange hypnosis. 1987) the therapists’ trance as one contribution of hypnotherapists in their clinical practice. mystic. surprising. Gősi-Greguss.” TRH Q (H1. 1986.” AAH Q (H6.) . that parallel with these alterations in cognitive functioning the hypnotist must keep control and takes responsibility of the whole process. strange.. my fantasy begins to work. p.. 1991. And he is sitting there so calmly. and Horváth..Patterns of Interactional Harmony 61 primitive circumstances . throughout from now. S9) “Sometimes I felt…that we were definitely together. 1984. Varga. Hypnotist focuses upon the subtleties of communication. in spite of the fact that I am the one who gives the suggestion. p.the life goes on. at the dream suggestion. physical-body involvement may help the hypnotist to bridge the gap between himself or herself and the patient (Bányai. but I think she also felt this kind of easiness. changing. p. joyful. S2/1) “When I hypnotize.” AAH Q (H7 S1/1) “I was not sure even that he had said ‘21 years’ (actually it was half minute earlier)... as if I entered a circle.....g. We can not forget. I start to dream.). trance state) (Diamond.. the hypnotist usually moves from the normal state of awareness to get closer to the subject’s state. This requirement involves dissociation on his/her part: at least one subsystem must keep the functions of reality-testing.” AAH (H6. 243).. The signs of ASC are possibly the natural consequences of the setting of hypnosis and the role of hypnotizing itself.244... planning and monitoring.) with the subject.” The shift from the normal state of awareness on the part of the hypnotist are explained by some theories as “dependency needs (that) are revoked by the subjects’ regression” (Lazar and Dempster. The intensive concentration.. Her face became so aggressive. 38. S9) “As she got relaxed her mouth curved down. 1992. TRH (H5. formerly complete strangers. The one whom you snap up into your arms willingly. GősiGreguss. 1989. Others (Hammond... and the issue of “appropriate language” is especially interesting in the experimental context. Bányai and Varga. Varga. the way they communicate and distribute information-channels (one with closed eye. The nature of the message exchanged between the hypnotist and subject is always determined in the hypnotic context (Haley. 2. Sheehan. really. In this intense. 2002.. other influencing by mere words) is very special.” (deep breath and coughing. Bányai et al.. Gősi-Greguss. Bányai. 2004) may be one of the objective indices of hypnotists’ trance states. The relationship between hypnotist and subject is most commonly approached by the process of transference. 1958). The experimenterhypnotists' ASC may urge them to use a language according to the demands of their own trance states instead of the standard protocol.. Gősi-Greguss..she stole her way into my heart. It disturbed me! She reminded me of the secretary of Dr. Nash. or archaic involvement (Horváth... and turning to other topic).. and Vágó. yes . S4) “She is a kind of woman whose eyes are worth looking into for a long. and it made her awfully antipathetic. they must reach a predetermined goal under limited time with special means. Varga.62 Katalin Varga.. If..3. AAH (H2 S8/1) “I like so much these type of persons. meet for the first time in their lives. long time.… and somehow very good type of men…I really like... SuhaiHodász and Varga. 1988..). 1991.. that almost all controlled experiments employ standardized.I take a shine to these kind of girls.” AAH (H6. enter an interactional process where the ways they seat themselves (proxemic). S2/1) “She was a sweet little girl. Bányai... verbatim inductions and suggestions. K. Éva I.. Emese Józsa.” (K: a head of another department). Józsa..It was like playing.All in all.. Our material yielded rich data on this respect: TRH (H4. 1996.. The restrictions of the standardized text may increase the inner tension (dissociation) in the hypnotists.. sometimes embarrassing situation it is natural to re-evoke earlier relationship-patterns and find one's way in the situation by their help. Nash and Spinler. Our result showed that usually an accidental physical resemblance to some relatives or other important persons in the hypnotist’s life evokes the transferential feelings. This way the amount and type of departure from the standardized text and changes in affective prosody (Gősi-Greguss.” . Transference on the Part of the Hypnotist An experimental hypnosis session is a very special situation: two persons. and simply ‘trusting the unconscious’ to formulate suggestions and conduct hypnotherapy” (p.her body as well. Bányai. Gősi-Greguss.. Enhanced receptivity and empathy are obviously important in experimental settings as well. but consider. this Rita is a really nice girl. and Horváth. and the whole process is recorded under very detailed observation. 1980). very intelligent. 1991) also discuss the possibility of “going into a trance oneself. this very clever. which leads them at a certain point to break the rule. 1982–83) developed the Experiential Analysis Technique (EAT) . 1962) so as to be able to gain the most from the benefits of the functions of the dissociation (Ludwig. DEVELOPMENT OF INSTRUMENTATION By demonstrating that even experimenter hypnotists have rich and important phenomenological data. Brown and Fromm. or undetected? (b) As almost all of our experimental settings showed the signs of some types of (counter)transferential feelings. 3. Clearly. well controlled situations? What if one of the most important features of the hypnotists' involvement—that is (counter)transference—remains uncontrolled.g. p.1. but not completely unresponsive to the actual situation” (Wachtel. Brown and Fromm (1986) defines countertransference as a situation. 215). “complex mode of interpersonal relation in which the therapist (hypnotist) comes to assume a particular importance for the client (subject) that is not accounted for in terms of normal social or psychological processes of interaction” (Sheehan and Dolby. the detection of signs of countertransference in experimental hypnosis sessions has some important implications: (a) What can or must be done if experimental settings are “infected” by these transferential feelings on the part of the experimenter-hypnotist? Can we say that the experiments remained standardized. They may feel for and about certain patients. emphasis added). In our view. 1978. though. 1987 about this distinction). In this case. the aim of the hypnotist is to find an appropriate position for himself or herself in the dimension from drive-organised primary process to concept-organised secondary ones (Hilgard. p. 1982. as if these patients were important figures from their own past” (Brown and Fromm. Parallel Experiential Analysis Technique (PEAT) Sheehan and his colleagues (Sheehan. it is rather a natural phenomenon than an unwanted side-effect to be minimised. based. and react to them. p. we had to develop appropriate methodologies for recording phenomenological data in interactional approach. 1979. 1983). These occasions are supposed to be dangerous for the success of the therapy. 3. Sheehan and McConkey.Patterns of Interactional Harmony 63 Wachtel’s comment on transference is especially relevant here: “(transference is) a particular way of organising new stimulus input. We wanted to enrich the research arsenal by methods that are suitable for both the subjects and for the hypnotists. Sheehan. If this is true. and other definitions of (counter) transference: e.328. where the “therapists sometimes look at patients through the distorting lenses of the past. 1973. McConkey and Cross. even the transfer of the patient to another therapist is suggested (Lazar and Dempster. 1986). 1984. 573). one hypothesizes that this phenomenon must be more frequent in clinical settings as well. Close analysis of the countertransference reactions in experimental context may help to differentiate the helpful countertransference—as a way for being in tune with the various aspects of the patient's personality—from those of antitherapeutic ones (see Diamond. 1986. the above examples match this. Apart from clinical evidence. Parting the Participants of Hypnotic Interaction After the hypnosis session the hypnotist briefly described the importance of the registration of subjective experiences. Video Picture In the interactional modification of EAT it is important to use a video recording of the hypnosis session where both of the participants can be seen. The essence of this technique is that the report of a hypnotic subject on his/her subjective feelings and thoughts is stimulated by the video-playback of the original hypnosis session. The problem arises however. called Parallel Experiential Analysis Technique (PEAT) has been described in details in Varga. 1982). Emese Józsa. whom s/he introduced by telling his/her name and affiliation. that the difference in the two separate inquirers' style and personality may result different influences on the reports. it is advisable to work with inquirers who share as many characteristics (age. immediately after the session: in this case both S and H can give fresh and spontaneous remarks. experimental research (Bányai. the same instruction and procedure was applied as those used by the original EAT method (see Sheehan and McConkey. and leaved the subject alone in the chamber. Inquirers It is better to use two inquirers interviewing the subject and the hypnotist simultaneously but separately. Nevertheless.64 Katalin Varga. The whole “parting ceremony” of hypnotist and subject was standardized. In this situation an independent inquirer listens to the subjects’ reports (for details of the original procedure see Sheehan and McConkey. Our interactional approach required to extend this procedure to the hypnotist. gender. in order to reduce the possibility of such differences seen above. Bányai and Gősi-Greguss (1994). and some of the preliminary results that later proved to be relevant (see Table 1 and Figure 1). and a single inquirer may mediate between the two reports. even the most comprehensive report on EAT (Sheehan and McConkey. The new method. here we restrict ourselves to the most important methodological points. So we analysed the effect of different inquirers: our results showed that only one thematic category was influenced (the male inquirer elicited more negative statements than the female). This parting leads both of them to a situation where they are supposed to give honest and deep reports on their feelings. hypnotic susceptibility. It would be very tiring for one inquirer to listen to the reports of both S and H one after the other. biasing the second by losing his/her independence. but this effect was observed only in the case of subjects. We think that the most important methodological point researchers using PEAT have to consider is the parting of the hypnotist and the subject at the end of their hypnosis interaction. 1982). Althought we did not compare this kind of picture systematically to a recording where only the subject is seen. for gathering data on hypnotic subjects' phenomenological experiences. Éva I. and reasoned that the subject would be interviewed by an independent person. and so on) as it is possible. we have the feeling that the “dyadic” picture elicit more comments on the partner. . 1982) misses to mention who is (or who are?) seen in the video picture used (subject alone or together with the hypnotist?). When the independent inquirer came in to interview the subject. Bányai et al. Unfortunately. Tearing them from this relationship and asking them to report on the hypnosis session is a problematic point. It is of vital importance to give an encouraging instruction to the hypnotist as well. The main groups of categories were as follows: 1. as the hypnosis session or the PEAT session with the subjects. sleeping. Data Analysis The subjective experiences related by the subjects and by the hypnotist were content analysed separately. 1989): so parting with the hypnotist immediately before the (P)EAT session doesn't exert equal effect on subjects of different hypnotizability. comparison with other states of awareness (waking. In our experiments the PEAT session with the hypnotist took place in the same or in a very similar experimental chamber. and sometimes the report was given in a high emotional tone. attitudes to and preconceptions and/or knowledge about hypnosis. but not deeply involved. A category system (of about 90 categories) covering the topics and features of the reports was developed to analyse the experiences.Patterns of Interactional Harmony 65 1991) also shows that very strong emotional bonds may develop between hypnotist and subject. One can follow several ways when comparing the independent reports of subject and hypnotist: • • • actual thematic concordances can be looked for independent raters can judge the degree of harmony between the reports temporal changes of the dynamics of the concordances in the independent reports can be followed. That is why it is crucial that before parting. 7.). even in the original form of EAT (where only the subjects are involved). etc. 3. Furthermore this problem is connected to the hypnotizability of the subjects: the higher is the susceptibility of the S. ego-involved topics. remarks on relational and emotional experiences. 6. ego-involving experiences. In our experiments the hypnotists during PEAT occasionally turned to very intimate. . and to remain within the strict experimental conditions determined for them in this method. and should briefly explain the scientific importance of the independent way of discussing subjective feelings. the hypnotist should put trust in the inquirer. 5. signs of alteration of consciousness. 2. the stronger is the observable bond to the hypnotist (Nash and Spinler. 4. to give a detailed report about his/her experiences. It may be difficult for the inquirers to handle these situations: to be empathic. The Hypnotist's Report It is equally—if not more—important to make every effort to help the hypnotist too. situational and contextual factors. It is important to train the inquirer to acquire the appropriate attitude: helping the hypnotist to change his/her role and creating an atmosphere where self-disclosure can take place. sometimes reaching the deep archaic layers of their personality. general evaluation of the state or of process. B.66 Katalin Varga. we realized that if we follow the video recordings of the two reports simultaneously—for instance. In some parts the hypnotist's and the subject's reports conflicted with each other. or judge the degree of harmony between the reports. on two monitors—we can detect characteristic changes in the degree of harmony between them. The agreement between the reports is sometimes striking. and so on. The rater may look for thematic concordances. Emese Józsa. Data analysis: comparing the independent reports by viewing it simultaneously on two monitors. In these latter cases the two people commented on the events in the same way. in the presence of independent inquirers (I1 and I2). Reports of hypnotist and subject separately. Steps of PEAT. 1. stimulated by the video recordings taken in step 1. 3. but there were points where the independent reports were in very high concordance. Bányai et al. Some verbatim quotations exemplify these concordances: . Thematic concordances: In the course of analyzing our records. Éva I. Original hypnosis interaction. they sometimes used the same expressions or metaphors describing their feelings and experiences. Below three points (A. • by intercorrelating the frequency of the appearance of specific thematic categories the hypnotic interaction in general can be characterized With the help of PEAT one can even utilize the opportunity that a video recording offers an objective time measure on the basis of which slight temporal changes can be followed: this way we can describe the dynamics of the interactional process. the color tone of their imagery scenes was the same. C) will illustrate the interactional nature of PEAT by demonstrating some connections between the subjective reports of the subject and that of the hypnotist. recorded. Figure 1. and discrepancies or concordances can be discovered in the timing of comparable features in the two participants' experiences. 2. A. 2008). As in PEAT the participants of the hypnosis interaction relate their experiences and feelings. respectively.referring to their “positive relationship” with the hypnotist . which indicate his cognitive style: these were: (1) . smiling). 1998. This connection was even stronger with low hypnotizable subjects (r=. the nature of the hypnotists' relational and emotional involvement in hypnosis and their so called working styles were different: One of the hypnotists (1st series) relied mainly on her physical feelings.10): that is. the subject said: “.53. This analysis was one of the first studies where the various working styles of hypnotists have been described. the same category in the subjects' reports . 1990. joint movements and posture mirroring in overt behavioral level. 1985.. or the common breathing rhythm and parallel myographic activity at the physiological level (Bányai Mészáros and Csókay. 1991). 1985. and their reports indicate a very fine harmony of their experiences.. Józsa and Gősi-Greguss.96. while the hypnotist in the second series remained at a more analytic. According to our analysis of different levels of the hypnosis sessions. however. Analysis of the subjects’ verbal reports given by PEAT showed that the degree of the subjects' “positive relational experiences” is closely connected to these different styles: In the 1st series the “positive relational” category in the subjects' reports showed tendency to correlate positively with an interactionally synchronous physical phenomenon. Bányai. using his cognition instead of his body. We postulated that in most of the cases the points of concordance indicate a deep attunement between the hypnotist and subject. 2002. it is very interesting to find that these independent reports still match each other.I felt that I was in a very deep hypnosis” while the hypnotist said: “I felt that he was in a deep trance” b) Subject: “at the end it would have been good to stay and continue. Varga and Horváth. Varga. Bányai. p<. and comment on the events of the hypnotic session completely independent of each other.g. 1991.. In the 2nd series.” c) Subject: “At this point there was something like sunshine. This phenomenon can be considered as another sign or example of interactional synchrony. Bányai.g. e. These styles were labelled as “physical-organic” and “analytic-cognitive”. Gősi-Greguss. Bányai. with the time ratio of the matching of breathing rhythm of the hypnotist and subject during the hypnosis session.. Vágó. cognitive level.was closely connected to those contents of the hypnotist's reports. p<. where they have common subjective feelings and associations.Patterns of Interactional Harmony 67 a) Commenting the same part of the session.” Hypnotist: “I felt that he would like to go on enjoying this hypnosis.05). with a beautiful calm feeling” Hypnotist: “At the moment a nice warm feeling spread over my body. Bányai. 1982. B. with the amount of the so called “common breathing rhythm and pulsation” (r=.” It is important to underline that these points of concordance cannot be attributed to the observation of obvious behavioral features (e. Bányai. apart from those that were described in other levels of the investigation.. Later on a detailed description and operationalization of hypnosis styles has been published (for detailed description of these styles see Bányai. Memory.65. Meaning). 1991). Kumar.05). Woodside. p< . and (3) the “professional statements” category (r=. This makes it a bit difficult to use it in relation to other measures. out-of-the-body experience (Maitz and Pekala. Pekala and Cummings (1996) reported a five factor scoring method of PCI. in that the factors of dissociative control. Concentration). Negative Affect (Anger. where only five scores characterize the phenomenological state of a person. The difficulty is even grater in the interactional approach. Attention (Direction.75. and firewalking (Pekala and Ersek. and with the “general good feelings” of the hypnotist (r=. and Woodside. p<. the intercorrelation of the participants' subjective experiences shows a very different pattern in the two series. Sadness. the “amount of interpretation” (r=. p<. So. In sharp contrast with these correlations. Imagery (Amount. 3. 1993).02). Our results are consistent with those of Kumar. Éva I. Five-score Version of the Phenomenology of Consciousness Inventory The Phenomenology of Consciousness Inventory is a paper and pencil test with 53 items. with the “total number of positive comments” of the hypnotist (r=. 1988). PCI seemed to be a good paper and pencil test to tap this aspect. Altered Awareness.68. As our earlier data proved that experimenter hypnotists’ free reports contain many details regarding their own alteration of state of consciousness. The intercorrelation of the categories of hypnotists' and the subjects' subjective experiences showed the following: In the 1st series the frequency of the subjects' reports on their “positive relationship with the hypnotist” correlated positively with the hypnotist “positive emotional-relational involvement” (r=. Kumar. none of these categories of the hypnotist of 2nd series correlated significantly with the subjects above mentioned category. Arousal. Time sense. Sexual Excitement. 1997). Emese Józsa. But originally PCI has no final score. measuring the subjective alteration of consciousness on 26 dimensions (PCI. Pekala.05). as the PCI have been used in wide variety of stimulus conditions (such as progressive relaxation and deep abdominal breathing (Pekala and Forbes. drumming and trance postures (Maurer.01). Kumar. to score their own feelings and experiences. The Hungarian version was validated by Szabó (1989. Positive Affect (Joy.2. (2) the “comments on his strategy in hypnosis” (r=. p<. 1982. Bányai et al. Pekala and McCloskey (1999). Perception. Pekala. and attention to internal processes were . positive affect.81. Especially. 1992–93) it was just one step to have hypnotists complete the Phenomenology of Consciousness Inventory as well. 1980. it gives 26 scores on the above mentioned scales and subscales. Vividness).01). PCI is suitable to map phenomenological states by having subjects complete it in reference to a preceding stimulus condition. Pekala. Internal Dialogue.63. 1991ab.05). Steinberg and Kumar. p< . p<. Love). see also Szabó. In our study we wanted to test via a confirmatory factor analysis (CFA) if the covariance matrix of phenomenological report during the entire SHSS:C administration in this study conforms (or fits) to that found in previous work (Kumar. Fear). Volitional Control. where the scores of both participants are taken into consideration. C.60. Self Awareness. 1997. 1986): Altered Experience (Body image. and Pekala. Pekala and Cummings. 1996). in reference to the preceding “hypnotizing” period.68 Katalin Varga. Rationality. Development. Brown. 4. Dissociative control: Higher factor scores reflect alterations in (a) trance effects associated with altered state of awareness and altered experiences (body image. 2001). Józsa. This fit suggests that the five factor model of the PCI obtained earlier with the HGSHS:A might be productively extended to other scales (the SHSS:C). in a different linguistic and cultural setting (see Table 1. 3. Visual imagery: Higher factor scores reflect more visual imagery (amount and vividness). for further details Varga. more love. Positive affect: Higher factor scores reflect more joy. The main motive for the development of this questionnaire was to get a measure that is: a) short and simple. and internal dialogue (i. In an earlier study. c) not specific for . and arousal.001) with the SHSS:C score. evaluated by the participants of the interaction themselves. Gősi-Greguss and Kumar. Pekala and Cummings (1996). b) easily applicable for parallel processing of the data. visual imagery. more sexual excitement. internal dialogue. the dissociated control factor combines Spinhoven et al. or when the PCI was completed in reference to the entire scale (as was done in our later study). and meaning) and (b) ego-executive functioning (Fromm. 5. and low imagery vividness. inward directed attention. 1978. altered meaning. these results hold whether the PCI was completed by the subjects in reference to a four-minute interval embedded in the hypnosis session (as in the original application of PCI). altered body image. perception. sadness. Both for hypnotists and subjects we calculate five scores. 3. The most important characteristic of this measure is its direct focus on the interaction itself. and altered perception.. but low rationality. Bányai and Gősi-Greguss. rationality. altered state of awareness.e. Attention to internal processes: Higher scores reflect greater alterations in time sense and perception.Patterns of Interactional Harmony 69 significantly correlated (p < . 1975). 1981) and reality orientation associated with decreases in memory. Negative affect: Higher factor scores reflect more anger. 2006. on the basis of these results we included PCI to our research arsenal. 2. Weitzenhoffer. Pekala and Cummings (1996). According to Kumar. The confirmatory factor analysis on the Hungarian data revealed a reasonably good fit for the factor model found by Kumar. 1992). Standardization and Validation of the Dyadic Interactional Harmony (DIH) Questionnaire The next step in the formation of our interactional methodology was the development of a new paper and pencil test called the Dyadic Interactional Harmony (DIH) questionnaire (Varga. 1981. see Appendix 1). Józsa. volitional control. the classic suggestion effect. Vanderlinden. Ter Kuile and Linssen (1993) had found two factors. That is. Hurt. Boxer and Pfeifer. greater absorption. time sense. even though there were methodological differences between the two studies. trance and reality orientation. associated with a shortened version of the PCI administered within the context of the Stanford Hypnotic Clinical Scale (Morgan and Hilgard.’s two factors into one factor. Oberlander. fear. So.3. as defined below: 1. Bowers. Bányai. Spinhoven. At first data were collected on 232 subjects in standardized individual (E1: Stanford Hypnotic Susceptibility Scale. WSGC. love. The interactants independently fill in the questionnaire indicating how much each feature characterized their recent interaction on a Likert-type scale. Bányai et al. 66 and 72% respectively. Cronbach alpha: 0. harmony.05.65** 0. but provides clinically meaningful data as well. as their Cronbach alpha values ranged from 0. In case of the individual sessions (E1) the measures were applied for the hypnotists (Hs) as well. Bányai. On the basis of these factors.01 Intimacy Communion Playfulness E2 E1+E2 E1 E2 E1+E2 E1 E2 E1+E2 (N=106) (N=337) (N=231) (N=106) (N=337) (N=231) (N=106) (N=337) 0.85). In the mutual Rorschach test situation the interacting partners should come to an agreement regarding the meaning of the ink-blots of the “classical” Rorschach-test.g.62** -0. fear. Bowers. Éva I.78). SHSS: A. accounting for 72% of the common variance. The standardization DIH data of Mutual Rorschach situation were factor analyzed. Communion (items like understanding.57** 0.31** -0. Of course after standardization we applied DIH to hypnosis sessions as well. as it was the case in the original standardization sample as well. Emese Józsa. Form C.92. Cronbach alpha: 0. Tension (items like anxiety. 1959) and 110 subjects in standardized group hypnotic sessions (E2: standardized protocol of Waterloo-Stanford Group Scale of Hypnotic Susceptibility. inspiring.25** . Weitzenhoffer and Hilgard.29** -0. 2.28** -0.00 0. 1999).70 Katalin Varga. PCI) were applied to validate the DIH subscales on a hypnotic sample.00 0.17** -0. 58. four subscales were created (3 positive and 1 negative). e) suitable to characterize the degree and pattern of harmony between the interacting participants. Wynne and Singer. where other measures of hypnosis (e. Gősi-Greguss.43** -0. Cronbach alpha: 0. Form A.59** 0. The subscales of DIH are not independent from each other (as can be seen in Table 3).69** 0. shows the data of factoranalysis of DIH. The Hungarian version of DIH was standardized in a sample of 256 subjects (Varga. 4.77 to 0.81). d) not restricted to experimental hypnosis sessions.59** 1. Cronbach alpha: 0. 1998). hypnotic interactions. Arnold and Eraschky. Correlations of DIH subscales (data of the subjects) Intimacy Communion Playfulness Tension E1 (N=231) 1. who were interacting in pairs in a non-hypnotic setting in a so called mutual Rorschach test situation (for the test see Engelbrecht. 3. ** p < .06 1. each having good internal consistency: 1. using iterated principle factor analysis with varimax rotation. 1987 and Loveland. from 1 (not at all) to 5 (completely). The hypnotist (H) and the subject (S) completed the questionnaires independently. hypnotic susceptibility. Table 3.86).51** 0.03 * p < . Appendix 2. Four factors were obtained. DIH lists 50 items: nouns and adjectives that are characteristic of various kinds if dyadic interactions.00 -0.41** -0. The cumulative explanatory values of these factors are: 42. Intimacy (items like passion. The four subscales had good internal consistency in this hypnotic sample as well. 1963).53** 0.63** 0. Playfulness (items like humour. so the perceived quality of the interaction by the hypnotists seems to be more closely related to the subjects’ hypnotizability scores than the DIH values of subjects themselves.19* 0.08 0.00 0.13* 0.00 -0.01).30** 0. It means that high level of susceptibility is characterized by an intimate and playful atmosphere with better communion between H and S.27** 0.06 0.04 0.05 0.17* 0.11 0.22* 0.21** 0.09 0. Table 5.02 0.21** 0.11 0.50** -0.13* 0. SHSS susceptibility scores of subjects have a low to moderate but significant positive correlation with their Intimacy.10 -0.27** 0.29** 0.24** S – scores of the subject.16* -0. Relationship of DIH with the other Measures of Hypnosis The correlation coefficients of the subscales of DIH and the other measures (SHSS: A.15 0.32** -0.14* -0.06 -0.01).51** -0.10 0.62** -0.05.29** 0.04 -0. WSGC and the 5 factor-based scales of PCI) are presented in Tables 4 and 5.01 -0.12 0.01 0.40** 0.06 0. ** p < .01 0. 9–12 High . ** p < .41** -0.08 0. 5–8 Medium susceptibility.02 0.04 0.82** 0.14* 0.05 -0.48** -0.14* 0.16* 0.07 -0.09 -0. Correlations of the DIH subscales with the other tests in E2 E2 N Intimacy DIH Scores of the subject Communion Playfulness Tension WSGC PCI DC PCI PA S PCI NA S PCI VI S PCI IA S 106 106 106 106 106 106 0. As it can be seen in Table 4 and 5.29** 0.33** 0.27** 0.14* 0.01 0.00 0.09 0. Correlations of the DIH subscales with the other tests in E1 Tension Intimacy Communion Playfulness Tension 231 228 228 228 228 228 227 227 227 227 227 Playfulness SHSS-A PCI DC S PCI PA S PCI NA S PCI VI S PCI IA S PCI DC H PCI PA H PCI NA H PCI VI H PCI IA H DIH Scores of the hypnotist Communion N Intimacy DIH Scores of the subject E1 0.20* 0. H – scores of the hypnotist (* p < .41** 0.03 0.14* 0.16 0.50** -0.12 0.13 0.34** 0.30** 0.06 0.14* 0.13* 0.16 -0.21** 0.02 0.21** 0.22* -0.18** 0.58** 0.13 0.14* 0.01 0. Communion and Playfulness DIH subscales.45** -0.63** -0.21** 0.06 -0.05.19** 0.08 0.08 S – scores of the subject (* p < .06 0. Furthermore the above DIH scales of hypnotists show higher positive correlation with the SHSS values.50** 0.26** 0.17* 0.46** -0.01 0.15* 0.00 0.00 0.Patterns of Interactional Harmony 71 Table 4.11 -0.19* 0.03 0.06 0.19** 0.11 0.14* 0.65** -0.29** 0.06 0. On the basis of their susceptibility scores the subjects were arranged into three groups of “susceptibility range”: 0–4 Low susceptibility.00 0.02 0.19* 0.13* 0. 29** 226 10. Medium and High susceptible subjects DIH scores of Ss Tukey Post Hoc test High F Post Hoc df Pooled (N=337) DIH subscale Intimacy x= sd= x= sd= x= sd= x= sd= Communion Playfulness Tension Low (N=111) Medium (N=164) 2.60 2. - * p < . to get a more suitable range for statistical analysis.7 0. 5–7 for Medium. In the pooled sample. due to the Low hypnotic susceptibles. “communion” and “playfulness” scores (see Table 6) as a function of hypnotic susceptibility of the subjects.73 4.05.71 2.1 0.55 0. Éva I.65 3.56 df 4.334 2.39 0.334 11. ** p < .23 0.01 Table 7.1 0.7 0. The DIH scores of hypnotists and subjects and their comparison by t-tests (in E1) DIH SUBSCALE Intimacy Communion Playfulness Tension x= sd= x= sd= x= sd= x= sd= E1 (N=227) t Ss Hs (N=227) (N=227) 2.4 0. Bányai et al.78 1.62 4.60 (N=62) 2. As there was no significant interaction of the “Experiment” and “Susceptibility ranges” we report the comparison of Lows.84 1.08 0. ** p < .76** L<M=H 2.65 3.55 0.s.13 0.01 * Analysing the distribution of susceptibility in the two samples of E1 and E2 we decided to rise the cutting value of the range for High susceptibles.84 2.55 0.30** 226 9.39 0.52** L<M=H 2.67** 226 * p < .58 2.3 0.05.2 0. who gave significantly lower “intimacy” “communion” and “playfulness” scores than the Medium or High susceptibles.64 3. Table 6. Mediums and Highs on DIH subscales in a pooled sample of E1+E2. and 8–12 for High.84 1.334 13.83 1.30 0.334 16.63 0. susceptibility*. a significant difference appeared in the case of the subjects' “intimacy”.73 3. That is why we do not exactly follow the conventional ranges of 0–4 for Low. .22 0.42 0. Comparing the means of the DIH subscales of the Low.66 3.19 0.35** L<M=H 2.72 Katalin Varga.61 2.71 4.13 n.76 1.26** 226 4. Emese Józsa. reflecting the fact that a dyadic situation is based more on the cooperation of the participants than the group session. As a summary we can say that the DIH questionnaire has good psychometrical features: very high internal reliabilities for the subscales in the original (Mutual Rorschach sample). The analysis of the pattern of correlations between PCI (the validating criteria ) and DIH. the hypnotists’ and subjects’ DIH mean scores were calculated and compared to each other. especially on the “communion” scale. we can characterize the relationship between the subjective alteration in consciousness reported by the participants on PCI. As it was seen. The DIH scores of hypnotists and subjects on the four subscales. with high level of felt communion. In case of all the subscales the difference is significant at p < . It can be seen in Figure 2 that the general patterns of the average scores of hypnotists and subjects on the 4 subscales do harmonize with each other.01. i. Phenomenological Data from DIH On the basis of the 227 hypnotic interactions of E1. the difference between the average scores of the subjects and hypnotists is significant in case of all the subscales of DIH. The high correlation between the factors and subscales imply that basically “one thing” is measured by DIH. In case of subjects the positive subscales of DIH are . that the similarity of subjects’ and hypnotists’ average scores in each DIH scale seems to be more important (see Figure 2..e. but the three other smaller subscales may contain important information. and some tension—according to the subjective judgments of both H and S. the “intimacy” subscale. and in these hypnotic samples as well. which is true both in the case of subjects and hypnotists. occasionally showing different relationships with the other variables than the strongest factor (details are shown later). So these types of experimental hypnotic sessions are moderately intimate and playful interactions. This strongest factor has the highest explanatory value. Subjects of individual sessions give higher scores on DIH.). The positive affects reported by the participants on PCI is strongly correlated with the way the interactants characterize the interaction itself (positive DIH scales). The data of comparison of “hypnotizing” and “being a subject” in a standardized hypnosis experiment on the 4 subscales of DIH are summarized in Table 7.Patterns of Interactional Harmony 73 5 4 3 2 1 0 Ss Te ns io n ul ne ss Pl ay f m un io n Hs Co m In tim ac y DIH score Average DIH scores of Ss and Hs (E1) DIH subscales Figure 2. and the way they characterized their interaction on DIH. but these differences are so small. Bányai et al. so we gave the same name to them: physical-organic style is now metaphorically called maternal hypnosis style. The first will be about the pattern of phenomenological and relational data in relation of hypnosis stiles (maternal and paternal). the physical-organic and the analytic-cognitive styles. but only if approached intreactionally. both in individual and group sessions. The most important features of these styles are summarized in Table 8.1. Éva I. moderately connected to the positive affect scale of PCI. describing special phenomena that were not appearing in other measures. . So the various subjective aspects of felt trance state while hypnotizing seems to be more connected to the felt quality (especially intimacy) of the interaction. SPECIAL POSSIBILITIES OF INTERACTIONAL APPROACH OF THE PHENOMENOLOGICAL DATA Finally we present two examples to show the special possibilities of interactional phenomenological analysis. 4. Emese Józsa. which is based on fear (Bányai. the second a twin-study on the heritability of hypnotic responsibility. 2002). These names. of course. These two basic forms of involvement closely resembled the hypnosis styles described by Ferenczi (1909/1965).74 Katalin Varga. the styles are only resembling them in some respects. do not mean (simply) the direct reoccurrence of the appropriate parentinfant relationship patterns. That is the phenomenological level of subjects’ (PCI) seems to be almost entirely independent from the way they evaluate the interaction itself (DIH). while analyticcognitive style as paternal hypnosis style. but all the other PCI scales are almost independent from the DIH scores (significant but close to zero correlations). could yield important empirical data. Phenomenology of Hypnosis Styles During the past decades our laboratory described two characteristic hypnosis styles. The application of DIH in a hypnotic sample fulfilled the aims and requirements set at the beginning of its development: this is an easily administered. On the other hand in case of hypnotists. positive affect. their own subjective consciousness alterations represented by PCI H (dissociative control. 4. than the state of being hypnotized. which is based on love. quick method which can be applied for subjects and hypnotists. These styles served as an appropriate basis to examine the nature of subjective experiences of the participants of the hypnosis interaction along with the hypnosis styles. In both of these cases phenomenological data. internal attention) are moderately or highly connected to the way they judged their interaction with the subjects (DIH). Mentally stimulating atmosphere Many professional remarks Interpreting and analyzing the hypnotic session Relationship between Phenomenological Measures and Hypnosis Styles In our laboratory experiment. The hypnotist is very much with the hypnotized person. 2008). The session was semi-standardized: free relaxation induction followed by free analgesia suggestion was used. breathing together) Relationship with the subject Main characteristics during phenomenological report Maternal (physicalorganic) style Hypnosis is built mainly on positive emotions More personal Paternal (analytic-cognitive) style Hypnosis is built mainly on respect of authority More formal Frequent and vigorous occurrence of interactional synchrony and eye-contact and proximity Absence or rare occurence More informal way of expressing emotions. Varga. The subjective experiences of the participants were screened with PCI and DIH questionnaires immediately after completing the session (see Table 1 for further details. Józsa and Gősi-Greguss. The most important features of the physical-organic and the analytic-cognitive hypnosis styles Verbal behavior during rapport formation Interactional synchrony parameters during hypnosis (such as posture mirroring. The hypnotist leads and directs the hypnotized person. He/she does not place emphasis on the current condition and wishes of the subject. the session was closed by free dehypnosis and a brief inquiry. Bányai. analgesia was tested by a standardized cold pressor test. and facilitates the independent initiatives of the hypnotized person. He/she mainly wants the hypnotized subject’s desires and ideas to come true. healthy volunteer subjects (including two simulators: subjects earlier proven to be extremely low hypnotizables were used as simulators).Patterns of Interactional Harmony 75 Table 8. . He/she places emphasis on the current condition and wishes of the subject. each of four hypnotherapists hypnotized 8 young. and slightly limits independent initiatives of the hypnotized person. more personal and emotionally comforting atmosphere. and then standardized age regression and trance-logic suggestions were administered. He/she mainly wants to realize his/her own ideas and intentions. simultaneous movement. Hypnotists relies on his/her bodily cues Deep involvement Slightly inhibiting the subject’s independent initiatives and verbal behavior. 29** a) . Éva I. Bányai et al. 1991). Reliability was considered acceptable if both measures were above . while they are negative with paternal scores.74+ t=2. All indications of name. Emese Józsa. The consistency of judgments was also assessed by calculating Cronbach’s alpha coefficient (Cronbach. and hypnotic susceptibility of the participants were eliminated from the transcripts. The results are shown both for the whole sample (N=32 interactions) and for the sample without simulators (N=24 interactions).60. To assess the judges’ aggregate reliability effective reliability was calculated (Rosenthal and Rosnow. intercorrelations were calculated. t=1. Judgment of hypnosis styles: Four expert judges trained in psychotherapy and in hypnosis rated the 32 hypnosis sessions independently: the verbatim transcripts of the hypnosis sessions served as a basis of judgment. Correlations between hypnosis styles and measures of subjective experiences: To characterize the relationship between the hypnosis styles and the subjective experiences. 1951).76 Katalin Varga. All of the correlations between maternal score and DIH scales are positive in every case both for hypnotists and subjects.36** t=1. As it can be seen with half an eye—although the correlations themselves are moderately high and because of the low sample size they are not significant—the pattern of the results is obvious and striking. gender. The relationships between maternal and paternal scores and DIH scores of hypnotists and subjects are shown in Figures 3a and 3b.8+ t=2. Patterns of Interactional Harmony 77 t=2.86** t=2.27* t=2.01+ b) † Note: In the small boxes t refers to the difference of correlations, +p< .1, *p< .05, **p< .01 Figure 3. a) Correlations between hypnosis styles and DIH scores: Results of SUBJECTS. b) Correlations between hypnosis styles and DIH scores: Results of HYPNOTISTS. There is a noticeable difference in the results of subjects and hypnotists: in case of subjects the lowest correlations turn up between maternal-paternal scores and the DIH intimacy scale (these correlations are close to zero), while in case of hypnotists these are the highest correlations (most of them are significant). Although on the grounds of correlation we cannot conclude cause and effect, this result may imply that hypnotists tend to judge their own intimacy score in a given situation according to their judged style (i.e., in case of maternal style, they report higher intimacy scores, while in case of paternal style, they report the lack of intimacy). Subjects, on the contrary, seem to score their intimacy independently of the style of the hypnotist. It seems to be an important result that real subjects produced more obvious, stronger relationships between hypnotist styles and DIH scores. (The correlations calculated with the inclusion of the simulators are always lower than those without them in the case of the subjects, while in case of hypnotists, the situation is reversed: the correlations with the simulators are higher than those calculated without them.). Hypnotists, on the other hand, seemed to be a little “more present” in the interactions when the simulators were involved † The difference between these correlations was calculated according to Williams’s T2 statistic that tests whether two dependent correlations (here: correlation of maternal style and a given DIH subscale and paternal style and a given DIH subscale) that share a common variable (here: the given DIH subscale) are different. This test is the one recommended by Steiger (1980) for this purpose (the same method is used in the following figures). 78 Katalin Varga, Emese Józsa, Éva I. Bányai et al. than with real subjects only (even if the hypnotists were not aware of the simulators). Perhaps they showed a more prototypical variant of their style when they encountered simulators. Among the numerous indices of PCI, we will discuss only the most important from the point of view of our question: how much is the components of the altered of state of consciousness experienced in the cases of the maternal and paternal hypnosis styles, and what kinds of emotions accompany them in both participants of the hypnosis interaction. These scales are Altered Experience main scale with its component subscales (alterations in body image, time sense, perception, and meaning) and the Affect main scale with its subscales here. Figures 4a and 4b show the correlation between PCI’s Altered Experience main scale (and its subscales) and hypnosis style scores both for the subjects (a), and the hypnotists (b). The experience or the lack of experience of an altered state of consciousness of the subjects seems to be independent of the style of hypnosis (Fig. 4a). The pattern is clear: the Altered Experience of the subjects is either independent from the styles (correlations are close to zero) or shows positive correlations with both styles (except for alteration of Body Image and Meaning: they show a very moderate negative correlation with paternal style). Since the highest correlations are around 0.2 here, it can be concluded that the subjects can experience the most important components of an altered state of consciousness with either hypnosis style. No wonder, that the hypnotists scoring their own alteration of consciousness by PCI show the connection unambiguously with (their own) hypnosis style (Figure 4b). Maternal style goes hand in hand with significant positive, paternal style with significant negative correlations. The more the hypnotist was characterized by maternal style, the more Altered Experience while hypnotizing he/she reported, while the more he/she was paternal, the more he/she reported the lack of these alterations. So paternal hypnotists’ experience of body image, time sense, perception, and meaning remained similar to the reality orientation of the normal waking state. In contrast to the pattern given on DIH by the hypnotists, in this case (PCI) the presence of simulators slightly moderated this connection, as if maternal hypnotists could experience these alterations less with simulators, and paternal ones needed less to indicate the lack of alteration—in this case they tend to keep the ordinary waking experience-modes as compared to the cases of hypnotizing real subjects. As it can be seen in Figures 5a and 5b, both the Positive Affect and the Negative Affect main scales and their subscales of PCI showed the same pattern both in case of the subjects and the hypnotists: maternal hypnosis was correlated with the experience and expression of (either positive or negative) emotions, while paternal style showed a reverse relationship. The only important exception to this pattern was that the more maternal the style was, the less the hypnotist reported sexual excitement. It is interesting that no opposite pattern was found in paternal style. During the interpretation of our results it is important to emphasize again the fact that the style scores—verbatim transcripts (!) judged by independent raters—and experience data— the interactants self-reported answers on the questionnaires—originated in very different kinds of characteristics of the given interaction. Patterns of Interactional Harmony 79 a) t=3.19*** t=3.1*** t=1.74+ t=4.02*** t=2.26** t=2.78* t=2.0+ t=2.14* t=1.88+p b) Note: In the small boxes t refers to the difference of correlations, +p< .1, *p< .05, **p< .01, ***p< .005. Figure 4. a) Correlations between hypnosis styles and PCI Altered Experience factor scores: Results of SUBJECTS. b) Correlations between hypnosis styles and PCI Altered Experience factor scores: Results of HYPNOTISTS. 80 Katalin Varga, Emese Józsa, Éva I. Bányai et al. a) t=1.74* b) Note: In the small box t refers to the difference of correlations, *p< .05. Figure 5. a) Correlation between hypnosis styles and PCI affect factors: results of SUBJECTS. b) Correlation between hypnosis styles and PCI affect factors: results of HYPNOTISTs. Patterns of Interactional Harmony 81 The construct of “hypnosis style” has been supported by these data, as the pattern of correlations of subjective experience data and style scores are in line with our theoretical expectations. In case of maternal style, subjects can experience the alteration of consciousness while their hypnotist “follows” (or “leads”?) them into the domains of alteration independently of the level of maternality. Higher maternality accompanied by a higher intimacy-experience on the side of hypnotists, and more expressed emotions in both interactants. Maternal style is characterized by a generally more overt presence of emotions, let them be positive or negative. Paternal style also makes it possible for the subjects to experience the alteration of consciousness subjectively, but in this case, either the subjects, or the hypnotists are moderate in the experience and expression of emotions, and there is no place for togetherness, playfulness, or intimacy in the situation—as opposed to the maternal style. Looking at the results from another point of view, these results serve as validation indicators for the subjective experience tests applied in this study, since hypnosis styles can be described and confirmed with several other parameters beyond the direct judgment of style (see Bányai 1998, 2002). Our result showed that from the point of view of the alteration of consciousness of subjects, any style can be favorable; this means that the experience of alteration is not dependent on style, rather, it is probably based on some other factor (that is not analyzed here). Because PCI is a state-indicator, experience of alteration might depend on some other, trait-like parameter(s) of the subject. 4.2. Phenomenological Patterns as a Function of Kinship The second example will show the relationship of various phenomenological measures connected to hypnosis as a function of kinship. Hypnosis is unique among the ASCs because of extended research under well monitored, standardised circumstances. Since the development of standardised susceptibility scales— most of them based on the Stanford Hypnotic Scales (SHSS:A, B, C, Weitzenhoffer and Hilgard, 1959, 1962) —the induction and the test suggestions can be administered in well controlled way, making it possible to investigate hypnosis in various international and cultural circumstances. Hypnotic susceptibility, that varies from individual to individual, is a highly stable trait of a person (Piccione, Hilgard and Zimbardo, 1989). The norms of standardised susceptibility scales in various languages and samples confirmed again and again the close to normal distribution of susceptibility. The individual stability and “same-distribution” nature of hypnotic responsiveness imply that it is based on at least partly biologically determined factors with certain level of genetic contribution. Surprisingly till today only one early study (Morgan, Hilgard and Davert, 1970; Morgan, 1973) investigated directly the heritability of hypnotic ability. That research focused only on the susceptibility scores of the hypnotized subjects. Table 9. Intraclass correlations of the twin study SHSS:A MZ twins DZ twins Siblings ParentChild pairs S-S 0.22 PCI DC S-H S-S S-H NA 0.35* -0.04 0.15 0.17 0.07 * p < .05; ** p < .01 PCI PA S-S S-H 0.52** 0.04 PCI NA Intraclass correlations PCI VI PCI IA S-S S-S S-H S-S 0.22 -0.03 S-H 0.36* 0.1 DIH Communion S-S S-H DIH Playfulness S-S S-H DIH Tension S-H DIH Intimacy S-S S-H 0.13 0.13 0.58** 0.03 0.55** 0.16 0.17 0.11 0.40* 0.05 0.09 0.28 0.32* 0.24 0.31* -0.01 0.19 0.1 0.19 S-S S-H 0.14 0.31* 0.19 0.34** 0.27 -0.04 0.34* 0.24 0.04 0.14 0.01 0.39* 0.2 0.08 -0.18 -0.06 -0.03 0.45** 0.2 0.07 0.2 -0.02 -0.01 -0.03 0.08 0.18 -0.15 0.11 0.03 -0.02 -0.06 0.12 -0.1 0.08 -0.1 -0.11 0.11 0.13 0.06 0.18 0.10 0.07 0.19 -0.09 0.04 a different pattern appears. while others do not match each other in the way they report their subjective feelings regarding the hypnosis session. the two persons of a twin pair) will be compared we indicate it by “S-S”. DZ twins show moderate significant correlation on the visual imagery scale. The S-H intraclass correlation of DIH scales apart from the significant moderate correlations between DZ twin members and their hypnotists. for further details see Table 1). and nonsignificant.. Subjects (Ss) (mono. by discussing their experiences) they were hypnotized at the same time in two separate experimental chambers. The relationship between the variables will be expressed in intraclass correlations (ICC)1. 1959). Here we report only the most peculiar results of our study. where the interactants evaluate the session itself. Apart from the basic data of hypnotic susceptibility.. siblings on positive affect and attention to internal processes.g. To prevent the relatives from influencing each other (e. positive and negative affect. Some hypnotic dyads show high agreement. In the case of S-S ICCs. well established measures of hypnosis (e. As it can be seen all the correlations of hypnotic susceptibility are low. DIH.g. systematically the effect of kinship on this aspect. by two different hypnotists. and nonsignificant. According to our earlier results hypnotic interactions do differ in the level of concordance/accord between the subjective reports of the hypnotist and subject. Immediately after the hypnosis session the hypnotist and the subject independently completed the questionnaires (Varga. Comparing the pattern of data between the subjects and between the hypnotist and subject of various degree of kinship we wanted to learn more about the possible genetic background of hypnotic responsiveness. all of the correlations are close to zero.. MZ twins yield high and highly significant correlations. 1 This type of correlation is used to determine a correlation between two variables when it is not clear which variable should be X or Y for a given row of data. we used the fromula: ri = within groups. and positive affect in cases of DZ twins. On the DIH scale.d. and nonsignificant. There are various ways to calculate ICC. however. Tauszik. when the subject and the hypnotist of the same session will be compared “S-H” will indicate it (see Table 9). Apart from this all of the correlations are close to zero. except for the moderate significant correlations on dissociative control. respectively—siblings and parent-child pairs) have been hypnotized using the standard protocol of SHSS:A (Weitzenhoffer and Hilgard. Among the ICCs in case of PCI there are significant moderate to high correlations between the members of MZ twins on dissociative control. PCI) have been used both with subjects and with hypnotists (Hs) to test the effect of kinship.Patterns of Interactional Harmony 83 Our laboratory. Gősi-Greguss. Considering the S-H intraclass correlation of PCI scales we see. extended it by (1) measuring the phenomenological aspects (apart from the behavioral scores of susceptibility) and by (2) including the investigation of hypnotist (apart from the subjects). and a similar pattern. We never tested. Bányai. that all of the correlations are close to zero.g. with the only exception of playfulness scale.and dyzigotic twins— MZ and DZ. when replied the work of Morgan (1973). n. When the two members of relatives (e. nonsignificant. s 2b − s 2 w s 2b + s 2 w where sb is the variance based on between groups and sw is the variance based on . MZ twins can be similar to each other while evaluating the hypnosis session because they follow the reactive interactional pattern: the environmental effects (in this case the standardised hypnosis session with two different hypnotists) might appear to them as something subjectively (almost) the same. It is surprising. where we also found a significant – but moderate – correlation). . So. that the key variable of hypnosis research. in cases of PCI subscales only the visual imagery subscale becomes more highly correlated (compared to the total sample of DZ twins. As the scores on SHSS:A are based on behavioral manifestations. all the others are either non-significant. 2 If we calculate the intraclass correlations only for the subgroup of the same-sex DZ twins. In cases of DIH subscales. The members of MZ twins (but nobody else) correlate highly on DIH scores with each other (and not with their hypnotists). the MZ group gave significantly higher averages than the other groups. or significant but moderate. and not in line with the evocative interaction pattern in cases of MZ twins. where MZ and DZ groups were similar to each other. thought. all the intraclass correlations remains nonsignificant. but not in cases of any other S-S dyads (even not in cases of DZ twins)2. According to our data the only moderately high significant intraclass S-S correlation on PCI is the positive affect scale in cases of MZ groups. 1995). however. MZ members of our sample gave relatively higher scores when evaluating the hypnosis interaction (on DIH). the average PCI scores of MZ twins are not significantly different from that of the other groups (with the only exception that MZ twins gave smaller scores on “attention to internal processes” subscale than the siblings did). They seem to evaluate the session similarly to their co-twins. Stern and Dillman. moderately high (r= 0. this imply that close or similar patterns of subjective evaluation of the interaction (expressed on DIH) can be connected to different behavioral scores. as the members of MZ twin evoke similar reactions from them. Bányai et al.84 Katalin Varga. All of these H-H correlations proved to be close to zero and nonsignificant (for the details see Appendix 4). and vice-versa: the same behavioral score may hide divergent evaluational patterns.41 for details see Appendix 5). As Appendix 3 shows. The other possibility is that following the rules of evocative interaction the two members of MZ twins evokes (almost) the same reaction from their interactional partners (in this case from their hypnotists). Behind this pattern of data two types of interactional processes could be hypothesised. where it becomes significant. except for communion. Comparing the highly significant correlations between the members of MZ twins with the correlations between the scores of MZ subjects and their hypnotist an interesting picture emerged. and not to the person they were actually interacting. It is surprising. On the DIH scale. in spite of the fact that they interacted with two different hypnotist. This implies that the way relatives of various kinship experience the phenomenology of hypnosis do not strongly resemble to each other. Two test this possibility we correlated the sores of the two hypnotists who hypnotized the members of the twins (or siblings or parent-child pairs). but not deviated from the other groups when their actual phenomenological experiences have been reported (PCI). We might suppose that they bring their own „interactional model” into the hypnotic situation (Burgoon. hypnotic susceptibility score does not show the same similarity in cases of MZ twins. that the way interactants evaluate their recent hypnosis interaction on DIH is very similar in cases of members of MZ twins. with the only exception of “communion”. Emese Józsa. In this latter case the independent hypnotist hypnotizing the members of MZ twins should give similar scores to each other. So our data seems to support more the reactive interactional pattern. significantly exceeding the other two groups). Éva I. . 1998). Dyadic Interactional Harmony (DIH) (Varga.g. It is especially relevant to have a closer analysis of the possibility that the trance state of the hypnotist may prevent some of the negative consequences of deep emotional involvement. 2006). magician-like figure who overwhelms the subject.. Varga. i. This inevitably leads the therapists to make impossible demands on themselves to get dramatic results quickly. Józsa. Józsa. Varga. Having a more realistic. based on EAT of Sheehan and McConkey. for details see Bányai 1985. self-criticism and other negative feelings that may lead to burnout. 1984). GENERAL CONCLUSION Over the past 20 years we have collected a large amount of data about the phenomenological involvement of hypnotic interactants (our findings have been reported in detail elsewhere: Varga. Bányai and GősiGreguss. In the interactional approach.g. more human picture about the hypnotist and about the process of hypnotizing seems to be crucial in educating and training would-be hypnotists. hypnotic interactions do differ in the level of concordance/accord between the subjective reports of the hypnotist and subject. e. According to our observation. 1979). Especially interesting patterns appeared when we interrelated the phenomenological data of the subject and that of the hypnotist.. In our view.. the Phenomenology of Consciousness Inventory (PCI) questionnaire of Pekala. 1982). 2008).g. 1991. sex. Bányai. Bányai and Gősi-Greguss. e. 1999. Varga.g. 1996. Józsa and Gősi-Greguss. As non-hypnotic therapists also report spontaneous trance states in which they are especially effective and full of healing powers (e. This may prevent the feeling of guilt. This level is at least as informative as the other indices analyzing the synchronous phenomena at the behavioral or electrophysiological level (e. music.g. Bányai and Gősi-Greguss. this possibly works in their case as well. and has extraordinary power (see. Bányai.Patterns of Interactional Harmony 85 Unfortunately. 1997. 2004. we had to develop interactional modifications of well-known “subject-centered” phenomenological measures— e. Some hypnotic dyads show high agreement and a similar pattern.e. puts him into trance. this can be considered a sign of interactional synchrony at the phenomenological level. joint movements and posture mirroring at the overt behavioral level. 2006. Varga. Bányai. or MZ twins would give the same concordance with each other while interacting with two different partners in some non-hypnotic settings (chess. Gősi-Greguss and Suhai-Hodász. apply for the hypnotist measures designed for the subject. etc. Józsa. the “Parallel Experiential Analysis Technique” (PEAT. 2000. or develop special measures to have the participants evaluate the hypnotic interaction itself. self-doubt. Gősi-Greguss. while others do not match each other in the way they report their subjective feelings regarding the hypnosis session. To do so.)? 5.. Today we can describe the state and process of hypnotizing much better than some decades ago.. Rogers. or the common breathing rhythm and parallel myographic activity at the physiological level. 1994. Steinberg and Kumar (1986). rich and valuable data has been gathered from the hypnotists. Yapko. The traditional picture presents the hypnotist as a powerful. . our data tell nothing about the question whether this phenomenon is hypnosis-specific. . 1996. 1991. Argyle and Dean. very special processes must be activated in both partners of the interaction. It is more probably construed along constant “message-exchanges” between subject and hypnotist. Hypnosis styles are related to the hypnotists’ overt behavioral parameters—e. This may “inform” the subject regarding what kind of relationship patterns should he/she mobilize (recollect or fantasize) along which he/she can organize his/her interactional expectations or experiences—probably at a non-conscious level—in connection with the actual hypnosis. synchrony (Bernieri. within the sociopsychobiological model of hypnosis. 1980). 1976). Many theories of intimacy predict that some people feel comfortable with closeness and intimacy. According to our .. smiling. for instance. 1978). calling the subjects by their first name (for more details see e. If this bargain remains one-sided. Bányai et al.. and Bányai.g.. Bowlby. Davis. All of these interactional synchrony indices formed the basis of the description of “hypnosis styles” (e. During a hypnosis session these underlying characteristics might mediate to the subject what kind of hypnosis can he/she expect with the given hypnotist.g.g. 1990). Capella 1997. then one of the participants cannot enforce his/her stable or momentary needs for relationship patterns (Bowlby. as it is not specific to hypnosis. e. 1999). Others report being very uncomfortable getting close to and depending on others (see. and Dillman. and Grahe. and can easily be applied to any other human interactions. if the participants come to an understanding in this “style-bargain”. There is a sharp difference between individuals with. MZ twins—most probably on the basis of reactive interactional pattern—evaluate the hypnotic interaction very similarly to each other. 1980)—and determine the person’s feelings in his adult relationships as well. Varga. The main requirements of a good rapport are selectivity. and are willing to rely on others when needed. eye contact. so we will find higher disharmony in the experiences. Gősi-Greguss. The results of our twin study showed that the phenomenologically experience of hypnosis is not based on genetic determination. we assume that the development of a given hypnosis style is not a unidirectional process going from the hypnotist to the subject. These models are based on early personal history—described by attachment theories (e. 1965 or Patterson. words used. a complex emotional relationship and a special need to be directed (to direct) (Bányai. Bányai. Emese Józsa.. The explanatory value of these aspects in the process of interactional adaptation need much further research (Burgoon. The influence of working models seems to be also relevant in this respect. 1995). e. 2002ab. Bányai. secure or avoidant attachment styles (Ainsworth. Tickle-Degnen and Rosenthal. regarding mutuality) develops.g. This was not true for their behavioral responses to hypnosis (SHSS: A). Stern. The DIH questionnaire is a promising tool to understand better the way people enter into important human interactions.g.g. but the way interactants evaluate the session (the interaction itself) seems to be closely related to the degree of kinship. 2002b). Gillis. possibly by activating early relational patterns. 1998. Presumably a kind of typical pattern is formulated in the harmony of their subjective experiences (e. it involves sensitivity to each other. In the case of hypnotic rapport. These findings can well be interpreted using the concepts of working models and early interactional patterns. Waters. To get to a relationship of this kind in a strongly controlled standardized hypnosis session. Éva I. reciprocity. and Wall. or the phenomenological aspects of the state (PCI). when entering a hypnotic interaction. According to our results. Blehar. touch. 1995). and there will be no “clear” experience-patterns of mutual attunement.86 Katalin Varga..g.. paternal and maternal styles. ......5 2.......... TENSION....... 1-2-3-4-5 3.....2 ................... ATTUNEMENT............5 DOMINANCE...... 1-2-3-4-5 2. HARMONY.........................................3 . 1-2-3-4-5 1-2-3-4-5 1.............. We are far from fully understanding the hypnotic interaction......... DEFENSELESSNESS.. 1-2-3-4-5 1............... 1-2-3-4-5 RIGOUR................ INSPIRING.. 1-2-3-4-5 1. 1-2-3-4-5 2......... but the interactional approach to hypnosis and the detailed analysis of phenomenological data of both participants seem to be a promising way to discover the real essence of hypnosis...2 .... 1-2-3-4-5 1-2-3-4-5 ...........4 ... COOPERATION.3 ............. meaning: not at all 5.. 1-2-3-4-5 1... This could be considered a clear example of the proposal that the hypnotic situation serves as a possibility to activate this early-based model....... 1 ........... 2.................. INTIMACY....................4 ................... 1-2-3-4-5 BOREDOM. 1-2-3-4-5 4........5 4... 1-2-3-4-5 1... 1-2-3-4-5 3.... WARMTH.............3 .... 1-2-3-4-5 2. Circle the corresponding number 1.... 1-2-3-4-5 1... 1-2-3-4-5 4........2 ........ ANXIETY............... 1-2-3-4-5 SELF-DISCLOSURE..... TENDERNESS.. 1-2-3-4-5 COMPETITION....................... CONSTRAINED........ MUTUAL CONFIDENCE… 1 ... 1-2-3-4-5 EXCITEMENT............ the influence of early models may be so strong that MZ twins are not really “disturbed” by the actual hypnosis situation....... 1-2-3-4-5 CLUMSINESS... proposed by the sociopsychobiological model (Bányai 1998............... SHALLOWNESS............... EROTICISM/SENSUALITY 1 .. INTIMATE....... 2002ab). RELAXED... DYADIC INTERACTIONAL HARMONY QUESTIONNAIRE Date: Name: Please consider your recent interaction.......... ACCORD / CONSONANCE 1-2-3-4-5 1.............. HUMOUR..... 1-2-3-4-5 4...4 ....... UNDERSTANDING……. HAPPINESS......... Please indicate how much the following features characterized your recent interaction. 1-2-3-4-5 2... CORDIAL...... 1-2-3-4-5 SUBORDINATION.... meaning: completely The numbers in between indicate gradual steps between the two extremes............ 1-2-3-4-5 4. 1-2-3-4-5 3. APPENDIX 1.......... 1-2-3-4-5 2......Patterns of Interactional Harmony 87 results. PATIENCE............... 1-2-3-4-5 3.. LIKING.............. OPENNESS.............. SYMPATHY.... 1-2-3-4-5 2... MUTUAL ATTENTION….... 1. PLAYFULNESS..... 1-2-3-4-5 2........... 1-2-3-4-5 RESERVE.......... Communion.000 0...000 0.......7545 0..9715 Rotated...2 .000 0... Bányai et al. Éva I....0519 1.. LOVE....... PASSION.. sorted factor values (Mutual Rorschach situation) ITEMS PASSION INTIMACY INTIMATE WARMTH EROTICISM/SENSUALITY TENDERNESS LOVE HAPPINESS CORDIAL LIKING ACCORD / CONSONANCE FACTOR1 0... 1 .4 .5 2........ 4.......4 .3 . (CONTINUED) SINCERITY......5 3...........5 3. 1 .. FREEDOM.....6142 1.000 0..000 0...585 0.000 0. 3.253 0..2 ...000 0... but is important to characterize your recent interaction? (You can write more than one): Note: “Easy-flowing” item scores inversely in the “Tension” scale.. The numbers before the items indicate the subscale to which the item belongs (1. 1 .......2 ............4 .534 0...... AGITATING. 1-2-3-4-5 1. 1 .000 0.... as their factor values were too small.... Emese Józsa...........000 0..5786 0...626 0.3 ..0000 Cronbach alfa 0............ 1-2-3-4-5 PERSONAL.....3 ...... FEAR.5 DISTANCE.....000 0.....4 ..Katalin Varga.0997 Cummulative variance in the data in the factor space 0.... Intimacy.000 0.. Items without number do not belong to any subscale... 1 ...545 0....000 0...3 ..4 ....000 0...2 ........5442 0.... DATA OF FACTORANALYSIS OF DIH IN THE MUTUAL RORSCHACH SITUATION Factor 1 2 3 4 5 Variance explained 10......3 .2 ..3 ..000 0..614 0.. 4.. 1 ....643 FACTOR3 0..000 0.000 0.. 2.....000 0..........618 0................... MUTUALITY....380 0.....000 0. 1 ...4 ..2 .000 0..... Playfulness.665 0..5 3.5 1.... 1-2-3-4-5 Is there any other feature that is not present here.........3 ...7234 0...... Tension)..000 0...453 0...000 0.. 1 ...4 EASY-FLOWING.000 0....5 ABANDONED..6596 0......2 ..5645 4.2 .000 0......7668 1.000 0.4 .4 .......000 FACTOR2 0.8602 0..4173 0.4 .... 1-2-3-4-5 INFORMALITY... 1-2-3-4-5 REJECTION.332 0.........5 1 .656 0... APPENDIX 2...3 .....5 CLOSENESS..000 0.......609 0.. 88 APPENDIX 1.2 ........000 0....0842 2...000 .9434 0.....3 .....000 0.000 FACTOR4 0...... 580 MUTUALITY 0.000 0.644 0.38 0.455 0.21 0.000 0.81 0.273 1.000 -0.000 0.000 CONSTRAINED 0.000 0.000 0.43 1.062 0.000 0.582 0.553 0.375 0.14 -0.000 0.537 COOPERATION 0.416 0.273 0.85 0.554 0.588 -0.273 2.32 -0.474 OPENNESS 0.64* MZ = DZ = SB= PC MZ = DZ = SB= PC MZ = DZ = SB= PC MZ = DZ = SB= PC MZ < SB .47 3.000 0.324 0.59 0.28 0.000 0.000 0.000 0.15 0.000 0.00 0.319 HUMOUR 0.000 0. COMPARISON OF THE MEANS OF THE PCI AND DIH SUBSCALES OF THE GROUPS (* p < 0.480 0.11 1.000 0.270 0.000 AGITATING 0.000 0.551 0.000 -0.25 1.000 0.000 ANXIETY 0.000 0.273 0.78 APPENDIX 3.000 0.260 0.47 PARCHILD 0.000 DEFENSELESSNESS 0.68 1.565 ATTUNEMENT 0.000 0.565 0.19 3.32 0.000 0.24 3.01) PCI subscale Dissociative control Positive affect Negative affect Visual Imagery Attention to internal processes x= sd= x= sd= x= sd= x= sd= x= sd= PCI averages of Ss MZ DZ SIBL.000 0.363 0.06 -0.000 4.24 1.000 0.000 0.588 MUTUAL ATTENTION 0.000 EASY-FLOWING 0.000 0.86 Cronbach-alfa Note: “RELAXED” item scores inversely in the “Tension” scale.535 SYMPATHY 0.12 2.000 0.18 -0.845 4.493 PATIENCE 0.000 PLAYFULNESS 0.05.34 2.000 0.000 RELAXED 0.25 1.09 -0.000 0.461 3. 89 0.000 0.000 FEAR 0.000 4.379 Eigen Value 0.Patterns of Interactional Harmony UNDERSTANDING 0.000 0.430 0.000 0.76 3.000 0.000 0.000 0.32 0.12 1.02 1.000 0.28 0.513 0.41 0.00 0.000 TENSION 0. ** p < 0.19 -0.273 3.62 3.599 0.000 0.000 INSPIRING 0.08 1.68 1.296 0.14 3.46 1.000 0.472 MUTUAL CONFIDENCE 0.496 0.37 3.620 HARMONY 0.000 0.30 df Tukey Post Hoc test F Post Hoc 3.000 FREEDOM 0.18 1.52 3.000 0.89 2.000 0.44 2.000 0. twins twins -0.000 0.258 0.04 1.511 0. 15 -0.02 0.01) S-S Intraclass correlation PCI Same-sex dizygotic twins (N=22) Dissociative Control Positive affect Negative affect Visual imagery Attention to internal processes 0.00 -0.36 0. 90 APPENDIX 4.00 -0.1 0.08 -0. ** p < 0.11 0.01 0.08 0.05 . ON THE SUBSCALES OF PCI AND DIH (* p < 0.13 -0.22 0.4 -0.01) H-H Intraclass correlation PCI Monozygotic twins Dizygotic twins Siblings Parent-Child pairs Dissociative control Positive affect Negative affect Visual imagery Attention to internal processes 0.23 H-H Intraclass correlations DIH Monozygotic twins Dizygotic twins Siblings Parent-Child pairs Intimacy Communion Playfulness Tension -0.15 -0.16 0.02 0.41** 0.06 0.05.05.08 -0. INTRACLASS CORRELATIONS OF HYPNOTISTS HYPNOTIZING THE TWO MEMBERS OF TWINS. Bányai et al.28 0.06 -0.23 0.1 -0. INTRACLASS CORRELATIONS OF THE SAME-SEX DZ TWINS ON THE SUBSCALES OF PCI AND DIH (For the Data of other groups see Table 9 in the text).06 -0. Emese Józsa.08 -0.54** 0.05 0.06 0.27 0.05 -0.02 0. (* p < 0.23 S-S Intraclass correlations DIH Same-sex dizygotic twins (N=22) Intimacy Communion Playfulness Tension 0.18 -0.06 0.07 -0.27 0.02 0.05 0. ** p < 0.01 0.31 0. Éva I.11 -0.08 0.18 APPENDIX 5.Katalin Varga. . (1995).I.. Bányai. Argyle. Contemporary Hypnosis. (1976). London: Guilford Press. É. International Journal of Clinical and Experimental Hypnosis. de Berk (Eds. Kardos. Germany. J. Waters. (1965). M. M. Bongartz. New York. L. E. E. I. Nijmegen: Cure and Care Publishers. S. (1978) Patterns of Attachment: Assessed in the Strange Situation and at Home. 203-214. I. É. Y. J. and W. and W. 1-19). (1990) Interactional Approach to the Understanding of Hypnosis: Theoretical Background and Main Findings. Bányai. Baker. A. and H. and Levitt.E.) Hypnosis International Monographs Number 6 (pp. De Moor (Eds.. Eye-Contact. .) Issues on Hypnosis (pp. É. I. J. (1998) The Interactive Nature of Hypnosis: Research Evidence for a SocialPsychobiological model. 52–63. É.I. Ph.) Problems of the Regulation of Activity (pp. Schaap. Journal of Abnormal Psychology. D. Vágó. 261–273). Hillsdale: Erlbaum.Patterns of Interactional Harmony 91 ACKNOWLEDGMENT Some charts and tables of this chapter are republished here by the permission of Contemporary Hypnosis. 85(2). Revenstorf. 186-210. Budapest: Akadémiai Kiadó.. (1980) A New Way to Induce a Hypnotic-Like Altered State of Consciousness: Active-Alert Induction. E. R. 1995. C. Peter. Gősi-Greguss. Sociometry. and J.. É. Baker. A. D. 289304. and Horváth. October 3-7. W.). Butollo (Eds. Varga. Distance. REFERENCES Ainsworth. Hypnos. 145-153. Munich: MEG Stiftung. C. Rhue (Eds. and Hilgard. Hoogduin. É. D.) Hypnosis: Current Theory. Research and Practice (pp. In B. R. 28. In S. L. É. W. Bányai. I. A. I. P. and Affiliation. (2002a) Hypnosis and Mainstream Psychology. 218-224. Van Rood. L. P. K. Bányai. International Journal of Clinical and Experimental Hypnosis. Van der Does. S. Amsterdam: Free University Press.. 37(2). (1987) The State of the Art of Clinical Hypnosis. E. In R. Theories of Hypnosis: Current Models and Perspectives (pp. In L. É. 564– 598). 15(1). 12. 35. and Wall. E. (1991) Toward a Social-Psychobiological Model of Hypnosis. (1989) The Hypnotic Relationship: An Investigation of Compliance and Resistance. W. Bányai. A Comparison of Active-Alert Hypnotic Induction with Traditional Relaxation Induction. É. Munich. C. Pléh (Eds. I. R. Bányai. and C. Van Dyck. A. Blehar. Spinhoven. Lynn. Nature of Rapport in Hypnosis: Theoretical Considerations and Empirical Results. A. (1985) A Social Psychophysiological Approach to the Understanding of Hypnosis: The Interaction Between Hypnotist and Subject. In C. 113). I. Bányai... Invited Address presented at the 2nd European Congress of Ericksonian Hypnosis and Psychotherapy. and Dean. Bányai.. M. (2002b) Communication in Different Styles of Hypnosis. 53–69). Bányai. Capella. P. and Dillman. 40. 238-246. and Grahe. 35. L. Cronbach. Diamond. (1983). . J. É. and Csókay. I. 46(3): 250-268. Gillis. J. Emese Józsa. M. Hillsdale. New York. M. 297-334. J. Journal of Personality and Social Psychology. Volume III. (Preliminary report). (1985) Interaction Between Hypnotist and Subject: A Social Psychophysiological Approach. 28(4). Gwynn. International Journal of Clinical and Experimental Hypnosis.N. D. Form C. 95-115. Manual and response booklet. American Journal of Clinical Hypnosis. I. Bowers. M. 110-129. J. Journal of Personality and Social Psychology. deGroot. (1981). J.. 97–108). 27. 253-275. (1998). 31. (1992). (1986) Hypnotically Augmented Psychotherapy: The Unique Contributions of the Hypnotically Trained Clinician.) Modern Trends in Hypnosis (pp. K. London: Lawrence Erlbaum Associates Publishers.. International Journal of Clinical and Experimental Hypnosis.C. Abstract. Waxman. Bányai. L. 3-13.. S. and Fromm. (1984) It Takes Two to Tango: Some Thoughts on the Neglected Importance of the Hypnotist in an Interactive Hypnotherapeutic Relationship. Basker (Eds. Journal of Personality and Social Psychology. Stern. 296. J. L. M. New Jersey. Waterloo-Stanford Group Scale of Hypnotic Susceptibility. Mészáros. J. (1982) Interaction Between Hypnotist and Subject: A Social Psychophysiological Approach. Davis. J. (1987) The Interactional Basis of Hypnotic Experience: On the Relational Dimensions of Hypnosis. Brown. 193. 71. Imaginative and Dissociative Control in Hypnotic Responding. E. 243-255. Do the Stanford Scales Tap the “Classic Suggestion Effect?” International Journal of Clinical and Experimental Hypnosis. A. International Journal of Clinical and Experimental Hypnosis. International Journal of Clinical and Experimental Hypnosis. 16. Interpersonal Adaptation.92 Katalin Varga. (1995). Bányai et al. (1988) The Effects of Contextual Information and Gender on the Prediction of Hypnotic Susceptibility. L. and M. (1996). I. The Clinical Use of Self-Hypnosis in Hypnotherapy: Tapping the Functions of Imagery and Adaptive Regression. American Journal of Clinical Hypnosis. S. Burgoon. Mészáros. (1997) Behavioral and Judged Coordination in Adult Informal Social Interactions: Vocal and Kinesic Indicators.. Coe. Psychometrika. 2-13. N. M. J. W. E. and Spanos.. E. and Csókay. Bowlby. (1951) Coefficient Alpha and the Internal Structure of Tests. R. New York: Basic Books. K. International Journal of Clinical and Experimental Hypnosis. S. 30. 54(6). Gibson. Bányai. Éva I. J. M. P. Diamond. Misra. 119-131. London: Plenum Press. Dyadic interaction patterns. K. (1977) Hypnosis From the Standpoint of a Contextualist. P. Dyad Rapport and Accuracy of Its Judgment Across Situations: A Lens Model Analysis. 72(1). Cambridge: Cambridge University Press. Bowers. and Sarbin. T. Annals of the New York Academy of Sciences. I.R. L. In D. Diamond. and Fromm.. K. É. Bowers.. Eisen. P. (1980) Attachment and Loss: Sadness and Depression. F. H. J. I. C. 42-53... A. Bernieri. S.1049-1053. M. (1986) Hypnotherapy and Hypnoanalysis. 29. Z. R. Fromm. Trans. H. E. S. Revenstorf. (1958). (1987). and Varga. M.C. 25. C. S. A. Arnold. K. New York: Holt. Skinner. (1992) Slip of the Tongue Slip of Hypnosis? Abstract. J. P. 1-14. The Modes of the Ego in Self-Hypnosis.. Fromm. July 25-31. 29. London: The Guilford Press. 11. G. Gravitz. Gősi-Greguss. and Varga... Hurt. F. (1987) Significant Developments in Clinical Hypnosis During the Past 25 Years. (1992). (1987-88). Gősi-Greguss. New York. R. É. (1983) Width of the Hypnotic Relationship: An Interactional View of Hypnotic Susceptibility and Hypnotic Depth. W. 62. 7(4). Jones. Lynn. Comments on Hypnosis. A. 13. and Kahn. Gill. Bányai. American Journal of Clinical Hypnosis. (1991) Early Theories of Hypnosis: A Clinical Perspective. W. Bányai. M. 1. Boxer. J. É.Patterns of Interactional Harmony 93 Engelbrecht. and Eraschky. Israel. 177-178). 231-247. Orne (eds. 129-136). Rhue (Eds): Theories of Hypnosis: Current Models and Perspectives (pp. Psychological Bulletin. Cognition and Personality. W. A. 1992.I. (1909/1965). International Journal of Clinical and Experimental Hypnosis. C. 41-57.. E. 35. E. A. Varga. Field. A. Jerusalem. K. E. Munich: MEG Stiftung. In B. K. P. International Journal of Clinical and Experimental Hypnosis. Hammond. Ferenczi.C.. (1981). 189-246. An Inventory of Hypnotic Depth. (1962) Impulsive Versus Realistic Thinking. Grazer Linguistische Studien. Bányai. New Jersey: Prentice Hall. Fourie. D. In R. 238-249. 59(6). (2002) Acoustic Analysis of the Hypnotist’s Voice—a preliminary study... The Phenomena and Characteristics of Self-Hypnosis. S. I. C. H. E.. Cierpka (ed) Family Diagnosis. (1996) Verbal and Paraverbal Communication in “Standard” Hypnoses. 335-349. The Mutual Rorschach in the Interaction-Diagnosis.. A. . A. (1987) Significant Developments in Medical Hypnosis During the Past 25 Years. International Journal of Clinical and Experimental Hypnosis. Haley.. Shor. Hilgard. International Journal of Clinical and Experimental Hypnosis. Józsa. G. August 17–23. M. L. and W. Farthing. Rinehart and Winston. D. E. Bongartz.. Gősi-Greguss. W. D. In S. International Journal of Clinical and Experimental Hypnosis. Imagination.. S. and Pfeifer. Brown. 58. 372-387. J. (1991) (ed.) The Nature of Hypnosis: Selected Basic Readings (pp.) Handbook of Hypnotic Suggestions and Metaphores. D..(2004): Voice Analysis of Hypnotists.. T. P. Peter. 27-35. M. London: Norton Company. G. and M. 19-42). In The Book of Abstracts of the 12th International Congress of Hypnosis. Oberlander. Fromm. E. Lombard. E. S. 215-230. New York: International Universities. Berlin: Springer-Verlag. and Horváth. I.) Hypnosis International Monographs Number 6 (pp. New York. Budapest... Australian Journal of Clinical and Experimental Hypnosis. Fromm. The Psychology of Consciousness. P. Suhai-Hodász. An Interactional Explanation of Hypnosis. M... G. É. Gősi-Greguss. Frankel. B. (1959) Hypnosis and Related States. (1977) An ego-psychological theory of altered states of consciousness. (1965). Butollo (Eds. 35. Book of Abstracts. J. and J. In Eurohypnosis’96: 7th European Congress of Hypnosis. and Brenman.. In M. 477-488. (1989). Vágó. S. M. In S.): Theories of Hypnosis: Current Models and Perspectives (pp. T. . J. 248-264. and McCloskey. (1991). E. 31. Second edition. A. S. J. 25-38. The Netherlands. Hilgard. International Journal of Clinical and Experimental Hypnosis. A. Fromm. R. (1988) Interactional Approach to the Understanding of Hypnosis: Relational dimensions. 125-131. S. The Relation of Self-Reports of Hypnotic Depth in Self-Hypnosis to Hypnotizability and Imagery Production.. August 1988. I. International Journal of Clinical and Experimental Hypnosis. State Effects and Hypnotizability. In C. K. Hilgard. E. and Cummings. É. 9-22. 9-22). N. New York: Horcourt Brance and World Inc. New York: John Wiley. Phenomenological State Effects During Hypnosis: A Cross-Validation of Findings. Lazar. E. R. R. Bányai. Wynne. Phenomenological Quantification of an Out-Of-The Body Experience with a Near Death Event. Lynn. 2. M... The Family Rorschach: A New Method for Studying Family Interaction.. Varga. International Journal of Clinical and Experimental Hypnosis. (1983) The Hypnotic Relationship . J.. 93-99. E. New York: Plenum Publishing Corporation. 35. Contemporary Hypnosis. E. and Sossi. Schwartz. R.Another Look at Coercion. (1984) Operator Variables in Successful Hypnotherapy. Kahn. E. Hilgard. (1991) (Eds. 199-214. Emese Józsa. The University of Chicago Press. 16(1). Altered States of Consciousness. V. International Journal of Clinical and Experimental Hypnosis.. E. L.. R. J. T. International Journal of Clinical and Experimental Hypnosis. Omega. 232249. 22(3). Hilgard. Paper presented at the 11th International Congress of Hypnosis and Psychosomatic Medicine. 38. and Pekala. M. and Baker. K.. M (1972). R. Hilgard. 187-215. P. 28-40.. T. J.. 26(2). and Rhue.. J. Shapiro (eds. Lombard. E. London: The Guilford Press. (1977\79) Divided Consciousness: Multiple Controls in Human Thought and Action.): Theories of Hypnosis: Current Models and Perspectives. New York. C. W. L. Rhue (Eds. V. In: G. (1983) The Psychobiological Function of Dissociation. Family Process. Lynn. Lombard. M. (1963). 397-438). Tart (ed) Altered States of Consciousness (pp. and Fromm. Kahn. E. and D. Maitz. A. P. Chicago and London. Ludwig.94 Katalin Varga. and Dempster. (1996). (1968) The Experience of Hypnosis.. Lynn and J. W. (1976) Neodissociation Theory of Multiple Cognitive Control Systems.. and Singer.R. Loveland. P. S. 37. A study of imaginative involvement. (1987) Research Advances in Hypnosis: Issues and Methods. L. and Resistance: A brief communication. R. The Role of Imagery in Self-Hypnosis: Its Relationship to Personality Characteristics and Gender. Trait Factors. (1991) An Integrative Model of Hypnosis. L.. B. (1999). New York. E.. Pekala. American Journal of Clinical Hypnosis. S. Levitt. J.. 290-304. Gősi-Greguss. S. International Journal of Clinical and Experimental Hypnosis. J. New York: John Wiley and Sons. R.. C. Kumar. A. J. K. Compliance. Kumar. Pekala. Ludwig. R. (1990).) Consciousness and Self Regulation. London: The Guilford Press. (1979) Personality and hypnosis.. 32(1). J. Leiden. Horváth. 44. Éva I. J. W. E. Bányai et al. S. and Rhue. Sr. 489). 983-989. Pekala.. J. V.. (1959) The Nature of Hypnosis: Artifact and Essence. (1991b). Journal of Abnormal Psychology. Hilgard (Eds. (1991a).L. 16. R. Measurement of Phenomenological Experience: Phenomenology of Consciousness Inventory. Firewalking Versus Hypnosis: A Preliminary Study Concerning Consciousness. and Pekala.. New York: Plenum. R. J. An Empirical-Phenomenological Approach for Mapping Consciousness and Its Various “States. (1991) Hypnosis as a Special Case of Psychological Regression. 12. C.. 277-299. pp. J. (1986) Child Abuse and Hypnotic Ability. V. R. and Davert. and Kumar. (1997). Pekala.. C. 63. London: The Guilford Press. J. (1973) The Heritability of Hypnotic Susceptibility in Twins. W. 284-293. American Journal of Clinical Hypnosis. 82. (1989). R. 55-61.. G. R. Thorndale. PA: West Chester. Hypnoidal Effects Associated with Several Stress Management Techniques.. 1-20. J. Stanford Hypnotic Clinical Scale. J. (1976) An Arousal Model of Interpersonal Intimacy. Phenomenological Patterns of Consciousness During Hypnosis: Relevance to Cognition and Individual Differences. and Spinler. 209-221). M. (1986). R. Pekala. 235-245. R. L. L. J. 171194). PA: Mid-Atlantic Educational Institute. R. J. and Personality. 129-143. H. Michigan state University (University Microfilm No. K.. CA: William Kaufmann. J. and Hilgard. 83(3). M. Australian Journal of Clinical and Experimental Hypnosis. B. 82-02. Imagery. Los Altos. Patterson.Patterns of Interactional Harmony 95 Matheson. . 32.. Nash. 5. Steinberg. (1975). V. (1989) Hypnosis and Transference: A Measure of Archaic Involvement. Psychological Review.T. J. The Phenomenology of Consciousness Inventory.L. In S. Perceptual and Motor Skills. (1988). Maurer. Attention. H.. Kumar. S. Orne. A. R. Pekala. and Ersek. 37. Pekala. Australian Journal of Clinical and Experimental Hypnosis. A. M. and Bart. K. The Phenomenology of Consciousness Inventory. (1982). and Forbes. Nash. Phenomenological experience in response to drumming and hypnotizability. and Kumar. Behavioral Genetics. Lynn. Pekala. R. Rhue (Eds.” Unpublished doctoral dissertation. American Journal of Clinical Hypnosis. A. Cognition.): Theories of Hypnosis: Current Models and Perspectives (pp. 211-218. 58. Imagination. R. R. 40. Woodside. 130-144. R. K.) Hypnosis in the Relief of Pain (Appendix A. 17. Quantifying Consciousness: An Empirical Approach. New York. In E. and Lynn. see 1991a). Cognition and Personality. Shue. 17-26. J. Morgan. D. Morgan. Hilgard. 121-132. (1980).. Pekala. Thorndale. J. and Fire Immunity. M. E.. R. J. R. (1992-93). and J. R. (1970) The Heritability of Hypnotic Susceptibility of Twins: A Preliminary Report. R Hilgard and J.. E. International Journal of Clinical and Experimental Hypnosis. E. M. Nash. Morgan. H. Journal of Abnormal and Social Psychology. K. PA: Psychophenomenological Concepts (Now published by the Mid-Atlantic Educational Institute. J. (1989) A validation study of a short-form hypnoticexperience questionnaire and its relationship to hypnotizability. Pekala. 1(3/4):213-223. International Journal of Clinical and Experimental Hypnosis. Norms on the Harvard Group Scale of Hypnotic Susceptibility. C. Bányai et al. (1979) Motivated Involvement in Hypnosis: The Illustration of Clinical Rapport Through Hypnotic Dream. . 2. Spinhoven. W. 263-281. Sheehan. Process and Method. and Sheehan. C. (1991). and McConkey. K.M.M.. P.) What is Hypnosis? (pp. 13. Ter Kuile. and Cross. Kennedy. 289-295. 177-194. P. W. Vanderlinden. (1993). In P.. R. K. P. 582-602. Journal of Abnormal Psychology. G. Piccione. D. Sheehan. (1989). R. (1979) The Foundation of the Person-Centered Approach.. Sheehan. 10.. I. P. and Linssen. 93(3):285-294. 210-223. Manuscript. 22(3). N. (1982) Hypnosis and Experience: The Exploration of Phenomena and Process. On the Stability of Measured Hypnotizability Over a 25 Year Period. and Gwynn. Rosenthal. P. Journal of Abnormal Psychology. R. R. 20(4). E. 256-262. P.W. Perry. W.(1978) Experiential Analysis of Hypnosis: Some New Observations on Hypnotic Phenomena. and Dolby. London: The Guilford Press. 89.. 23-38. M. (1962) Three Dimensions of Hypnotic Depth. S. Journal of Personality and Social Psychology.Jarrett. Sheehan. I. 520-541). Cognition and Personality.W.W.W. (1980) Hypnotherapy With Psychotic and Borderline Patient: The Use of Trance by Patient and Therapist. E. P.. and Commitment. K. Éva I. 164-169. Spanos. American Journal of Clinical Hypnosis. New York: McGraw-Hill. Emese Józsa. Context. Sheehan. McConkey. R. 57. M. New Jersey: Lawrence Erlbaum. M. R. International Journal of Clinical and Experimental Hypnosis. (1978) Aptitude for Trance and Situational Effects of Varying the Interpersonal Nature of the Hypnosis Setting. C. G. Shor. Sheehan. (1982-83) Imaginative Consciousness . Scagnelli.(1989) Contextual Determinants of Hypnotizability and of Relationships Between Hypnotizability Scales. E. L.96 Katalin Varga. Spanos. E. London: Open University Press. Hilgard. (1980) Factors Influencing Rapport in Hypnosis. Imagination. (1959) Hypnosis and the concept of the generalized reality-orientation. and Rosnow. L. N. W. New York. 57(2):271-278. N. Hillsdale. Shor. American Journal of Psychotherapy. and Orne. Journal of Personality and Social Psychology Review. Essentials of Behavioral Research: Methods and Data Analysis. R. (1963). W. Lynn. 88(5). M. 41. Form A... P. Naish (Ed. (1986). and J. Hypnosis and the Modification of Hypnotic Susceptibility: A Social Psychological Perspective. and Gwynn.P. 11.. Rogers. (1991). In S. C.R. American Journal of Clinical Hypnosis. P. Hypnosis. Rhue (eds) Theories of Hypnosis: Current Models and Perspectives (pp. Journal of Abnormal Psychology... Spanos. 85-120). C.. 87. Shor. E. (1984) Moderating Effects of Contextual Variables on the Relationship Between Hypnotic Susceptibility and Suggested Analgesia. Assessment of Hypnotic Processes and Responsiveness in a Clinical Context.. J. P. Journal of Abnormal Psychology. 570-575. M. and Zimbardo... P. J. 39-47. N. 573-583. E. J. Gabora.Function. International Journal of Clinical and Experimental Hypnosis. J. (1989). Tests for Comparing Elements of a Correlation Matrix. II. and Horváth.. (2000) Transference and Countertransference in Experimental Hypnotic Settings. and Gősi-Greguss. A: C. Varga. Scientific Presentation Abstracts. August 17-23. Hungary. E. K. J. 245–251. A.. 291-308). International Congress of Hypnosis. (1969) Psychedelic Experiences Associated With a Novel Hypnotic Procedure. Debrecen. Contemporary Hypnosis. É. T. Cs. Gősi-Greguss. Jerusalem. Tickle-Degnen.C. Paper to be submitted to International Journal of Clinical and Experimental Hypnosis. Book of Abstracts. Szubjektív élmények különböző indukciós technikákkal létrehozott hipnózisokban [Subjective experiences induced by various hypnosis techniques]. C. California. (1992) Interactional Application of Experiential Analysis Technique. A. Szabó.d. July 25–31. I. A. New York: Anchor Book Doubleday and Company Inc. A. Abstract. (1994) Parallel Application of the Experiential Analysis Technique with Subject and Hypnotist: A New Possibility for Measuring Interactional Synchrony. Tart.I. É. In C. C.. K.. Bányai. (2008): Interactional Phenomenology of Maternal and Paternal Hypnosis Styles. 2-7. C.. Bányai. H.. R. I. A. Hypnos.C. 38. (1997) New Ways of Characterizing the Phenomenological Aspect of Rapport. L. 25(1). 42(1): 130–139. C.. International Journal of Clinical and Experimental Hypnosis. 64-65. I. Bányai.. K. C. Mutual Hypnosis. K. (1999) Hypnotists’ Phenomenology: Toward the Understanding of Hypnotic Interactions. International Journal of Experimental and Clinical Hypnosis. and Rosenthal. 225-233. É. Budapest. Varga. Varga. T.. Bányai. Varga.. Bányai É. 21-27. Abstract. Cs. The Phenomenology of the Experiences and the Depth of Hypnosis: Comparison of Direct and Indirect Induction Techniques. San Diego.) Altered States of Consciousness (pp. 7th European Congress of Hypnosis. 120.) : Phenomenological Aspects of Hypnotic Interactions: The Effect of Kinship. K. T. 15. Bányai. New York: Wiley. C. and Gősi-Greguss. É.. Varga.Patterns of Interactional Harmony 97 Steiger. Józsa.. Hungary. Tart (ed. Bányai. É. K. Gősi-Greguss. . Gősi-Greguss A. 87. Psychological Inquiery. Varga. Tart. (1991) Investigating the Phenomenological Level of Hypnosis Within the Social Psychobiological Model of Hypnotic Interaction. Gősi-Greguss. Budapest.. July 8–12. United States of America. Varga. I. Varga K. Gősi-Greguss. R. Kossuth Lajos University. I. München. Szabó. October 2000. Varga.. 14th International Congress of Hypnosis. I. J. In Book of Abstracts of the 12th International Congress of Hypnosis. Hungary. 128. (1996) Harmony in Phenomenology: A New Way to Measure Interactional Synchrony.C. and Gősi-Greguss. (1972).. 26(4): 181-193. Book of Abstracts. June. 41. In Abstracts of the Second European Congress of Psychology. (n. A.. (1980). (1990) The Nature of Rapport and Its Nonverbal Correlates. Bányai. and Tauszik. K. K. (1993). 14-28. C.I. I. K. A... Vol.. Unpublished doctoral dissertation. É. 1(4): 285-293 and 324-329. É. Israel. Psychological Bulletin.. Bányai É. 1991. 147. Altered States of Consciousness. Gősi-Greguss. 24 (4). 2004. 324-334.. A. Weitzenhoffer. Palo Alto. C. (1959) Stanford Hypnotic Susceptibility Scale. R. New York: Springer. V.. London UK.. Gősi-Greguss. Józsa. M.. Woodside. Forms A and B. É... (1973) Psychodinamics. V. Tarter (Eds. É. Kumar. K. Varga. E. L. R.. 183225).. Bányai I. M. J. I. Weitzenhoffer.. 49(1): 19-29. and Hilgard. 82. and Kumar. International Journal of Clinical and Experimental Hypnosis. 151-166. G. Journal of Abnormal and Social Psychology. Wachtel. I.. Palo Alto. Gősi-Greguss A. Hypnotism and Altered States of Consciousness. C. E. October 17–22. (1941) A Preface to the Theory of Hypnosis. Knoxwille. 27(2):137-143. P. E. and the Implacable Experimenter: An Inquiry Into the Consistency of Personality. E. Bányai. Emese Józsa. California: Consulting Psychologists Press. and by Professor Michael Nash.. 36. Book of Abstracts.. Behavior Therapy. 20(2):94-99. Bányai. Department of Psychology. Vas. Suhai-Hodász. R. A. Weitzenhoffer.. A. USA. Éva I. Monotonous Percussion Drumming and Trance Postures: A Controlled Evaluation of Phenomenological Effects. (2001) Phenomenological Experiences Associated With Hypnotic Susceptibility. Reviewed by Professor John Gruzelier. Goldsmiths College. J.98 Katalin Varga. (1993) The “Counter-Trance” Concept: Pulling Psychotic Patients Out Of the Well of Pathological Regression. (2006) A New Way of Characterizing Hypnotic Interactions: Dyadic Interactional Harmony (DIH) Quastionnaire. A. Sugarman and R. . (2004) Hypnosis Interaction from an Evolutionary Perspective: the Patterns of Harmony in Phenomenology.. É. 477-505. Varga. 69-87. and Pekala. Józsa E. C. Varga K. R. (1984) Implications of the Ericksonian and Neurolinguistic Programming Approaches for Responsibility of Therapeutic Outcomes. Journal of Abnormal Psychology. Bányai et al. M. L. Anthropology of Consciousness. American Journal of Clinical Hypnosis. In A. California: Consulting Psychologists Press. (1978). W. and Hilgard. 17. E. N. K. Contemporary Hypnosis..) Expanding Dimensions of Consciousness (pp. K. Gősi-Greguss A. Forms C.. (1962) Stanford Hypnotic Susceptibility Scale. Hypnos. A. K. Paper presented at the 16th International Congress of Hypnosis Singapore. Józsa. (1997). 8(2-3). M. Yapko. White. University of Tennessee. behavioral activation.In: Hypnosis: Theories. R. etc. such as exposure. are not amenable to starting a treatment using the choice techniques for their problem. Koester and P. Spain 3 Private practice ABSTRACT In this chapter. which correspond to the different types of cases that have been considered the most relevant according to our clinical experience. Difficult cases and/or emergencies are defined as follows: 1) people who have gone through a number of treatments without receiving significant benefits. D. 3) people whose problem needs to be solved or improved immediately. M. Research and Applications Editors: G. Elena Mendoza2. and Antonio Capafons2 1 University of Coimbra. 4) people in shock. * Illustrations by João Pires. consequently. our approach puts forth three intervention models for difficult cases and/or emergencies.3. . due to their poor clinical condition. Portugal 2 University of Valencia. Delisle ISBN 978-1-60456© 2009 Nova Science Publishers. 2) people in despair (for several reasons). albeit introducing substantial modifications to adapt it to the specific characteristics of the intervention in these cases. Chapter 3 APPLICATIONS OF WAKING HYPNOSIS TO DIFFICULT CASES AND EMERGENCIES * Carlos Lopes-Pires1.3. they have fewer therapeutic options. 5) people who. and. we describe the use of this approach for difficult cases and/or emergencies based on the Valencia Model. As a result. Inc. On the contrary. 3) People whose problem needs to be solved or improved immediately. Also. these cases are very relevant in private practice. Weisz. to carry out the so-called empirical research. 4) People in shock. the complexity of these cases makes it difficult. there is no empirically validated research devoted to these kinds of cases. Elena Mendoza and Antonio Capafons INTRODUCTION For years now. However. 2001). in private practice. as we will explain in the course of this chapter. in a way that all patients receive the same therapy. he has recently developed some intervention models specific to difficult cases and emergencies based on the Valencia Model of Waking Hypnosis (VMWH) (Alarcón and Capafons. what are difficult cases and emergencies? Overall. The first author has a wide experience in this type of patient and has been interested in the development of systematic psychological interventions to treat these patients maximizing the benefits. which very often lead to the development and chronicity of emotional problems. medicines do not foster the development of coping strategies for the patient’s problems.100 Carlos Lopes-Pires. Hence. 2005). if not unfeasible. An obvious problem is the difference found when comparing the clinical work aimed at research with the private practice. some problems arise when these therapies have to be adjusted to the clinical setting. 2001. Despite the advantages of this initiative. there has been an attempt to validate empirically psychological therapies (Chambless and Ollendick. all of the experimental variables are intended to be controlled as much as possible. Capafons. DEFINITION AND CONTEXTUALIZATION OF DIFFICULT CASES AND EMERGENCIES One reason that these sorts of cases are unsuitable for evidence-based therapies (EBT). This is an initiative of the American Psychological Association that has been extended internationally (Woody. In the first case. these interventions are probably more beneficial than pharmacological treatments. But. consequently. 2004b). These differences are even more noticeable regarding difficult cases or emergencies. in other words. the approach is that the therapy is adjusted to take into account the patient’s individual characteristics so that the treatment can be more efficient. and. In fact. to the best of our knowledge. is the existence of some very specific and varied particularities. and McLean. These models can be included in a stream of psychological approaches put forth to provide psychologists with a feasible alternative for treating people in these cases. This is because they do not use a self-regulatory perspective. 2) People in despair (for several reasons). at least in their first stage. these are cases with the following characteristics: 1) People who have gone through a number of treatments without receiving significant benefits. Moreover. have fewer therapeutic options. . M. 2006. 2004a. These people need immediate relief from the distress they are suffering. this person has simultaneously the above-mentioned five characteristics. sometimes. First.. whereas those in points 2. second. For example. while at the same time doubt and. In fact. they develop negative expectancies toward a possible psychological approach. Often times. are not amenable to starting a treatment using the choice techniques for their problem. Obviously. emergencies cannot wait weeks or months to obtain the benefits of a therapeutic approach of whatever kind it may be.Applications of Waking Hypnosis to Difficult Cases and Emergencies… 101 5) People who. but that the former share a common condition that distinguishes them from the latter—namely. besides the necessity of correcting beliefs and expectancies related to the nature of the psychological treatments as well as the psychological disorders. it is common that patients searching for psychological counseling on their own initiative establish an ambivalent relationship with that possible help. etc. These patients show a variety of characteristics that differs whether they have been taking treatments including drugs or not. too. caused by pharmacological treatments. 3. An important issue to consider is the tendency of psychologists. behavioral activation. it is necessary the immediate implementation of psychological means that help change the patient’s psychological dynamics. due to their poor clinical condition. to ignore the problems caused by medications. Patients classified in points 1 and 5 are considered difficult cases. there will be a wide variety of characteristics at the starting point. at least in Europe. in which drugs are the choice treatment. In the next paragraphs we will describe in detail these characteristics. 1. since in their case drugs have failed. a problem in the neurotransmitters). even resist to the concretization of that help. which are crucial in this kind of patients. they suffer from iatrogenic problems. Some of these characteristics are the following: a) hopelessness. In this way. Nevertheless. c) problems caused by medicine withdrawal. and 4 are considered emergencies. such as exposure. As a consequence. these patients are a professional challenge from a psychological perspective. because the patient has already attempted to quit the medication and . This classification does not imply that emergencies are not difficult. b) holding the belief of having structural and functional problems in the brain (e. above all. since they were told that the pharmacological approach is the only treatment and it has failed. not only the uncomfortable symptoms directly derived from the withdrawal. but also the psychological impact that makes the patients feel vulnerable because of the decrease or withdrawal of the medicine. it is worthy to describe these characteristics separately. Since we are talking about real people with real problems. they can think of it as their last chance. a person who has been suffering from a panic disorder for many years can also be in shock at the same time. Therefore. That is. this problem tends to be worsened when there is polymedication.g. People who have Received a Number of Treatments either without Obtaining Significant Benefits or Worsening their Condition The most common cases we see in our private practice are patients that have already gone through several treatments for a number of years with poor advances or none. because the medication becomes a part of the problem (it generates new symptoms of distress and disturbance). such as a child who in response to a fright quits ingesting solid food. reasoning. It is because of this confusion that patients keep on taking harmful medications that make their disorders become chronic. Therefore. M. All of them show a high degree of disorientation. withdrawal symptoms are an additional target of the intervention in our approach (it may have the same characteristics of an emergency. improve the mood. However.but above all that they are in need of finding or at least discover a way out of the situation. It is worth mentioning that the usual approach to these patients is considering them as in urgent need of taking medication arguing that a psychological approach is too slow. it is worth pointing out the confusion between relapse and withdrawal that both physicians and psychologists show very often. and memory. according to the diagnosis. 2. and it does not take into account those cases in which 1 Insofar as this chapter does not intend to discuss specific aspects relative to the use of drugs in psychological treatments and its consequences (positive and negative). whether have gone through previous treatments or not. . This is a point of view without any scientific support in regard to the pharmacological action. patients find themselves cornered and feel like they had reached a dead end. anxiety and discourage. the sleeping time is perceived as insufficient. the implementation of an intervention based on an EBT. It is important the fact that this state prevents patients from. before thinking of implementing any specific treatment. People whose Problem Needs to be Solved or Improved Immediately This category refers to people who. which also reinforces the conviction that the medication is the only way of feeling a little better1. 3. Moreover. conflicts. but we will discuss it further in point 4). Therefore. It is not only that these patients are in despair –like in point 2. it is clear the indication of a particular treatment. among others). affective problems (couple problems). and discourage. In other words. which generates disturbance (tiredness. we are referring to cases in which the immediate improvement is needed to avoid severe or unwanted consequences.102 Carlos Lopes-Pires. difficulties with concentration. From a psychological point of view. for instance. In all these cases. or in case the disorder is relatively recent. the therapist have to use a previous procedure in order to decrease anxiety. mood disorders. Elena Mendoza and Antonio Capafons has experienced negative consequences. Other cases that can be classified here are those people who are in a situation of strong suicidal ideation. People in Despair These patients. or that since several years ago only sleeps regularly 2 or 3 hours per night. suffer severe or chronic insomnia. a solution to the suffering they are going through. Also belonging to this category are those cases of sudden situations with severe consequences. etc. overall as a result of a prolonged emotional suffering. It would be the case of a person who has been days or weeks sleeping only in a residual way. anxiety. have suffered from a disorder for many years. irritability. authors do not detail this matter further. the cases included in this category are patients suffering from phobias. or create a minimal emotional stability that allows to proceed with the intervention. even though. it has had a strong impact in patients’ well-being. or makes difficult. and that is a goal that may be achieved quickly. This is often the case of treatments using techniques such as exposure whether exteroceptive or interoceptive5. For instance. it would be indicated in these cases an efficacious psychological management of these symptoms using hypnosis. People who Are not Amenable to Start a Treatment It is not rare to find people who despite being very motivated for starting a non pharmacological treatment. in sudden grief2. it is evident the existence of a severe agitation and anxiety. It helps pre-activate the patient (e. It is common that a person in shock goes to an emergency room where the most common procedure is the use of short-acting benzodiazepines (such as sublingual ethyl loflazepate.. It does not allow the establishment of the necessary steps to implement the therapeutic procedure (e. weak. In fact. motor or both). active-alert hypnosis procedure). Additionally. exposure. suffering trauma3. probably the idea that psychological treatments are very slow was brought about by preconceptions derived from the long time that Psychoanalysis led the American and European cultural perspective. 2 The grief can be the consequence of an actual loss of a beloved one. a psychological approach should be incisive enough to be able to take into pieces the intricate affective-cognitive conflict in which the person is involved. Hypnosis is a very beneficial strategy. 4 There has been recognized in the DSM-IV a category called “Delirium Disorders”. . 3 For instance. People in Shock A general characteristic of emergencies is the presence of agitation (mental. Therefore. or an affective loss such as a relationship breakup. cases of delirium or cuasi-delirium caused by stress4 can be also included. etc. In the latter. Bentall. or simply induces expectancies for change. 5.Applications of Waking Hypnosis to Difficult Cases and Emergencies… 103 the medication causes either the induction or exacerbation of the suicidal ideation (Healy. relaxation. According to our experience. people with moderate-severe depression present some important obstacles at the beginning of the treatment. In addition.g. 2002. the dropout from the psychological treatment in this stage is a possibility. how to start behavioral activation with somebody who feels apathetic. etc. 5 It is included the exposure in imagination. or intravenous diazepam) or an intravenous neuroleptic. present major difficulties to actually initiate such treatment. 4. an assault. the most usual problem in practice is that the recommended procedures in these cases are the ones causing more resistance in the patients because of the strong discomfort they produce. and also it is possible to hear voices. in the course of an accident. 2007). In other words. This point even relies on evidence about the phenomenological and epidemiological nature of these disorders (Barlow. symptom that traditionally has had as a first-choice treatment the prescription of antipsychotic drugs.g. Clinical situations considered in this category are people with panic attacks. 2004). a rape. Additionally. without energy? It is as if the person was overwhelmed by an immense burden that prevents his/her from cooperating. cognitive restructuring) indicated to a given disorder. it is important the establishment of the perception of safety and surprise. Nevertheless. 2) the psychological treatment is not compatible with the medication. unfortunately very numerous. the psychologist keeps the same frame of mind than when using any other psychological procedure (since hypnosis is also a psychological procedure). 7 An important line of research by Kirsch (2007) on the role of expectancies in human behavior. the VMWH has fewer limitations as the reader will notice. generate favorable conditions to the modification of competences. however. Even though we have already mentioned these cases in point 1. patients who would be amenable and show positive psychological treatment expectancies cannot benefit of such treatment since they are under the effect of drugs that have a pernicious action over the implementation of a psychological intervention. From our perspective. .104 Carlos Lopes-Pires. The most adequate option seems to be the slow reduction of medication along with counseling and the introduction of psychological procedures aimed to reduce the withdrawal symptoms. there exist several fundamental therapeutic elements to take into account in the psychological approach of these cases. This means that not everybody can benefit right away of these procedures. support our interest in the VMWH. people suffering from an obsessive-compulsive disorder can be included in this group.. They need a previous emotional stabilization. change. the psychologist utilizes hypnotic techniques to modify expectancies. the perspective here is a different one. According to our clinical experience. For one. the patient will suffer from withdrawal symptoms. 3) it would be desirable to discontinue the medication. the patient has to have an adequate level of suggestibility. which. Elena Mendoza and Antonio Capafons Furthermore. exposure and response prevention). their problems have been brought about by the spontaneous use of dysfunctional self-suggestions. GENERAL APPROACH FOR DIFFICULT CASES AND EMERGENCIES BASED ON THE VALENCIA MODEL OF WAKING HYPNOSIS (VMWH) First of all. to be willing to develop this quality. Hypnotic techniques appear to be interesting in these cases. these assumptions and limitations should be borne in mind so that the approach can be serious from a scientific and clinical point of view. establish beneficial conditionings. in hypnosis. In other words. a positive surprise for the person is therapeutic on its own.e. to some extent. It is our view that. 6 To be precise. These patients are so much confused and agitated after weeks or months experiencing intense compulsive anxiety that they are not amenable to initiate the appropriate treatment (i. On the other hand. First of all. On the other hand. and to teach new healthy competences7. because it helps be open to novelty. M. or at least. This entails the following: 1) the medication has not helped the patient. In any case. Indeed. and perhaps hope. found that there is no doubt that there is an essential and deliberate utilization of expectancies for therapeutic purposes. an interesting fact is that the most of these patients tend to be very suggestible. when using hypnotic techniques. in fact. and particularly. People under medication constitute another group of cases. in our opinion based on clinical experience. our view is that there are two essential assumptions that simultaneously base and limit the use of hypnotic procedures in general and the VMWH in particular6. and confidence in. the therapist and their attitudes toward hypnosis. All this would go unnoticed by other people around him. which once learned. the patients are taught the rapid self-hypnosis method. 1998b). The purpose of these exercises is to assess patients’ collaboration with. namely. In this context. . 1998b). After this. Additionally. Corrections to the popular misconceptions about hypnosis are provided. This induction method is closely linked to the hypnotic suggestibility exercises. its sequence is flexible. such as that hypnosis is a safe technique for hypnotized individuals or that it does not involve an altered state of consciousness in which a person can become “trapped”. The VMWH. The exercises are: postural sway. this perception of safety is essential for achieving emotional stabilization. 1998a. For instance. includes three procedures to establish good rapport: the cognitive-behavioral presentation of hypnosis. Two methods of waking hypnosis are used along with these procedures. this man is smoking while hypnotized and he might be suggesting himself to feel satisfied right after starting to smoke that cigarette and feel like throwing it away. can be performed very quickly.Applications of Waking Hypnosis to Difficult Cases and Emergencies… 105 the perception of safety allows establishing a therapeutic relationship of trust that will provide the patient with subsequent therapeutic benefits. and a didactic metaphor about hypnosis. and creating a “soothing” effect. being the former the core of the method (Capafons. with eyes open and in a disguised fashion (Figure 1)8. and a third one is added that involves a challenge suggestion (exercise of “confirmation”) (a detailed description of this method can be found in Capafons. as we will detail further in the presentation of clinical cases. Furthermore. namely. The cognitive-behavioral presentation of hypnosis illustrates its association with everyday life situations. or to be calm in that situation without needing a cigarette. in this case. Another important aspect is regarding to intrinsic characteristics of the VMWH. this presentation conceptualizes hypnosis as a means of gaining self-control. falling backwards and hand clasping. and hand clasping. the fact that this approach is focused on the implementation of self-control and is very structured in a very understandable and practical way for the patient. the patient is willing and ready to move on to the assessment of suggestibility. 8 As shown in this figure. clinical assessment of hypnotic suggestibility. namely. in the moment of attending an emergency or approaching a person in a difficult clinical situation. which also reduces any fear of loosing control that the patient may hold. that is conducted without previous hypnotic induction and using classic hypnosis exercises with a different meaning. based on the socio-cognitive or cognitive-behavioral paradigm of hypnosis. A description of the main elements of the VMWH will help the reader comprehend better these and other characteristics that make this model be an innovative approach. falling back. patients using Rapid Self-hypnosis may be in a public situation and doing other things while giving themselves the therapeutic suggestions. Even though it is very structured. Rapid Self-Hypnosis (RSH) and (hetero) Waking-Alert Hypnosis. it does not imply a lack of effort or perseverance to change behaviors. Once the patient has experienced hypnosis. M. all the procedures included in the VMWH have been empirically validated (Capafons. people in despair and people who need an immediate improvement. the application of hypnosis to difficult cases and/or emergencies has been mainly focused on patients in need of relief of the acute pain and/or anxiety suffered either in accidents or in peri-surgical procedures. Elena Mendoza and Antonio Capafons Figure 1. respectively. Finally. albeit only as a helpful agent in the treatment to be implemented (since hypnosis is an adjunctive to the psychological intervention). see Capafons. whereas they keep the efficacy attributed to other forms of hypnotic suggestion management and have even surpassed other methods. and it is an important instrument. a metaphor is used to convey the following ideas: hypnosis is not dangerous. it is worth mentioning that all these methods of suggestion management has been described by patients as pleasant.106 Carlos Lopes-Pires. Alarcón and Hemmings. REVIEW OF RESEARCH OF APPLICATIONS OF HYPNOSIS IN DIFFICULT CASES AND EMERGENCIES As mentioned before. enjoyable. that is. and useful. Likewise. 2004a). The first kind of patients corresponds to points 2 and 3 of the classification of cases mentioned above. Studies found in the literature are mainly relative to burn patients and to patients undergoing surgery. Hypnosis has been successfully used in cases of burn-injury patients to . hypnosis is an essential component of the VMWH. This exercise is conducted while the patient is self-hypnotized and consists in asking the patient to imagine his/herself facing a series of fictitious difficulties (surviving in a jungle) that s/he solves successfully thanks to his/her effort and the correct use of a machete that represents hypnosis (for a detailed description of the metaphor. According to the literature. 1999). Likewise. there exist studies carried out to assess the efficacy of hypnosis in patients suffering from chronic disorders whose symptoms do not respond to the conventional medical treatment for that problem. There are two structured protocols for the application of hypnosis in the treatment of IBS. Questad and de Lateur. Middelkoop. There is a great deal of research whose results support the efficacy of hypnosis in this area (e. Conventional medical treatments for IBS are unsatisfactory for more than half of all patients. as well as changes in central processing. The second area of study is focused on patients suffering chronic pain caused by temporomandibular disorders. Among the studies that have addressed this kind of cases. Additionally. This was revealed both in self-report measures and in objective measures. 2006).. it has been utilized to reduce the pain medication needed before and after surgery. 2006. Both protocols have proven that the treatment with hypnosis has an important impact that is well maintained for most patients for years after the end of treatment. 2006). quality of life impairment. 1991.. which suggests that hypnosis used as an adjunctive procedure helped most patients reduce the adverse consequences of surgical interventions. 2000. as well as to facilitate post-operative recovery (Pinnell and Covino. Devlieger. hypnosis has shown to be efficacious in managing the anxiety and reducing the pain associated to dressing changes (Frenay. Lang et al. Wiechman. 2006. psychological effects and improvement of quality of life. Patterson. 2007. Patterson and Ptacek. It is estimated that 23% of patients do not respond to conservative treatments involving a dental and physical medicine approach (Clark. Patterson. Faymonville. it is important to take into account the meta-analysis performed by Montgomery. hypnosis has been used as an adjunct to psychological interventions for reducing anxiety. and disability for many patients. Jensen and Sharar. Patterson. even in patients that do not respond to conventional medical treatments (Gonsalkorale. Burns and Marvin. those conducted on two particular areas are relevant for the low efficacy of the conservative medical treatments in contrast with the success of hypnosis. Furthermore. Whitehead. leaving them with significant chronic symptoms. 2000). 2006). David. Research has shown that this protocol benefit more than 80% of patients (Palsson. Lang et al. 2006). 1997. as an adjunct to pharmacological analgesia and to teach patients strategies to cope with peri-surgical procedures. 1999. Silverstein and Bovbjerg (2002) in which it was found that 89% of surgical patients benefitted from interventions with hypnosis compared with to patients in control conditions. One has been developed in the University of Manchester (UK) (Gonsalkorale. and the hospital stay. 1989). Whorwell. Albert and Vanderkelen. a seven-session hypnosis-treatment.g. Blankfield. Faber and Van Loey. Winkel. Whorwell. Gains of intervention include changes in colonic motility and rectal sensitivity. The first area concerns the incorporation of hypnosis as an adjunct to cognitivebehavioral therapy in the treatment of irritable bowel syndrome (IBS). Everett. Gonsalkorale and Whorwell. 1992. The other one is the North Carolina Protocol.. 2002. The second kind of patients mentioned are those with a chronic disorder that does not respond to the medical conservative treatment and correspond to point 1 of the classification. 2005. Results indicate that patients treated with hypnosis as an adjunct obtained significant pain reductions relative to pretreatment baseline or control groups and needed less medication (de Jong. Houghton and Whorwell. This disorder leads to considerable emotional and physical suffering. 2001. Faymonville. unique because the entire course of treatment is designed for verbatim delivery. 2006. Meurisse and Fissette. the bleeding. 2006). Relative to studies with patients who have to go through surgery. Lanham . In addition.Applications of Waking Hypnosis to Difficult Cases and Emergencies… 107 manage anxiety and pain while they go through dressing changes and wound debridement. and intensity. it will be helpful to review the general frame of these models concerning their psychological origins. according to our clinical experience. second in the use of the waking version of hypnosis and in particular the therapeutic procedures of the VMWH adapted to these cases. and 3. the use of hypnosis as an adjunct to cognitive-behavioral treatment in these patients is promising. these two elements can be viewed as essential in the establishment of this approach. First of all. 2. safety and surprise. see Weitzenhoffer. in medical use. the two aspects already mentioned are very important. whether the cases are difficult and/or emergencies or not. They are as follows: • 9 Assessment procedures do not predict clinically the therapeutic benefits. in a strict sense. After the treatment. Elena Mendoza and Antonio Capafons 108 and Flack. participants showed and increase in daily functioning. which is focused on cases sharing some of the characteristics of the cases we consider as difficult or emergencies.Carlos Lopes-Pires. In our approach. there are no published studies about the use of hypnosis in the kind of cases we describe in this chapter. 1988). the establishment of safety and use of surprise are inherent conditions to any profession in which there is a relationship of help. Besides this research. Another aspect that we consider important to explain is the assessment of hypnotic suggestibility. Before further describing each model. since. and their treatment gains were maintained for six months after hypnosis treatment (Simon and Lewis. the different items used to assess the suggestibility are not related to the clinical and therapeutic response. . it is important to point out that this work is pioneer in two aspects: first. to create safety in an approach as specific and incisive as the one we set forth is crucial and can not be postponed until the safety is established throughout several sessions. Therefore. patients of this study reported a significant decrease in pain frequency. 2001). the application of hypnosis to cases that psychologists can find in their everyday private practice (differing from those mentioned before that can be often found in hospital practice). 2000). to the best of our knowledge. and whose characteristics make them difficult and in need of a special approach to achieve a quick improvement. In fact. as well as. Likewise. above all. According to Simon and Lewis’ study (2000). 2000). but they are not relevant in our approach as we will explain further on. The models are simply called model 1. 2008) intending to respond to the clinical diversity of difficult cases and emergencies. there are several limitations or determining factors that make it not useful9. namely. However. Indeed. the hypnotic suggestibility is not assessed. The approach is supported by three models of intervention (Pires. This opinion has been also advocated by others (for a review on this topic. THE THREE MODELS OF INTERVENTION DERIVED FROM THE VALENCIA MODEL OF WAKING HYPNOSIS This approach results from the experience with some hundreds of difficult cases and emergencies that led the first author to develop different models of hypnotic intervention based on the VMWH. duration. the possible use of psychometric instruments. Beliefs and attitudes toward hypnosis are more interesting factors (Capafons. On the other hand. M. 2. The “didactic metaphor” is taken off since this approach aims to be as quick as possible. The assessment procedures can foster a traditional perspective of hypnosis in people that hold these beliefs. However. This will be better understood when each model be explained. and implement the wide range of hypnotic procedures. . In emergencies especially it is pursued an immediate therapeutic impact. To sum up. at the time of using hypnosis with therapeutic purposes. In table 1 is shown the logic that directs these models.10 As soon as the patient has some experience in the benefits of hypnosis. the VMWH is adapted to the clinical circumstances and characteristics of these patients. they are more receptive and willing to comprehend. The surprise factor. 11 Except for when in the development of our approach (in subsequent sessions). The clinical approach begins with an induction procedure. In the following diagram the models can be compared to each other. The main characteristic of our approach is the development of brief procedures taking the psychological. maybe because their misconceptions about hypnosis. given that the first contact with hypnosis is through the items (which are actually induction procedures). after the beginning (rapid hypnosis)11. we have found that patients that responded very well to the items. the “presentation of hypnosis” is carried out. they are also told that their purpose is the assessment of the hypnotic suggestibility). 4. that is. 10 Notice that in some cases. after the patient’s emotional stabilization. Thus. the format is already set according to the usual VMWH. That is. Often times. this does not mean that it can not be used subsequently. and consequently they are not suitable for the kind of clinical situations that we are describing here. the approach is directed immediately in terms of “self-hypnosis”. There is not a presentation of hypnosis. 5. and philosophical assumptions of the VMWH as a starting point. accept. that is a very important condition for this approach. 3. kind of a line of reasoning for decision-making concerning whether or not using hypnotic techniques. The hypnotic induction is directed in the sense of its maximization in an only session. The resulting models can be called Very Brief Models. The reason is obvious: when patients have already felt benefits and have personally experienced what hypnosis is. is completely lost. ended up resisting or rejecting its use. That is the reason why the patient is immediately trained in rapid hypnosis. This would be what in the VMWH corresponds to the stage “Practice and training suggestions” or later. besides the lack of a presentation of hypnosis. comparing the two figures the following differences can be easily noticed: 1. technical. since the exercises can remember familiar scenes of hypnosis (it is important to take into account that when these items are introduced to patients.Applications of Waking Hypnosis to Difficult Cases and Emergencies… • • • 109 They are very extensive and take time. the clinical assessment of the hypnotic suggestibility is transformed into a hypnotic induction procedure. There is a high risk of spoiling effects that could be used for the patients’ benefit. Comparison of Valencia Model of Waking Hypnosis and Very Brief Model (Taken from Alarcón & Capafons.110 Carlos Lopes-Pires. . 2006). M. Elena Mendoza and Antonio Capafons Diagram 1. that she had taken for 5 days). For instance. Is there a strong pressure to get the problem solved immediately? 4. according to the clinical history. Model 1 There is not any preparation or mention to hypnotic suggestions. but they failed. something different should be done. after suspending the drug. Is this an emergency? 2. Procedure (one of the models) ----------------------1. Conclusion: Is the use of hypnosis feasible? 5. although taking as a reference the previous treatments. This position in itself produces swaying. If they were not adequate. In point 4 of difficult cases the goal is to know. This protocol was put forth with the goal of causing surprise. the focus would be a therapeutic adaptation. it was possible to initiate an approach including hypnosis. Is this a difficult case? 2. After 5 or 10 seconds the patient will be asked to open again his/her eyes. asking ourselves the questions of the table 1. Line of reasoning for decision-making concerning whether or not using hypnotic techniques 1. Relative to the point 4 of emergencies.Applications of Waking Hypnosis to Difficult Cases and Emergencies… 111 The discussion of the first three points is framed in terms of the so-called difficult cases and emergencies above-mentioned. The patient is also asked to fix his/her eyes on a spot and after that to close his/her eyes (Figure 2B). Table 1. If the treatments were adequate. only counseling could be more feasible and have more benefits. in may be the case that the person is not in conditions to pay attention12. we implement the Model 1. which produced her to suffer from vertigo and to be unable to keep a hardly coherent dialogue. Procedure (one of the models) Postural Sway The patient is asked to stand up and stand facing the wall with his/her feet together and his/her arms and hands stretched out beside his/her body (see Figure 2A). Point 5 in both situations consists in the implementation of the approach through one of the models. Is the suffering unbearable? 3. 4. When the patient has opened his/her eyes s/he is asked the question: “what 12 The first author has already had the experience of an emergency in which the patient was under the effect of an antidepressant (a substance called escitalopram. Two days later. context. After listening to the patient’s complaints. and establishing the rapport with the patient. and clinical characteristics. Conclusion: Is hypnosis a feasible alternative? 5. Have there been previous treatments? Were these treatments the most adequate? 3. The models are explained in the next section. whether the use of hypnosis is possible. and the first exercise was selected due to its similarity to tests used in neurology. . Elena Mendoza and Antonio Capafons did you feel in your body?” Most patients answer that they felt like swaying13. . the protocol goes on with the next exercise: falling back. 13 Some people. Figure 2B. Then. Figure 2A. especially very hypnotizable people. M. may feel a little dizzy.112 Carlos Lopes-Pires. asking him/her to fall backwards. It is worth noting that this exercise not only pursues to help develop .Applications of Waking Hypnosis to Difficult Cases and Emergencies… 113 Figure 3. This exercise is carried out several times. and assuring the patient that s/he is safe since s/he is going to fall into the supporting hands of the therapist (Figure 3). Figure 4. Falling Back The patient remains in the same position and the therapist places him/herself behind the patient. 114 Carlos Lopes-Pires. hands attracting to each other. Figure 5A. it is not so important that the person falls backwards. more and more until eventually they touch (Figure 5B). and close his/her eyes. After repeating the exercise follows the same one but adding the use of suggestion.” (Figure 4). Falling back Using Suggestion As in Figure 2A. put his/her arms parallel to each other (Figure 5A). It also prepares the patient for the next exercise that is actually the one to use in a therapeutic way: side arm lift (levitation). the patient is asked to fix his/her eyes on a spot and to stay put. The underlying idea of this exercise is. the development and increase of the surprise. while imagining that his/her hands (separated 15-20cm) are getting closer to each other. the therapist says something like the following: “Please. It is thought that this exercise leads to an increase of the involvement in a suggestive activity as well as causes surprise. namely. Elena Mendoza and Antonio Capafons confidence in the therapist. In our approach. The goal is to involve the patient in a setting of surprise that will lead him/her to the main exercise (the last one of this Model). M. imagine that my hands are powerful magnets that are attracting you backwards. The therapist warns the patient that s/he is going to place him/herself behind his/her and put his/her hand in a way s/he can hold the patient when s/he falls. The next exercise used in this Model is a simple exercise of suggestion that appears in many scales to assess suggestibility. . Attracting you…Attracting you…Attracting you backwards…More and more…. After that. but also to create a setting of surprise (“what are these exercises for?”). once again. Hands Attracting to Each other The patient is asked to stand up. the sun. there are several alternatives. The therapist says something like the following: “Notice how interesting… your arm lifting on its own… and notice that it is not only interesting but also gives you a pleasant feeling of relaxation. all these exercises can be performed while the patient is sat. the starting position may be with the patient sat as close to the edge of his/her wheelchair or the chair as possible. In fact. I would like you to feel your arm lifting. the pass of the year seasons. Side Arm Lift (Levitation) The patient is in a standing position (this time his/her feet are separated so that s/he does not sway too much)14. the clouds. and then proceeding like in the standing version of the exercise. I am going to take your right (or left) hand by the wrist and push it upwards. the rain. knowing that statues do not suffer. and right after the previous exercise. by means of creating a movement perceived as involuntary. Now. most people quickly experience this involuntary arm movement. they just observe the world movement. depending on the clinical case and the goals intended to achieve through this intervention.” It is obvious that this exercise is intended to be used as a hypnotic induction. In the “falling back” exercise. From our point of view. do not move. . This movement will be repeated several times.Applications of Waking Hypnosis to Difficult Cases and Emergencies… 115 Figure 5B. the therapist says the following: “In this exercise. there are two major alternatives considered especially helpful to attain emotional stabilization and step back from conflicts: a) Suggesting to the patient to feel as if s/he was a stone statue placed in a garden. the birds that come and 14 Obviously. but substituting the suggestion for feeling that the therapist’s hands attract him/her to fall backwards with the suggestion of the same effect but produced by the back of the chair. This would be the case of either temporarily or permanently disabled patients. after asking you to close your eyes. to feel its movement. pay attention to what is going on… the left arm also lets go and begins to lift…and both arms lift…lift…they go up until a certain moment comes when they no longer lift but go down.” At this point. do not think. and appreciating how big things are small. Elena Mendoza and Antonio Capafons the birds that go away. the left arm).. we have noticed that most of these patients tend to sway more or less slightly when they are in a standing position. even when keeping their feet separated from each other. regarding induction techniques derived from this initial exercise of arm lift.116 Carlos Lopes-Pires. calm. but do not experience the sensation of involuntariness. Even it may be suggested that the person mentally leaves the statue and sits in a bench in the garden observing with serenity the events. Therefore.g. but the pendulum is fixed in the base…Swaying…Swaying. The first variant consists in proceeding with the same procedure with the other arm. Some people do not move their arm (even when the therapist is pushing).. These people tend to do catalepsy. an alternative to the side arm lift (levitation) is the watch pendulum. It is worth pointing out that there are some other possible variants. you will see that it will let go and will start lifting like happened with your other arm…” This way of proceeding results in hypnosis deepening. Relative to the case of catalepsy.. the cars.. if you pay close attention. M. and small things are big. the leafs of the trees.. In a second alternative (b) it can be suggested to the patient to listen to the sound of the road. such as shown in Figure 6A. Figure 6A. you will notice a very interesting thing: your body is swaying…swaying as if it was a watch pendulum…The pendulum of a very big and antique watch. The wording for the watch pendulum may be as follows: “Now. . in a moment may happen something very interesting: when I touch you with my finger in your arm (e. In this case the wording may be something like the following: “If you wish. leaving their arm extremely rigid. an alternative to the side arm lift (levitation) can be the suggestion of feeling as being a stone statue (according to the mentioned scenery). depending on the perspective and importance that we give to them. In regard to the second case.Insofar as it sways…” And it continues with those suggestions thought as the most appropriate for the case. going further every time and very relaxed. Others simply leave their arm flaccid. I think you will enjoy being even more surprised. Listen to a very important thing I am going to tell you… Everybody has conscious and unconscious activities. I know you are listening to me and you are going to find this very interesting and amazing.Applications of Waking Hypnosis to Difficult Cases and Emergencies… 117 Figure 6B. you do not know either. when I say “now”. little by little moving. and fingers.. Another variant. In this case. you will be able to feel some changes in your right arm and hand. The learning of better regulating that unconscious activities will be very important in order to change difficulties. Thus. sometimes we do not know why we do this or that. hypnotized…). then a time will come in which your right hand is going to move to a part of your head… I do not know where it will go. etc. Once the arm is in the initial position it may be suggested that at any time the right hand and arm will move. Often times. Notice those small and very subtle movements inside your hand. suggestions for the arm to descend are given (for example by saying: in a moment I am going to touch your right shoulder with my finger and then I am going to go down touching your forearm. Finally.. after the right arm has lift. The movement involuntariness is reinforced constantly and.. An interesting way of letting these unconscious processes show themselves is by means of the movement of the left arm. Will it go to your face. 2) At the end.. it is explained to the . moving. either emotional or any others. hand. arm. this is the more complex procedure and the most productive. to your mouth. Perhaps. calm. and because of that. and you will be able to feel this arm going down until it touches your body. to your forehead. is shown in Figure 6B. you do not know either.. to your chin? I do not know. and it can be used subsequently. this one more complex but also very interesting in terms of the suggestive-therapeutic possibilities. we use the following procedure in which a metaphor about “unconscious processes” is included (it can be used any other metaphor that is appropriate for the goals): “Well. at the same time. to one of your ears. there are some aspects to emphasize: 1) The patient is ready for rapid hypnosis through several inductions that will prepare the next stage. Your arm will no longer be rigid and hard as if it was a rock).. its relationship with something pleasant (as your hand and arm raise you feel more confident. to your nose. to your hair. Model 2 By and large. this second model uses waking hypnosis and is adapted to a self-hypnosis format. The kind of speech and suggestions given can be as follows: I am going to ask you to sit as much comfortable as possible (Figure 7). It is explained that the important thing is to “let him/herself go”. which subsequently can be associated with other elements leading the patient. However. this model has two stages and both of them are intended to cause surprise. brief. such as hot/cold or simply the immobility of one or both hands. It makes it immediately appealing for those who has private practice and many times need to make the patients understand that the way they think or interpret the situations (internal or external) has a strong influence over their dysfunctional emotions. from the start. LIGHT/HEAVY ARMS FOR EMOTIONAL EQUIVALENCE. For example. Everything is ready for preparing the next session. not to make efforts to produce the sensations that the therapist will refer. there are alternatives to the heaviness/lightness sensations. this is one of the most interesting aspects of the VMWH. Most people tend to report an increase of heaviness or lightness in their hands. The therapist asks the patient to keep his/her eyes open and talk whenever s/he asks him/her something. the hand and arms will lift (Figure 6B). Please.118 Carlos Lopes-Pires. Probably. the sensations of heaviness/lightness in the arms. It is almost sure that the patient will notice changes. above all. For this exercise the patient is comfortably sat. to understand that his/her emotions are determined by his/her thoughts. we only realize the presence of certain sensations when we pay close attention to them. and misconceptions or negative attitudes toward hypnosis are clarified in a conversation. in other words. We use a combination of several items belonging to the VMWH. the final goal is to deal with the patient’s emotional agitation and activated state.) If the patient does not report anything. Overall. 15 In our opinion. I am going to ask you to pay attention to your hand and tell your brain or simply let it know that feeling your right hand is not the same than feeling your left hand. the development of patient’s absorption in his/her inner processes that will be the target of the therapist’s intervention. Moreover. since it is much more direct. and incisive. The following paragraphs detail the procedure. Likewise. the patient may choose to keep his/her eyes closed if s/he feels more comfortable this way. in a gradual way. it is worth pointing out that. The first stage involves. pay attention to check if something like that happens to you. this model is the most appropriate for emergencies. Often times. Give that information to your brain and wait… Wait to see what happens and let me know… (Pause for some seconds. in particular. the therapist may go on as follows: Most of people notice that one hand turns a little heavier and the other a little lighter. M. . As mentioned. by his/her “mind”15. that is. Elena Mendoza and Antonio Capafons patient how hypnosis can be incorporated in a therapeutic plan in order to help him/her. calmer…” In our clinical practice. the important thing is the rapid induction of (self) hypnosis. the patient is sat with his/her arms over the table in parallel from the elbows. It makes no difference. Hands attracting to each other. Actually. and confidence. with the patient’s hands over his/her thighs (Figure 8B). now tell your brain that to the extent that your right hand and arm lift. among others). deepening above all selfhypnosis. you feel more relaxed. . or moving on to another script that can be started in the same session or in the following one. etc. you relax yourself… You start feeling a sensation of calmness… Observe how interesting and pleasant this is… Notice that you are starting to learn to regulate better your emotions and that it will have many benefits for you. Additionally. that is performed over the therapist’s table (Figure 8A). This decision will depend on the clinical assessment of the patient at that moment. serenity. although we recommend for the homework to use the latter position. First. this induction procedure is very efficient and pleasant for the patients. as it is carried out in the VMWH. which will be associated subsequently to wanted emotional aspects.. For example: Please. and at the same time a quick stabilizing emotional effect (brought about by the suggestions given in order to achieve relaxation. or. if the hands do not move. The other script is the hands attracting each other. alternatively. because it is very quick. for example. safer. The important thing is the occurrence of those alterations. they are immobile… more and more immobile”.).Applications of Waking Hypnosis to Difficult Cases and Emergencies… 119 Figure 7. The second stage may simply consist in keeping this script. as it can be done with other kind of inductions. The separation between the hands should be about 20 cm. over the thighs. not too much since it is more difficult the movement over a surface than. For instance: “As your hands move approaching to each other. As is shown in Figure 8A. and second because it causes a noticeable surprise effect. different suggestions can be employed (“Your hands can not move.. as well as the association of the movement of the hands approaching to each other (Figure 8B) with a desirable psychological effect. overall. Model 3 This model is mainly used when the patient has already achieved an adequate emotional stabilization. Elena Mendoza and Antonio Capafons Figure 8A. Nevertheless. Figure 8B.120 Carlos Lopes-Pires. because patients improve or solve their difficulties in a satisfactory level. Indeed. it is developed in terms of the VMWH. . it can be more beneficial for the patient to go on working with the approach explained in the Model 2. M. it is a result of the previous model and. as it was described in the beginning of the chapter. It is worth mentioning that according to our clinical experience. many emergencies do not need a transition to this Model. but including new clinically and therapeutically relevant aspects. However. what led him to drink and consume marihuana. After a minimal emotional stabilization is achieved through the Model 2. Anxiety) The first case is an emergency. along with the obvious reduction of oxygen and increase of carbon dioxide in blood. paradoxically. initiated a relationship with one of his colleagues. at the end of the academic year. A. his father passed away many years ago). such as going to see some friends. When the patient is in self-hypnosis. 2002). according to the assumptions of the VMWH). and having been suffering repeatedly from crises in the last days. When he came back home (Center of Portugal. It is A. 2004b). and second. in July 2007 the event that led him to our office took place.Applications of Waking Hypnosis to Difficult Cases and Emergencies… 121 What does the Model 3 consist in? Actually. For example. In order to understand and illustrate the clinical applications of these Models. Perhaps related to this somehow delirious activity. since they are the same than for the two previous Modes (above all Model 2). he confirmed that he was mistaken. This training will allow the patient to understand two important theoretical facts of the panic disorder. since that would be going backwards. breaking it in stages. A. (Delirious Agitation. the aim is not using the VMWH as it is established. The latter caused him to start having some persecutory ideas as well as hearing voices. The patient. or any other of those included in the VMWH (Capafons. A. was always a person showing a high social anxiety and obvious interpersonal difficulties. in a city named Leiria). . Specific induction techniques will not be presented for this Model. had done unpredictable things. first. tried to fit in with his colleagues. this Model develops the VMWH in a slower way. namely. The techniques included in the latter are all aimed to achieve Rapid Self-Hypnosis.’s mother who contacted us. the therapist may spend more time explaining and training in the influence that thoughts and interpretations have on what we feel. 2) The patient is asked to hypnotize him/herself and is trained in producing alternatively relaxation/calm and anxiety/fear. that it is done by increasing his/her respiratory rate. and lengthening the hypnotic procedures16. there is an increase of the respiratory rate. while giving him/herself suggestions of safety and confidence. 2001. that it is the patient him/herself who. which is not possible. it can be emphasized what happens in the breathing cycle. CLINICAL CASES Case A. in the next section we will introduce a variety of clinical cases. which leads to the conditions for the development of the panic attack (Barlow. During the past academic year. 2004a. is a high school arts teacher who had a position in the South of Portugal (Algarve) during the past academic year. However. For example. the intervention may proceed as follows and according to this rationale: 1) The interoceptive exposure is the choice treatment for this disorder (Craske and Barlow. and it was only an illusion of his own mind. which he regarded as a romantic relationship. In this emotional condition he came back to his family home (his brother and his mother. Capafons. some of the essential elements of the VMWH can be used working with them in more detail (thus. giving them the keys of 16 Clearly. a 30-year-old man. that leads him/her to produce an increase in anxiety/fear. let us suppose that a patient comes in a situation of panic attack without agoraphobia. She was in despair and worried since in the last days A. produces the panic attack. 2007). with his head opened. Five days before. 18 The total therapeutic process (including the first session) took place between July and October. it was possible to clarify the events he told us as well as the impact they had had on him. Elena Mendoza and Antonio Capafons his car stating that he was not going to need them anymore. At that point. and his own wife reminded him his cousin’s wife. the variant of the hand and arm going up to a specific place of the head was used. A.’s mother preferred that we assess his son first. and then being found in the beach trying to go out of sea. Relative to his family his own children reminded him his cousin’s children. The patient was able to live with those voices without any problem. hardly slept and experienced permanent and intrusive flashbacks about the accident. He also reported to suffer a high level of emotional/physiological activation (heart rate and breathing cycle accelerated). he showed to be calm and ready to use the procedure in self-hypnosis (without knowing anything about that). It was immediately clear that he was emotionally destabilized and to help stabilize him was considered as the main and immediate goal of the intervention. and with difficulties to explain what happened to him. again and he confirmed to be very well18. is a 41 years old male who was referred by a colleague. This information given by phone was enough to realize that this could be a case of psychotic agitation (delirious disorder). we contacted A. M. The response was excellent. was received the same day in the evening (A. He considered being able to proceed on his own in this matter17. safety. Some months later he contacted us again to improve some interpersonal aspects (related to social skills). The Model 1 was applied with the arm lift procedure. He appeared to be a very anxious person. rather than proceeding directly to his hospitalization in Psychiatry. Even so. and tranquility were given. The patient practiced at home during the following three days and then came back. B. generally neutral or even positive ones. In the way back home they were involved in a serious car accident. including the hearing voices. agitated. Taking into account that A. B. He was able to achieve what he called “meditation”. A. One of the things that most impacted B. In these two sessions the work with him was focused on problem solving. he used to talk to himself as if there were somebody else. A. anguish. . now a widow… 17 An interesting aspect is that the patient went on hearing “voices”. was to see part of the brain of his cousin spread on the ground. some nights he slept inside his car or outside in the beach. came back to the office after two weeks and one month and he kept his positive progress. Suggestions of calming down.122 Carlos Lopes-Pires. (Traumatic Stress) This case is an emergency too. anxiety. and after several weeks he had gained good results.’s mother called at midday). the patient along with four of his friends (among them there was a cousin of him that he considered as a brother) were hunting. He had difficulties to concentrate in his job as a business man. responded very well. From that day on. and sadness. a hobby all of them had some years ago. Case B. as a result of which the patient’s cousin passed away. Previous to introduce this case in the chapter. and was very agitated without being able to sleep. 2007. Furthermore. after it was verified that he was in a trauma. now without his father. by nature.. as well as allowing him/her to feel safe. We implemented specifically the Model 2. after talking with the patient about the therapeutic goals. you feel that the accident took place long time ago. acute and its treatment has preventive characteristics.. the use of waking hypnosis to be able to proceed to vanish this process. it happened long.Applications of Waking Hypnosis to Difficult Cases and Emergencies… 123 The rationale of the intervention. an unpublished recent exploratory study conducted by one of the authors (Pires and Peralta. a process of guilt that. and night). anxiety. This helps reestablish an adequate balance of brain oxygenation and helps decrease the symptoms causing anxiety. and fourth session. two benzodiazepines.. However. The patient not only was completely limited (he did not go anywhere alone or too far away from his home). The next sessions were one and two weeks later respectively. The second session was intended to deal with the link that people tend to do after the death of a close person. first in hetero-hypnosis and then in self-hypnosis. namely. To this end. to reduce his state of high emotional activation. The patient felt very relieved and showed to have good ability to use self-hypnosis. since the intervention worked out successfully. paying close attention to the exhaling. long ago. 2008) suggests that the cognitive involvement subsequent to the exposure to unpleasant scenes increases drastically the dysphoria.. Therefore. second session four days after the first one.. and this is why you feel that your distress. decreasing the appreciation of neutral or positive scenes. everything indicated that the patient would be vulnerable to develop post-traumatic stress. Case N. He came back two days later for the next session. The treatment lasted 6 months and it revealed to be a very complicated case. by “withdrawing” the patient from the cognitive involvement in the traumatic event. There was another session four days after this one. Indeed. That is.. For example. first of all. 2007). It consists in breathing in a controlled way during about 15-20 seconds (more than 12 seconds). It is worth pointing out that this kind of emergencies is. several days after the trauma. and was asked to repeat it at home several times during the day. was told to practice several times per day this procedure (at least once in the morning. The patient was trained in this procedure in the first session. third session seven days after the second. (Panic Disorder with Agoraphobia) The patient is a 30-year-old male that had been suffering from panic disorder with agoraphobia since he was 17 years old and had always been under pharmacological treatment. the technique of breathing control was used (see Craske and Barlow. as the time passes. may be very relevant in order to the post-traumatic stress does not develop further. in which B. that development never reached to an end. above all depressive feelings. 14 days after the third session. afternoon.. . using the second stage (hands attracting each other) to give temporal distancing suggestions (and in this way. but he also was under much medication (two antidepressants. We proposed B. it did not happen one month ago nor a year ago. anguish are vanishing and decreasing. The objective is to change the pectoral breathing into a diaphragmatic breathing.. long time ago. fades away. was. in this case. achieving a decrease of negative emotions): “Tell your brain that as your hands approach attracted by each other.” Most part of this session was devoted to implement this procedure. the exercise of the hands attracting to each other is applied without too many details. This patient was not an exception to these cases. The latter21 was alone at home and tried to swallow a too big amount of food without chewing. it was possible to initiate interoceptive exposure that the patient accepted this time. after all those years. had not solved his problem and had caused him several problems (“side effects”). (Phobia to Eat) The patient is an 11 years old male child who quitted eating solid food. Even so. N. the choice treatment for panic disorder is conducted through the implementation of exposure variants. M. For that reason. many patients are reluctant to go through such procedures. Hypnosis allowed overcoming the patient’s difficulties to cope with phobic situations. Elena Mendoza and Antonio Capafons propanolol. such as in vivo exposure (agoraphobic aspects). in a way that he would be able to use it subsequently during the exposure. and ended up asphyxiating herself. In this context. In this way. the case became a complicated case at the same time that was an emergency because the problem was already causing an impact on the child’s health. and interoceptive exposure (inner/somatic aspect of panic). Inasmuch as children tend to be very suggestible. Then they looked for another Pediatrician who referred the case to us. Meanwhile. Meanwhile. and to suggest courage by means of some coping scenes of hard adversities in a mountain area. the use of hypnotic techniques was essential for the effective treatment implementation. admitted to be a “coward”: he did not bear to cope with agoraphobic situations. these were the first steps to work with the exteroceptive exposure. several months had passed. there were substantial difficulties and resistance. Then this situation was trained in vivo while in waking hypnosis. Due to they did not obtain any result. As it is known. in cases involving children a simple approach of the Model 2 has shown to be useful. The procedure was repeated several times. and a mood stabilizer). according to 19 We counted on a physician’s collaboration. The patient’s parents realized what was happening to the child several weeks after the problem was already consolidated and started by asking for help to the Pediatrician.124 Carlos Lopes-Pires. also without any result. Therefore. Just as we expected. 20 . The important goal here was to elicit his feeling of courage and associate it to the word “courage”. The Model 1 was applied and the statue scene was used to generate in the patient a feeling of distancing regarding the fear. At this time the patient was no longer taking medication20. the use of hypnosis was put forth as an alternative. It is important to emphasize that even though he exposure has been the basis of the treatment. Even though from a clinical perspective. taking only liquids after the death for asphyxia of a neighbor child. we agreed to proceed with gradual in vivo exposure. Case T. whenever it was necessary to “unblock” the agoraphobic coping. they turned to a Psychologist. the first months the intervention was focused on reducing gradually the medication19. As a general rule. Additionally. the patient did not have at this time any improvement. 21 This child had trisomy 21. he considered that the medication. After a negotiation process with the patient. above all to the interoceptive exposure. in order to facilitate the ingestion of solid and harder food in his mouth. After this procedure. but also present clear symptoms of emotional. . was told the following: “Very well. T. Everything was going well. producing salivation. You will remain alone. that the exercise of the hands attracting to each other would be helpful to make changes in the brain so that the food turned tastier…22 Also. The procedure was the same one with the hands trying to cause sensations of hunger. was told that this training is called self-hypnosis. Pharmacological Iatrogeny) This case is framed in what we consider as “difficult cases”. The food I ate before was not so tasty”. More than three years has passed and there has not come up any problem. the mentioned exercise “to turn food tastier” was utilized.. not only do not improve the initial clinical situation. more and more distant. You will be able to move. and with the passing of the years. Indeed. with 22 This procedure was necessary to avoid the contradiction created by doing something with the goal that he eats. First. stayed alone with us while his parents went to the living room. In the next few months a follow-up by phone was performed. his mother confirmed that when she asked him the reason to do that exercise. As a rule. The following sessions took place every other day during a week in which we went to his house at dinner time. there was a break to assure that the oblivion was working. The instruction was: “Tell your brain…” Before terminating. most of all as a result of the own treatment iatrogeny.” Two weeks later we went to the patient’s house again to observe his progresses and reinforce the procedure. After finishing hypnosis. to watch TV. Right after this. children like to keep their eyes opened. hunger. To be precise. as if he had never had such a problem. the psychologist’s intervention (hetero-hypnosis) was alternated with the performance of the child (selfhypnosis). T. T. he replied: “it is for improving my appetite. whereas it has been suggested oblivion… Subsequently. and behavioral deterioration. The suggestions resorted to a detailed description of the somatic and cognitive signs of hunger. they are people without motivation and hopeless. cognitive. in our clinical practice a kind of case very common is chronic depression.Applications of Waking Hypnosis to Difficult Cases and Emergencies… 125 our experience. the patient said that he had a stomachache that felt like. further in time until it had completely disappeared. they are depressed patients who initiated a pharmacological treatment many years ago. See you later. to drink water. In this stage. The intervention in this case was conducted in several stages that where established in accordance with the goals estimated as necessary at each moment.. it was suggested to T. to his mother astonishment. He ate in a natural way. and in order to prepare for future sessions. now you are in self-hypnosis and are going to eat until you do not feel like eating more. As soon as it had worked it appeared helpful to produce in the patient the sensation of hunger in a way that he could eat a bite of a sandwich that his mother had brought. (Depression. the above-mentioned event would turn distant. etc. Case C. The first few minutes were spent in remembering the good flavors of food. the advantages of eating well to obtain energy to be able to jump and study. call me. During the exercise of “hands attracting each other” it was suggested that as his hands approached to each other. and to the anticipation of the pleasure of satisfying the hunger. When you are finished. it was thought helpful to proceed to a sort of “oblivion” of the event that brought about the phobic situation. you know that. a few months have passed since your health improved and you feel better. two antidepressants (fluoxetine and fluvoxamine). Despite all this. You are happy and satisfied. we can pass to the following scenario: “Now. That is. since she has reasoning and memory problems and repeated work absences. Actually. The same rationale was applied and usual elements of cognitive-behavioral therapy for depression were used. This kind of scenario was repeated with some variants during the first weeks in order to reinforce and develop positive expectancies in a way that the therapeutic process became more feasible. Hypnosis and withdrawal. Let us proceed explaining these points with this illustrative case. During this time. This may take a more or less long period of time. In this way. This prescription is the most recent from a very long list. there are good things and not as good things. they are not able to leave the medication since those times they have tried. hypnotic techniques can be useful in different points. there were few things left to do after this. She is on psychiatric pharmacological treatment since the start of the problem. After proceeding as it was described above. trying to know in details the relationship between the drugs and the complaints. in life. Building of a context of hope. She is married and has two children. and the latter are difficulties. an antipsychotic (risperidone). and two benzodiazepines (alprazolam and triazolam). such as behavioral activation and correction of dysfunctional cognitions. imagine yourself walking by the seashore. many patients complain about being always sleepy and with the necessity of lying down but they still take the drugs that have those same effects… . In the background. In this case hypnosis was also used to cope with withdrawal symptoms that the patient reported to be the most distressful. pain and anxiety. Elena Mendoza and Antonio Capafons severe difficulties in their jobs (they are on sick leave many times or retired). it is important to take into account the pathological role of the own medication in the patient’s current state. You have become a better person. that is. Do you like going to the beach in a summer’s evening where there are few people and the sea is very calm? If so. while thinking that all the efforts are really worthy. The period in which the withdrawal of the medication took place lasted about two months. a detailed intervention is carried out. little by little you overcame all the difficulties. Actually. Smile… Smile while looking at the sea and the seagulls. education. Turn to face the sea. From our approach. Today the sea is very calm and smooth. At the beginning everything seemed to be impossible. namely. restructuring of the psychological components essentials for a comprehensive and in-depth psychological treatment. walking on the wet sand. Take a deep breath… notice the smell of the sea… You are satisfied… Now. obstacles that can be overcome. This procedure had to be repeated inasmuch as all the medications dosage reduction had effects of withdrawal of variable intensity. Just before the complete withdrawal the patient was ready and felt like starting with behavioral activation. For example. but then. some ships hardly move on the horizon. the situation becomes very complicated and the first objective is the relief of the side effects of the medication. In this case. and benefitting from 23 Sometimes. the patients are so medicated that it is necessary to wait a few weeks of medication reduction to be able to conduct what is going to be described. It consists in creating positive and favorable expectancies toward this new process of help23. You know that the sand is wet because you are walking barefoot. they go through strong withdrawal syndrome and their physicians reject such a possibility. you can be in any place.126 Carlos Lopes-Pires. M. The seagulls fly along with the air current. The patient is a 41 years old woman who has been depressed for nearly 6 years. We turn to the Model 1. She has many difficulties in her job as a lawyer. for one. hypnotic techniques can be integrated easily in the intervention and. but it is still possible to apply and adjust its principles and its philosophy. On the whole. it allows the patients to integrate more easily what they are . and these stages are so clear and simple that its use becomes very appealing for those using it in their clinical work. hope. psychological procedures based on psychological variables and fitting into a set of therapeutic procedures that psychologists can use. in a way that some appealing and elegant intervention models can be obtained and offered to those patients in need of help. Due to their nature. Therefore. their parsimony and simplicity are very important. that the therapist can work these aspects integrated into his/her usual professional work insofar as it is not necessary to resort to concepts that. the VMWH cannot be used as it was initially put forth and described. The intervention is focused directly on the clinical aspects using hypnotic procedures that are simple. Another characteristic is that the models are quick. according to our point of view. The VMWH itself is quick. patients are not afraid of losing control over themselves or being in a trance state. interesting.Applications of Waking Hypnosis to Difficult Cases and Emergencies… 127 a self-help book wrote by the first author (Pires. it allows an easier approach in which there is no need for giving explanations to the patient24. but the variants presented here are even faster in responding to the demands of these kinds of cases. It was from the clinical experience with the model that its application to difficult cases and emergencies arose. Notwithstanding. Likewise. 2004). which helped the patient to follow the psychologists indications. The resulting models are specific versions of the VMWH for very specific cases. surprising for the patients. etc.). what are the most interesting aspects of the models described in this chapter that could be emphasized? Most of all. DISCUSSION AND CONCLUSIONS This chapter describes and illustrates the use of waking hypnosis based on the Valencia Model and applied to clinical cases considered difficult and/or emergencies. overall. our view is that this rapidity is an element of the surprise itself. In point of fact. It allows. there are some additional advantages: It is standardized in a protocol of procedures established in stages. hypnotic techniques are. Waking hypnosis has a great advantage compared with the so-called traditional approach: It does not put forth the existence of a mental or cognitive discontinuity between a normal consciousness and an altered state of consciousness. oftentimes. Another interesting aspect is the easy integration of the logic of these models in a cognitive-behavioral psychological approach. these cases represent a major challenge for professionals. On the contrary. at least for the patients. the application of hypnotic techniques and procedures may be an important instrument to help these patients. could appear as mysterious (such as the idea of trance). on the other hand. the aim is not to apply techniques on their own without the support of a planned psychological intervention. As we have pointed out. In these kind of cases. In the case of the VMWH. motivation. and. the quick involvement of patients in the rapid inductions of these models lead also to quick changes in the patients’ psychological state in a positive way (helping to produce calm. courage. above all. From a clinical/therapeutic point of view. Empirical evidence supporting these models is recently increasing. A. Contemporary Hypnosis. Halucinatory experiences. Hipnosis (Hypnosis). D. (1991). (1998a). Clinical applications of “waking” hypnosis from a cognitivebehavioural perspective: From efficacy to efficiency. Are these new or innovative techniques?) Papeles del Psicólogo. Obviously.P. relaxation.H. Capafons.) Psychologica. above all.). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed. Bentall.H. (2007). M. & Kripper. in particular. hypnotic techniques and. Together with the therapeutic arsenal that psychological therapies represent nowadays. American Journal of Clinical Hypnosis. along with the evidence coming from clinical practice (Ludeña and Pires. in press). Likewise. and psychological treatment. Lynn. Capafons. diagnosis. constitute another instrument that can be very useful to help patients. In Cardeña. In D. El modelo de Valencia de hipnosis despierta: ¿técnicas nuevas o técnicas innovadoras? (The Valencia Model of Waking Hypnosis. (Eds. 70-78. Barlow. (2004a). (2006). those related to popular beliefs and misconceptions about hypnosis. 1782-1786. Barlow (Ed. Rapid self-hypnosis: A suggestion method for self-control. (In press).). Papeles del Psicólogo. M. 71-88. R. S. Elena Mendoza and Antonio Capafons learning from a self-regulatory or a self-control point of view. Blankfield. DC: American Psycological Association. Psicothema. the cases described here are only illustrative. 69. including the use of hypnosis. 27. 24 The referred explanations are. Fear. New York: Guilford Press. Capafons. Anxiety. (Re)Definindo a Perturbação de Stresse Pós-Traumático: Revisão da literatura sobre Avaliação.128 Carlos Lopes-Pires. in press). Madrid. 4ª edition. 187201. Tratamento Psicológico e tendências actuais incluindo o uso de hipnose. (2004b). those characterizing waking hypnosis according to the Valencia Model. A. (2001). 136-145.). 571-581. E. more modern and psychologically integrated. Varieties of anomalous experiencies: Examining the scientific evidence. since these models can be applied to the majority of psychological disorders encountered in the clinical practice.. will constitute in future a relevant research field and an important set of clinical interventions (Agostinho. and Theories of Emotion. Waking hypnosis for waking people: Why from Valencia? Contemporary Hypnosis. this is also one of the essential aspects of the VMWH. 21. (1998b). (Redefining Post-Traumatic Stress Disorder: Review of the literature on assessment. Waschington. . Alarcón. Capafons. We consider that the dissemination of these techniques. Suggestion. & Capafons. and current tendencies. R. REFERENCES Agostinho. Hipnosis clínica: una visión cognitivo-comportamental (Clinical hypnosis: A cognitive-behavioral perspective). and hypnosis as adjuncts in the care of surgery patients: A review of the literature. 21. (2002). A. Capafons. A. A. A. S.. Spain: Síntesis. Diagnóstico. A. 33. Adjunctive non-pharmacological analgesia for invasive medical procedures: A randomised trial. Nonpharmacological nursing interventions for procedural pain relief in adults with burns: a systematic literature review. Kirsch. A. E.R. Berbaum.. Meurisse.T. 97. Empirically Supported Psychological Interventions: Controversies and Evidence.M. S. & Van Loey. Silverstein. 954-61. Lutgendorf. Australian Journal of Clinical and Experimental Hypnosis.J. Faymonville. 355. Alarcón.. Oral presentation at I Simpósio Ibérico de Hipnose Experimental e Clínica.. S.. Craske. L.. Berbaum. November). W.. J. & Hemmings. Hypnotherapy in irritable bowel syndrome: A large-scale audit of a clinical service with examination of factors influencing responsiveness. Annual Review of Psychology. Logan.E. Gonsalkorale. (2006). A. 60-67. W. & Baum. Hypnotherapy in the treatment of irritable bowel syndrome. A. (In press). Winkel. D.J. 1639-1645. (1997).. (2004). A metaphor for hypnosis. American Journal of Gastroenterology. Hatsiopoulou..S. M.W. Acta Chirurgica Belgica. Houghton.S. International Journal of Clinical and Experimental Hypnosis. & Pires. D. P.M. Gonsalkorale.. & Marvin.Applications of Waking Hypnosis to Difficult Cases and Emergencies… 129 Capafons. Hypnosedation: A valuable alternative to traditional anaesthetic techniques. Frenay. N. D.C. L.. (2005). K.. E..J... Anesthesia and Analgesia. 27... O. D.J. M. 33. (1999). Faymonville. G.A. E. 27-50. D. Halsey. H. Healy. M. 685–716. S. De Jong. M. & Barlow. 713-717.. Li.G. T.H. E..L. Standardized hypnosis treatment for irritable bowel syndrome: the North Carolina protocol. 811-827. D.. & Vanderkelen.. UK: Churchill Livingstone.. 51-64. Faber. X. International Journal of Clinical and Experimental Hypnosis. Berbaum.. Everett. & Whorwell. Berbaum. Middelkoop. (2007). M. Lang. (1999).. M. G. Ludeña. (2007). 1486–1490. N.V. & Bovbjerg.. J. & Whorwell. C. Psychologica. Baseline pain as a moderator of hypnotic analgesia for burn injury treatment. 99. J. M. J.R. P. 65. Hypnosis for the treatment of burn pain. 94. K. Lancet. (2002). (2002).E. The Placebo Effect and the Power of Belief. O. 3–4. 141–146. 793799. G..E. A. D. D.L.V. Adjunctive self-hypnotic relaxation for outpatient medical procedures: A prospective randomized trial with women undergoing large core breast biopsy. & Spiegel. A. & Ollendick. M.. 126. (2006). Lang.S. Gut-directed hypnotherapy: the Manchester approach for treatment of irritable bowel syndrome.). . & Ptacek. Pain. Mastery of your anxiety and panic: therapist guide. J. M. (2001). 158-172. Patterson.L.. Coimbra.M.E. London. Laser. Psychiatric drugs explained (4rd Ed. European Journal of Gastroenterology and Hepatology. Patterson. Benotsch.. 54. Palsson. 54. Journal of Consulting and Clinical Psychology. New York: Oxford University Press. A inclusão de hipnose nas terapias psicológicas (Hypnosis in psychological therapies). 27. I. (1992). Albert. 15-20. & Fissette.A. Chambless. The effectiveness of adjunctive hypnosis with surgical patients: A meta-analysis.. Faintuch. Portugal. J. (2007. Fick. Gonsalkorale W.. (2000). David.. (2006). Montgomery.L. E. 60.. Journal of Consulting and Clinical Psychology. Burns. A. 52. 17.. Devlieger. Burns. Psychological approaches during dressing changes of burned patients: a prospective randomised study comparing hypnosis against stress reducing strategy.. (2001). Burns.. S. A depressão e o seu tratamento psicológico: Guia de auto-ajuda (Depression and its psychological treatment: Self-help guide). Wiechman. C.A. J. Jensen. Pires. (2008. C.) Oral presentation at XIII Congress of the School of Education of the University of Coimbra: Current tendencies in Education and Psychology. Woody. 31.A..R. 1. Patterson. Portugal. C.. & de Lateur.. Pires. (2006). El uso de la hipnosis en casos difíciles y/o urgentes (Use of hypnosis in difficult cases and/or emergencies).L.R. Invited oral presentation for the School of Psychology. & Covino. C. Questad. 170194. S. Coimbra. Empirically Supported Treatments: 10 Years Later. (Experimental exploratory study on the impact of highly stressful images over the emotional memory modulated by cognitive retention.. M.130 Carlos Lopes-Pires.R. Leiria: Editorial Diferença. The practice of hypnotism. June). S. Pires. Elena Mendoza and Antonio Capafons Patterson. N.L. Spain. A. & McLean. . (2005). April). 130-142. Hypnotherapy as an adjunct to narcotic analgesia for the treatment of pain for burn debridement.A. Estudo experimental exploratório do impacto de imagens muito desagradáveis na memória emocional mediada por retenção cognitive. C. 58. (2004). American Journal of Clinical Hypnosis. M. International Journal of Clinical and Experimental Hypnosis. (1989). Vol. International Journal of Clinical and Experimental Hypnosis. Weitzenhoffer.. University of Valencia. Clinical Psychologist. & Sharar. C.. B. D.L. K. D. Weisz. 54. & Peralta. Hypnosis delivered through immersive virtual reality for burn pain: A clinical case series. (2008. 48.M. (2000) Empirical findings on the use of hypnosis in medicine: A critical review. New York: John Wiley & Sons.R.J. 5-11. (2000). Pinnell. 156-163. METAPHOR AND NEUROSCIENCE: SCIENTIFIC EXPLANATION AND PRAGMATIC RULES FOR EFFECTIVE COMMUNICATION IN HYPNOSIS Renzo Balugani1. in particular thanks to imaging techniques.ducci@tin. sensorimotor nature of many cognitive domains including action perception. now makes it possible to express the embodied. Research and Applications Editors: G. INTRODUCTION In recent years. Chapter 4 LANGUAGE. Arguments about the close link between hypnosis and metaphor are given.In: Hypnosis: Theories. Italy Società Italiana di Ipnosi. Italy ABSTRACT Neuroscience.balugani@libero. emphasizing both their universality and their variations in specific pathological populations. 00198 Rome. There is also growing neurophysiological evidence regarding the sensorimotor basis of language and concept formation. D.* and Giuseppe Ducci2. Via Tagliamento 25. Inc. Koester and P. as previously theorized by cognitive linguistics.† 1 2 Società Italiana di Ipnosi. the opportunity of a finely graded assessment of the particular use of metaphors in any particular patient is suggested in order to build up a more effective intervention in the practice of Ericksonian psychotherapy. Conceptual metaphors and their use in everyday language are discussed. R. In a previous contribution we reviewed the implications of mirror neuron functions in * † Contact: renzo. Via Tagliamento 25. The role of metaphor posited by Lakoff and Johnson in the construction of the thought and abstract thinking is described. simulation and imagery. 00198 Rome.it . the discovery of new classes of neurons has allowed behavioural scientists to build on more solid foundations the origin of some peculiar features of the human brain.it Contact: g. Delisle ISBN 978-1-60456© 2009 Nova Science Publishers. “the motor system…includes representations of other agents as qualitatively different from the self” (Schütz-Bosbach. Balugani and Ducci. Even considering the criticisms raised against the hypothesis of a unique.has been recently criticised by research from other fields of study (Fonagy. other researchers have found a wider activation pattern. Saxe and Kanwisher. developmental research has found in infants as young as six months old the activation areas lacking in motor properties (such as the superior temporal sulcus [STS]) during the observation of actions for which they still don’t have motor schemes (Kamerawi. Luo and Baillargeon. These neurons. as well as the agent’s intentions (Iacoboni. 2008. 2008. 2004. we are not prone to abandon the importance given to embodied processes. this automatic and preconscious process would predispose the adult human being to empathy (Gallese et al. 2003. there are other features of brain function that highlight the existence of such a mechanism. Wagner and Carey. 2007). mental imagery is . Molnar-Szakacs. The ability to autonomously activate representations of fine-graded. Secondarily. such as the above-mentioned superior temporal sulcus (STS). As we described in a previous work (Balugani. A central role of mirror neurons has also been postulated in the ability to create an inner representation of the other’s mind state (including perceptual.132 Renzo Balugani and Giuseppe Ducci the practice of psychotherapy (Balugani. lately. which have no mirror properties and which are typically involved in mentalisation and belief attribution tasks (Grezes.. 2005. & Target. Frith and Passingham. 2007). also fire during the observation of the same action performed by someone else. 2004.a mirror system allowing action understanding by mean of an inner simulation mechanism . 2006). Gallese. by using neuro-imaging techniques with very accurate experimental designs. Aglioti and Haggard. 2007) is the postulated mechanism of resonance emerging from their functioning: this preconscious. through the process of internally simulating the other person’s goals. Balugani and Ducci. This radical view . Gergely. the temporo-parietal junction (TPJ) and the anterior fronto-median cortex). the comprehension of fine actions performed by another and the inference of the purposes of such actions. The embodied simulation (Gallese. sensory-motor mechanism able to manage the attribution of meaning to human experience. Thanks to the encoding of the observed experience in the observer’s physiological parameters. 2005). 2007). rather than solely localized to the mirror neuron system: the activation involves brain areas. through neural resonance evoked by the automatic activation of our brain’s mirror neuron system during the observation of the other person’s behaviour (Gallese et al. automatic mechanism would also allow many fundamental abilities of the mind. This involves mentally inducing the internal subjective states of the other in ourselves by imitation. mental imagery being one of these. Ishiguro and Hiraki. 2007): in the authors’ hypothesis. Lastly. an fMRI study used the ingenious method of “rubber hand illusion” in order to determine whether the brain attributed the same observed action to the self versus to another agent: the authors concluded that.. 2007). rather than simply monitoring action execution. one comes to infer and represent the other’s mental state as well as anticipate the actions these intentional mind states are likely to cause. Gallese. the ability commonly addressed as “theory of mind”. Gallese. in contrast to the radical “shared representation” model of self–other understanding. identification or. Kanda. Mancini. Mazziotta and Rizzolatti. 2005). affective and emotional features). Firstly. 2005). Saxe and Wexler. 2005. same-as-real sceneries in the absence of the actual perceptive and motor input and output is a quite different kind of simulation: if compared to the embodied one described by Gallese and colleagues. such as the imitative learning. 2004. Buccino. Kato. the loss of which would cause the loss of its semantic counterpart. motor actions. and arbitrary.. touch. If this is true. concepts are embedded in a web of connections. “It is important to distinguish multimodality from what has been called ‘supramodality’. conscious and controlled. we consider hypnosis embodied in nature per se. The human brain can generate and use concepts owing to the previous experiences of interaction with the phenomenic world. Accordingly. After that. and in hypnotic therapy in particular. Balugani and Ducci. Metaphor and Neuroscience 133 deliberated. concepts are primarily embodied. hearing. They begin with a firm critique of the classical theories of language. the theory of the “grandmother cell” is refuted: a neuron codifying for the “grandmother” meaning. it follows that there is no single “module” for language1. & Lakoff. But let us look in detail at the arguments regarding the categorisation and concept formation. we would like to analyse concept formation. endowed with characteristics and rules totally independent from those governing the input/output modules. for which concepts were conceived as abstract. doesn’t exist. ascribes the inferential structure of concepts to the web-like structure of the brain as well as its organisation in functional clusters. 2008. From this position. in contrast. Gallese. an embodied simulation process is implicated.e. In spite of that. in this regard. seminal work of review by Gallese and Lakoff has recently highlighted the role of the cognitive linguistics in the comprehension of concept formation and managing (Gallese and Lakoff. 1975). 2005. the purported amodal (or supra-modal) nature of concepts would be implemented in putative brain structures. Language exploits the pre-existing multimodal character of the sensory-motor system. The term ‘supramodality’ is generally (though not always) used in the following way: It is assumed that there are distinct modalities characterised separately in different parts of the brain and that these can only be brought together via ‘association areas’ that somehow integrate the information from the distinct modalities” (Gallese. made up of symbols and having the properties of productivity and compositionality. and to the development of perceptual and motor processes in charge of regulating these interactions. amodal. Similar characteristics are traceable in another cardinal cognitive domain: language. 2007). Contrarily. categorization and reasoning and their correlations with embodied mechanisms. with the functional clusters governing the sensory motor experience (Lakoff and Johnson. 2005). sight. CONCRETE CONCEPTS: CATEGORIES AND BODY A vast. . and so on. i. language is inherently multimodal in this sense: it uses many modalities linked together.Language. In Fodor’s theory (see Fodor. 2001). As we pointed out previously (Balugani. Our aim is to ascribe the linguistic features of hypnosis (such as the use of metaphors) an effectiveness descending from the sensory-motor computational level they work at. 1 In the words of Gallese and Lakoff. At least. we would like to discuss some important implications in the psychotherapeutic process in general. In the present work. This is to say that a certain part of understanding and reasoning skills rely on the activation of processes primarily involved in perception and action: that is. Cognitive linguistics. 2003). 1998) at the most basic level. among others. neurophysiologic registration as well as neuroimaging studies show that it can elicit the activation of a great part of the very same cortical and sub-cortical structures involved in actual perception and movements (Jeannerod. The basic level is the highest level at which this is true. 2005) using motor-evoked potentials (MEP) and transcranial magnetic stimulation (TMS). A growing body of neurophysiological evidence confirms that it is true for concrete concepts. The consequence is that categorisation is embodied—given by our interactions. One can get a mental image of a car but not of a vehicle in general: we have motor programmes for interacting with cars. to be shorter (e. what is true for the basic level category is also applicable for the more particular ones: with few variants. indicating a facilitation due to a sub-threshold activation. and the posterior middle temporal gyrus. Johnsrude and Pulvermuller. 1973. which is the way in which our brain and the brains of our evolutionary ancestors have been shaped by bodily interactions in the world.. more general “feline”). hand and foot) activates the specific motor system involved. those sectors of the premotor cortex where the actions described are motorically coded. such as “vehicle–car–sports car”. These data provide direct evidence that listening to sentences that describe actions engages the visuomotor circuits. the results obtained with TMS and MEP recordings show that when the response to the behavioural task is given with the hand. words for basic-level categories tend to be recognisable via gestalt perception. learned earlier. one (Hauk. 2 Furthermore. not just by objective properties of objects in the world. reaction times are slower during listening to hand-action-related sentences (Buccino et al. We can here argue the importance in the phylogenesis of such an experience-dependent concept formation: what would happen to a man interacting with a tiger using the same lovely behavioural repertoire used with a cat (cat and tiger being two very different basic level categories. to be remembered more easily. and so on. 2004) using fMRI and one (Buccino et al.134 Renzo Balugani and Giuseppe Ducci The classic theory of categorisation assumed that categories formed a hierarchy—bottom to top—and that there was nothing special about those categories in the middle. Two research studies. who found that in the hierarchies continuum. This is coherent with the hypothesis that concept understanding involves sensory-motor mechanisms (the embodied simulation postulated by Gallese). as they argue about the concept of grasp. which subserve action execution and observation. but not with vehicles in general (a bicycle requires very different motor skills of those involved in the driving of an articulated lorry)2. to be more frequent. 1978). both part of the same. 2005). This view was challenged by the research by Rosch and her co-workers. understanding requires simulation. as well as the inferior parietal lobule. An fMRI study by Tettamanti and colleagues (2005) shows that listening to action-related sentences activates a left fronto-parieto-temporal network that includes the pars opercularis of the inferior frontal gyrus (Broca’s area). In particular.. such as physical actions and physical objects. the drive programmes of a sports car and a runabout are the same.g. the intraparietal sulcus. the one in the middle is special: Rosch called it the “basic-level” category (Rosch. He just didn’t have the time to transmit his genes to the descendants! This way. Rosch observed that the basic level is the level at which we interact optimally in the world with our bodies. Moreover. car vs. as a long philosophical tradition had assumed.. it is easier to consider the actual brain organisation as a consequence of our evolutionary history. vehicle). . pointed out that processing verbally-presented actions (related to mouth. It is now simpler to hypothesize a body-based comprehension: according to Gallese and Lakoff. Our ordinary conceptual system. since it has no senses to catch them in a perceptual-like fashion? How can it operate on them the necessary transformations requested by the domain of abstract thinking. In order to catch and manipulate an abstract concept. Nowadays. In some common utterance like “Christmas is arriving” or “the summertime has gone away” we can easily recognise a precise mapping of the abstract concept and its features (e. time and its . through a systematic projection from a source domain to a target one. ABSTRACT CONCEPTS: METAPHORS AND BODY As everyone knows. equivalent to the sensory-motor representations required for the enactment of the concepts described (Aziz-Zadeh. these results taken together give us a confirmation of the thesis of embodied semantics. As it is customary to interact with the latter. in part. before being something the human being is prone to live and die for. are daily matters to deal with. The roots of social network (the formal institution as well as the informal bonds) rely on the ability of men and women to think about such concepts. in terms of which we both think and act. moral values and spiritual ideals. McNamara and Binfofski.. wellknown concept that will work as a prototype. It holds that conceptual representations accessed during linguistic processing are. How can the human brain build a stable representation of the concepts of freedom. and if it exists. has selected a rich repertoire of metaphors used as equivalences. morality and causality. “time is moving objects” being one of these. Lange. Every natural language. 2007). The cognitive linguistic calls these metaphors “conceptual”: the abstract concept requiring explanation (the explanandum) is mapped on an image-schemata (the explanans). but a way we think. its principal characteristics are compared to those of another concrete. In Lakoff and Johnson’s words: “Metaphor is pervasive in everyday life.g. Buccino. 2006). Let’s look at an example: How do we reason and talk about the concept of time? Through a limited number of metaphors. in the course of cultural evolution. Wilson. The modality-neutral structure is just not needed. Metaphor and Neuroscience 135 A more recent study using fMRI technique confirms the key role of the pars opercularis in the embodied simulation engaged during the comprehension of sentences describing goaloriented hand actions (Baumgaertner. in such a flexible way that allows it to cope with a permanently changing reality? By a dodge. 1980).Language. metaphor is not just a matter of rhetoric. it would be a useless duplication. human language and thought don’t operate just on concrete concepts: many facts of interest can appear to the consciousness without any impact on our sensory filters. allowing a fictitious—abstractly and no more concretely—but effective interaction with it. talk about them and regulate their behaviours by virtue of them. so will it be with the former. is fundamentally metaphorical in nature” (Lakoff and Johnson. On the contrary. In such a way. which is a neural representation whose origin lies in the experiential. not just in language but in thought and action. Rizzolatti and Iacoboni. sensory-motor domain. Abstract concepts such as feelings. contravening Occam’s argument. Following Lakoff (1987). any traditional theory that claims that concrete concepts are modality-neutral and disembodied encounters great difficulties. furthermore. the knowledge accumulated during the sensory-motor interactions with the physical world—real sensations and actions with real objects—are projected by analogy to the explanandum. we make daily efforts to share them with others. g. I see what you mean). Anyway.g. the most basic of these schemas are limited in number. Another frequent metaphor is the seemingly different one of “time is a fix field which the observer moves on”. More is up (e. I’m close to being in a depression). Affection is warmth (e. Embodiment is sometimes also referred to as semantic or symbol grounding. As everyone can note. in natural language we use a number of conceptual metaphors larger than that permitted by the primary mappings listed above. Tomorrow is a big day). but they’re close). How do pieces of the theory fit together?). Time is motion (e. Difficulties are burdens (e... Support your local charities).g. the kinds of sensorimotor experiences that begin at the earliest age and involve the most central objects and actions in our lives.g. Help is support (e. This step is very close to the concept of embodied simulation (Gallese.. He’ll be successful. rich description of the primary imageschemas we use everyday in thought and in language.. automatic way.. 1987). often in a preconscious.136 Renzo Balugani and Giuseppe Ducci discrete moments) on the image-schema of the source domain (moving objects). Those colors aren’t the same. States are locations (e. but isn’t there yet). Organization is physical structure (e. by which is meant a process for assigning meaning to an arbitrary symbol.. causality and time . The image-schemas consist of basic level kinaesthetic programmes (Johnson. Lakoff and Johnson (1998. 1999) give us a full. 2004).g.is ubiquitous in our everyday lives. the speed of its movement being the same as that of the time flow.. Time is seen here as a fix background where the observer can move forward (future) or backward (past). then we are no longer just talking about metaphor.g. Change is motion (e.g. They greeted me warmly). Understanding is grasping (e. This basic level is characterized by gestalt perception (the whole is more than its parts). This way...g.. A “compound” or “complex” . Prices are high). the use we make of them in understanding and talking about abstract concepts such as love. Purposes are destinations (e. My car has gone from bad to worse). mental imagery. any discrete future moment is intended as a concrete object moving from a perceptual-like horizon toward a fixed observer. Causes are physical forces (e. She’s weighed down by responsibilities). but rather about a system for the embodiment of human cognition. A key note: Because they originate in the kinaesthetic possibilities that our body has to interact with the physical world. I’ve never been able to grasp transfinite numbers). Knowing is seeing (e. In this case.g...g.. such as when it deals with human kinaesthetic experience or knowledge of the properties of physical objects. the observer moves along a field punctuated of discrete objects representing the discrete moments: Think about the expressions “We’ll arrive at the date without finishing the job” or “I’d like to come back to my childhood time”. When the source domain is suitably basic..g. Some of the prominent primary schemas are the following: Intimacy is closeness (e. Time flies). They push the bill through Congress).g. Similarity is closeness (e. as that level of interaction with the external environment at which people function most effectively and accurately.. Importance is big (e.g.g. We have a close relationship).g. “Basic-level” is meant in the tradition of Rosch. and motor movements and our proprioceptive perception of those movements. Let’s now see how cognitive neuroscience help us to understand the way our brain process metaphors. partially losing the involvement of sensory-motor areas. are coded in secondary areas. without any mappings such as “theories need windows”. Costa Limab and Francozo. Lakoff offers the hypothesis that the most abstract concepts. and perceptual-affective relations demonstrated to be uniquely mapped onto brain networks (Seitz. and so on (Gibbs. Complex metaphors are created by blending primary metaphors and thereby fitting together small metaphorical pieces into larger metaphorical wholes. such as metaphoric ones and those belonging to grammar in any natural language. “I got carried away by what I was doing”. The way people comprehend and explain to other the abstract properties of a concept is strictly correlated to (and precisely mirrors) the embodied comprehension they have in the sensory-motor areas about the physical event used as image-schema.. secondary metaphor is a self-consistent amalgam of more than one primitive. On the base of connectionist models (Narayanan. These three primitives can be combined in different ways to give rise to compound metaphors that have traditionally been seen as conceptual metaphors. Metaphor and Neuroscience 137 metaphor is a self-consistent metaphorical complex composed of more than one primitive. “structure is physical structure”. Thus. he posits that linkages belonging to a complex. developmental. sensory-motor ones. manages and talks about conceptual metaphors through the very same parameters emerged during the development of sensory-motor skills. Linguistic analysis as well as psychological studies indicate an embodiment of metaphor. on which are built a number of daily used metaphors. Given the complexity which compound metaphors can reach. and “interrelated is interwoven”. But the combination of these primitives allows for metaphorical concepts without gaps. neuropsychological and cognitive): he suggests that humans recognise and create basic metaphoric associations across disparate domains of experience partly because they are pre-wired to make these linkages. 2004). 1999). “You had better stop the argument now before it picks up too much momentum and we can’t stop it”. Gibbs and co-workers give us a convicting description of the physical momentum / representational momentum matching. These basic metaphoric equivalences operates largely outside of conscious awareness. cross-modal (synesthetic). Human brain creates. Indirect evidence of the link between metaphorical generation and manipulation skills and the embodied simulation system is given by the neuropsychology of patients suffering . 2005). consider the following three primitive metaphors: “persisting is remaining erect”. Seitz (2005) accurately reviewed some major strand of scientific evidence (evolutionary. and include perceptual-perceptual. movementmovement.Language. not directly involved in the action/perception information processing (Gallese and Lakoff. it seems likely that a part of the cerebral circuitry in charge of the processing of the most abstract concepts rely in areas relatively segregated from their primitive sensory-motor precursors: they could emerge from the differentiation of secondary areas whose roots lay in the primary. 2005). etc. as in the expressions: “I was bowled over by that idea”. For instance. Thanks to the latest results of neuroscience we already accepted that linguistic processing of concrete concept is possible through the involvement of part of the very same brain structures implicated in perception and action. In accordance with Gallese and Lakoff (2005) and Gibbs and colleagues (2004). combining “persisting is remaining erect” with “structure is physical structure” provides for a compound “theories are building” that nicely motivates the metaphorical inferences that theories need support and can collapse. moreover. Balugani and Ducci. Moreover. in which a metaphorical image is explicitly sorted out by the speaker in order to pict out a nonliteral meaning. in the inferior frontal gyrus (IFG) of the RH. For example. a patient feeling having not enough resources to fly up in his/her existential journey could say “I have loosen my wings”. 2006). in contrast. we could refer to an impulsive patient by saying “He doesn’t let the grass grow under his feet”.138 Renzo Balugani and Giuseppe Ducci from autism: they can not make any use of metaphorical images. in the posterior superior temporal sulcus (STS). 2005). 2007). The comprehension of new. from our point of view. Moreover. the RH activates a broader range of related meanings than the LH. Neuropsychophysiologic theory of hypnosis postulates that during this altered state of consciousness the aware. Is it possible to extend the same advantages to the linguistic domain of the patienttherapist relationship? We often refer to the right hemisphere (RH) as the (largely unconscious) container where the personality draws the necessary skills to explore new experiences and meanings in order to get a creative change in the personality. analogical processes (Gruzelier. nonsalient meanings (Mashal. the processing of semantically correlated concepts inside salient and conventional verbal expressions relies in the LH functioning. adaptive skills (Rossi and Rossi. 2006). as well as its possibility to directly modify the basic computational level of the patient. Hubbard. Ramachandran. The evidence relies in their recently recognised deficit of such fronto-parietal circuitry having mirror properties (Oberman. being their language strictly literal. unconventional metaphors is processed in the Wernicke homologue area. functional link between metaphors and hypnosis. the results support previous researches indicating that during word recognition. These data suggest a close. 2007). having recourse to the experiential repertoire about our previous interactions with the . 2005. Neurophysiologic researches about the skill of use and comprehension of metaphors permit us to ascribe to metaphorical language a key role in the course of a therapy based on hypnosis. at the root of the implicit acquisition of new. McCleery. Faust and Hendler. logic. Altschuler. Faust and Mashal. the sensory-motor one (Balugani. and so on. rapport and many of the classical phenomena of suggestion: action/perception matching mechanism and empathy would play a key role in creating a rapport zone mediating between consciousness and the brain plasticity. hypnotic psychotherapy is a very advantageous one by virtue of its embodied nature. 1998. including novel. ERICKSONIAN PSYCHOTHERAPY: THE EMBODIMENT AT WORK IN HYPNOSIS Some authors found enlightening implications of the mirror system in elucidating hypnotic induction. In every linguistic transaction we can make two kind of use of metaphors: the first and more obvious is the rhetoric one. controlling role of left hemisphere (LH) is reduced. The second use we can make of metaphors is the one described above: the metaphor gives us a mapping by which we can operate on abstract concepts as they were concrete entities. 2008. in favour of RH holistic. & Pineda. he/she uses the metaphor in a particular way: the observer is oriented toward the future. it’s already gone”. but in order to encode his/her very specific phenomenological horizon in his/her own sensory-motor parameters. and their movement toward future events is impossible. emotional. It means that we have 3 See a French work discussing the conceptual metaphor “body as container”. Freudian and Ericksonian psychotherapy. the second one is pre-reflexive. 2006) . ‘pacing’ implies the acceptance and utilization by the therapist of the spontaneous characteristics of a patient’s language (Bandler and Grinder. Once a good rapport is built and every useful detail is recorded in our hypnotic diagnosis. empathize and understand our patients’ phenomenological experience. Even universal. In fact. In agreement with the primary embodied nature of language (as discussed above). a patient could select a particular case of the conceptual metaphor “emotions are forces”. as described in any Ericksonian psychotherapy handbook. we record the conceptual metaphors used by the patient for the same reason we observe and collect all the elements needed to build our ‘hypnotic diagnosis’ (Lankton. elusive way. 1982. Zeig. Using the same metaphors will allow us to better attune with him/her. Blanchet. verbs and their modifiers) allows the therapist to tailor a finer graded intervention following the patient’s existential point of view (Gordon and MeyersAnderson. In the utterance “anger urged me to react that way”. and behavioural attunement existing between patient and hypnotist: thanks to this attunement. 1976. or “I can’t go on” mean that they are turned to the past. I can’t see any association between my problem and your solution” we first categorise him/her as visually/kinaesthetically inclined. On the other hand. 1994).Language. Cavallo and Raynaud. Gilligan and Zeig. 1977). and its variants in fields as clinical psychopathology. “seeing is knowing”: not just as a technical imperative. Rapport is the name given to the intense cognitive. by which showing the impotence and passivity he/she felt. The same use of predicates (nouns describing action or events. Among the most frequent techniques used to empower rapport.3 Psychotherapeutic relationship is not an exception. is the known existence of variants in their use among different psychopathological conditions. such as in mutually segregated cultural contexts. some variant can be more frequent in specific conditions. the both become more and more mutually responsive. unaware and largely universal for the speakers a specific idiom. Pacing facilitates rapport in the fact that the therapist is in the patient’s (linguistic) shoes. 2004). we have to meet another principle of Ericksonian therapy: utilization. A second argument in favour of including the metaphoric expressions in our hypnotic diagnosis. and poetry (Santarpia. Gilligan. conceptual metaphors being real organizational principles allowing the building and sharing of shared narrations between therapist and patient (Casonato. 1975. “I live in an eternal present”. While the first kind of metaphors is conscious and arbitrary (often a matter of eloquence). depressed patients who say “When I realize that time goes on. If the patient says “I can’t catch the meaning. Zeig. 1984. 1984). then we can think about the specific use of the conceptual metaphors “grasping is understanding”. time has stopped its flow. 1991. research studies show evidence that conceptual metaphors like “time is moving objects” declines in very different ways if the patient suffers from hypomania or from depression (Casonato. 1982). and time runs away in a fast. Metaphor and Neuroscience 139 physical world. If we are able to catch these detailed “minimal cues” we will better attune. When the excited patient says “Events run over me” or “The present rapidly runs away”. and the actual situation reactivates old feelings of being inadequate and a loser. It is absolutely necessary that utilization include the metaphorical repertoire of the patient. new associations. as a personal experience. the largest part of Ericksonian tools plays its role in that middle ground with on one side the literal language and on the other side the bodily action: that middle ground is metaphor. contemporarily making him/her feel accepted and authentically understood: at the same time. The illness is being managed well and he doesn’t need to take medication. Utilization will mean using that repertoire in a strategic way. 1973): in order to raise the effectiveness of our intervention. giving the opportunity for the subject to identify himself in these features. 2007. our images would be chosen from the basic level categories in order to allow the patient more rapid access as well as a more salient representation. a metaphor or an anecdote using his/her very same idiom but also promoting the therapeutic change. 2002). we will have more chances to tailor an effective treatment: we will build interventions at a level of information processing largely unperceived by the patient. based on the fact that they cannot resist a suggestion that they are unaware of receiving (Haley. to give attention to some little and usual experiences. getting over any obstacle. and how all these usual experiences come together to bring about the comfortable feeling of being alive. our purpose will be to virtually imagine walking toward a well-described point in a field of grass. in order to allow him/her to build new narratives. evokes the strength and the stability during the time (in the past. analogical and metaphoric techniques are particularly effective with resistant subjects. Taking into account a hypnotic diagnosis that includes all of the communicative aspects (beyond the cognitive and the behavioural ones usually considered). denying that the reason is the risk of infection. 1998). new evocations (Casilli and Ducci. of the beach. In fact. grounding its root in his/her sensory-motor code. clear and easy as possible: such is the language used by the right hemisphere (Gruzelier. we then tell a story. in the future) of the cottonwood. But his partner is trying to leave him. Our language will be as concrete. 2008) remind us that “Ericksonian hypnosis is characterised by the use of indirect suggestions grounded on linguistic metaphors of the body […] indicating conceptual metaphors of the body” (Santarpia. at the same time. For the same reason. Blanchet. both the rhetoric and the conceptual ones. First of all. Casula argues that “metaphor allows therapists to send messages resulting from a combination of scientific reasoning and therapeutic intuition” (2005). Cavall and Raynaud. the embodied parameters of patient and therapist (Balugani and Ducci. The repetition of these suggestions.140 Renzo Balugani and Giuseppe Ducci to start our intervention from the frame given by that patient. Following Haley. or the sweet sound of little waves on a beach and the smell of the sea in a night lighted by the moon. Balugani. or the smell of the wet ground after a summer rain. Venturini. above all. in the present and. a young patient who has discovered he is HIV positive only five months ago. Franco is very depressed. the hypnotist suggests. If a ruminating patient complains about the difficulty of making a decision and says “I can’t come to the point”. During the therapy. The following is the case of Franco. and of the ground. It wouldn’t be the same if we just suggested Franco to feel comfortable and confident with his own body and sensations: the richness of the description proposed is . we will enrich a metaphor of such sensory-motor features belonging to the real action involved as if it were real. like lying on the grass looking to the sky with some rapidly moving clouds and the leaves of a cottonwood moved by a gentle wind. 2006). from the lenses he/she uses to look at the reality. then. directs the patient to “watch the field and the aqueduct in charge of carrying the water. But how do they know where to dump it and when? They just know. Metaphor and Neuroscience 141 intended to bring about the desired representation in a way that is mostly outside of the field of consciousness and intentionality. with not energy enough inside of me”. They’re not stupid. You mean they know where to dump it. don’t force. accurately clean up the conduit with your own hands (and ideo-motor actions by the hand can be suggested to enrich the proprioception) and see the water starting to flow again in the right way. The utilisation on one side and the use of evocative suggestions on the other allow our patients to mobilize their own internal resources and to be the protagonist of their changes. confident way”.: T. Once found. Boy: Therapist: B. in his words. what do you think? We would like to conclude with a consideration evoked by the nature of Batesonian’s syllogism in grass (grass dies. then.: T. They dump it? Yeah. He depicts the case of a nine-year-old child suffering from encopresis (Roffman. patiently go back along the aqueduct and find out the exact point where an amalgam of withered leaves and dead branches obstructs the water flow.: B. Back to the soil. This is why a humble attitude is cardinal among therapists: they offer. the therapist follows him. Then it can be just a matter of time to discover the moment in which the first little plant emerges into the sun and starts growing in a progressive. dried. Then what happens? The dumptrucks take it to the place.: T. transforming that casual description in an effective therapeutic metaphor. men are grass). asking him what these machines do with the dirt they pick up. look at the slow but inexorable impregnation as the ground becomes soaked and fertile. Another delicious example of the Ericksonian approach is offered by Roffman. Often. the easiest way to find a good one is to accurately listen to our patients. This is the case of Gianluca. . They don’t just dump it wherever or whenever? They do it in the right place at the right time? Of course. In metaphors as well as in psychotherapy. and drop it off. the dump or whatever. as a part of an insightful article explaning how metaphor works in psychotherapy. nevertheless. 1987. 2008).: They dump it into the dumptrucks.: B.Language. Casula. 2004). there are numerous works indicating lists of therapeutic metaphors (Barker.: B. The therapist. In this regard. what else should they do with it? Quite right. whose feelings of emptiness and demotivation to meet the challenges of everyday life are described. men die. identifying these details as a part of the metaphor “interior life as soil”. as “being barren. we operate in a domain where associations are right if and when they work: consistence or logical are often question of no importance. as discussed in Roffman (2008). When the excited boy narrates in detail his uncle operating with excavators and bulldozers. and Binkofski F. & Grinder R.. Gallese V. Rizzolatti G. European Journal of Neuroscience.. The structure of magic. A neuroscientific grasp of concepts: from control to representation. (2002). B.. Casula C. Lange R. 22:455-479. Ducci G. (2007). Philosophical Transactions of the Royal Society of London. The role of the right cerebral hemisphere in processing novel metaphoric expressions taken from poetry: A divided visual field study. Buccino G.. 358: 1231–1240.L.. (2007).D. Ericksonian Approaches to Hypnosis and Psychotherapy.. S. Gergely G. Balugani R. (2005). 45: 860–870. (2005)... Listening to action-related sentences modulates the activity of the motor system: A combined TMS and behavioral study. Philosophical Transaction of the Royal Society of London. In: J. Congruent embodied representations for visually presented actions and linguistic phrases describing actions. The Ericksonian approach to clinical hypnosis. & Ducci G. Palo Alto. Gallese V. CA: Meta Publications. & Grinder R... 25: 881–889. Casilli C. (1977). Contemporary Hypnosis. Buccino. (2004). Bandler J. Raggio L. (1976).. Mass: Harvard University Press. Ipnosi e neuroscienze. CA: Science & Behaviour Books. Gallese V. Balugani R. Embodied simulation and imagery at work in hypnosis: Ericksonian psychotherapy and its uniqueness. Neuroni specchio. & Iacoboni M. Come la metafora concettuale motiva le alterazioni della temporalità nei disturbi affettivi maggiori. & Grinder R. Cognitive Neuropsychology. Ipnosi. Erickson. 16: 1818-1923. 24: 355– 363. Metaphor is grounded in embodied experience. Bandler J. Rizzolatti G. (2007). V. Cupertino. (1982). La supervisione nella nuova ipnosi. Polymodal conceptual processing of human biological actions in the left inferior frontal lobe. Journal of Child Psychology and Psychiatry. The parent-infant dyad and the construction of the subjective self. Zeig (Ed. Neuropsychologia.. The structure of magic.. Cambridge. A unifying view of the basis of social cognition. Casonato. . Binkofski F. McNamara A. Costa Limab P. Palo Alto. Baumgaertner A. Target M. 2: 5-14. Metafore per risvegliare la resilienza nei pazienti. simulazione ed immaginazione all’opera nell’azione terapeutica. Gilligan. (1975). (2003). Trends in Cognitive Sciences.G. 25: 29-38. Current Biology... 36: 1189–1210. II: A book about communication and change.. CA: Science & Behaviour Books.J. Gibbs R. 1: 27-39. Melli G. Wilson S. (2007). Cognitive Brain Research. FodorJ. Journal of Pragmatics. Francozo E. Faust M. Gallese.. Patterns of the hypnotic techniques of Milton H. Fonagy P. 8: 396–403. (2005)..). Ipnosi.142 Renzo Balugani and Giuseppe Ducci REFERENCES Aziz-Zadeh L. M. The Brain’s Concepts: The Role of the Sensory-Motor System in Reason and Language. (1975).G. Before and below ‘theory of mind’: embodied simulation and the neural correlates os social cognition. (2008). Mashal N. 48: 288-328.A. I: A book about language and therapy.M.W. Psicoterapia Cognitiva. Milano: FrancoAngeli. Keysers C. 1: 5-18. (2007).. M. (2004). II. & Lakoff G. 362: 659-669. (2004)... New York: Brunner/Mazel.. & Rizzolatti G. Gallese V.. B. Bandler J..(2006).. The language of thought. 27: 169–192. The body in the mind: The bodily basis of meaning. K. (1987). Psychological Science. G. (2006).. Lloyd (Eds. 21: 744–750.. from: http://www. and dangerous things: What categories reveal about the mind.. Frontal functions. (2005). B. New York: Brunner/Mazel. Metaphors we live by. Neural simulation of action: a unifying mechanism for motor cognition.icsi. Contemporary Hypnosis..H. J. S. Erickson. Can a self-propelled box have a goal? Psychological reasoning in 5-month old infants. Craighero L. M. 21: 188-194.Women. A working model of neurophysiology of hypnosis: a review of the evidence. McCleery J. (1998).M. NeuroImage. Rosch E.Language. & Pineda J.. Mashal N. 20: 303–320. . Cambridge. The role of right hemisphere in processing nonsalient metaphorical meanings: application of principal component analysis to fMRI data.. 41: 301-307. Kato M. (1973). S. Pulvermuller F..M. & Arbib M. Trends in Neurosciences. Jeannerod M. Rosch. & Hendler T. S. Erickson. R. connectivity and neural efficiency underpinning hypnosis and hypnotic susceptibility. AAAI-99. Inferring false beliefs from the actions of oneself and others: An fMRI study.. (1978). Lakoff G.P. & Passingham R. Johnsrude I.. Cognitive Brain Research. Chicago: University of Chicago Press.. & Baillargeon R. Haley J. (1980). Annual Review of NeuroScience. (2004). Chicago: University of Chicago Press. Cupertino. In: E. NJ: Laurence Erlbaum Associates Inc. Cognitive Development. (Eds. process and action. Meyers-Anderson M.D. Johnson M.. UK: Cambridge University Press. Cognition and categorization. 43: 2084-2100. Hauk O. (2004).. 23: 15-32. Frith C. Somatotopic representation of action words in human motor premotor cortex. (1998). Roffman A.) (1991). Kanda T. (2001). Moving right along: a computational model of metaphoric reasoning about events. Chicago.H. Proceedings of the National Conference on Artificial Intelligence.. New York: Basic. (1981).D. Gruzelier.). fire. Ramachandran V.. Altschuler E. number 8: Views on Ericksonian brief therapy. Neuron. (2002). utilization and metaphor. Uncommon Therapy: The Psychiatric Techniques of Milton H. J.E. Faust M. Ericksonian monographs. The mirror neuron system.B. Ishiguro H.berkeley. imagination and reason. NeuroImage.ps. (2005). 24: 180-198.edu/~snarayanan/met. (2005). American Journal of Clinical Hypnosis. Neuropsychologia. & Johnson M. Grezes J. & Hiraki K. Rizzolatti G..L.. Metaphor and Neuroscience 143 Gordon D. Contemporary Hypnosis.. (1987).A. Oberman L. 50(3): 247-257. Six-and-a-half-month-old children positively attribute goals to human action and to humanoid-robot motion. Pulvermueller. Narayanan. Language within our grasp. 14: 103-109. (2005). Hubbard E. 27-48. IL: University of Chicago Press. Principles of categorization.. Gruzelier. (1999). Phoenix – Therapeutic Patterns of Milton H. Men are grass: Bateson. Lakoff G. Erickson. Rizzolatti G. Hillsdale.. 15: 3-21. Luo Y.. The neuroscience of language. Kamerawi K. CA: Meta Publications. & Zeig. 16: 601–608. Gilligan. (2004). J..S. EEG evidence for mirror neuron dysfunction in autism spectrum disorder..A. (2008). Lankton. F. Neuropsychologia..L. Buccino G. Aglioti S.. . & Kanwisher N. In: T. & Rossi K. Ipnosi. NeuroImage. Making sense of another mind: The role of the right temporoparietal junction.. developmental.. Danna M. Sitz. Wagner L. 23: 74-95. & Raynaud S.. (2006). New York: Academic Press.144 Renzo Balugani and Giuseppe Ducci Rosch E..)..E. 12-month-old infants represent probable ending of motion events. Journal of Cognitive Neuroscience. (1973). Cavallo M.M. The role of the temporo-parietal junction in ‘theory of mind’.. Tettamanti M.. Zeig J. Listening to Action-related Sentences Activates Fronto-parietal Motor Circuits. Current Biology. M. and Perani D. 7: 73–83.. J.. (1984) La diagnosi ipnotica.L... Moore (Ed.. Gallese V.K. Zeig J. Self and other in the human motor system. People thinking about thinking people. (2005). On the internal structure of perceptual and semantic categories. evolutionary. In: E. Fazio F. Infancy. Santarpia A.K. The neural. Rossi E.. 164: 476-485.Del Castello. Scifo P. New York: Brunner/Mazel. C. & Carey S. Loriedo (Eds.). Rizzolatti G. Categorization of conceptual metaphors of the body. Seminari di Jeffrey Zeig. 43: 1391–1399. & Wexler A. Cognitive development and the acquisition of language. 17(2): 273– 281. Saccuman M. Saxe R. Cappa S. (2005). and bodily basis of metaphor.. Mancini B.La Manna. 19: 1835–1842. (2005).A. Napoli: L’Antologia. 48(4): 263-278. Blanchet A. Annales Medico Psychologiques.. 16: 1830–1834. (2005). New Ideas in Psychology. (2006).. and Haggard P. (2003).C..F. (2006). The neuroscience of observing consciousness & mirror neurons in therapeutic hypnosis. Schütz-Bosbach S. Saxe R. American Journal of Clinical Hypnosis. Ericksonian Approaches to Hypnosis and Psychotherapy. (1982). Research and Applications Editors: G. Zefat. R. This is a major perspective in psychoanalysis. Where things had begun… HISTORICAL VIEW Psychoanalysis and Hypnosis Psychoanalysis was born out of hypnosis. D. so that hypnosis can be considered a two-person rather than a one person process. Delisle ISBN 978-1-60456© 2009 Nova Science Publishers. Chapter 5 THE RELATIONAL (INTERSUBJECTIVE) APPROACH TO HYPNOSIS Udi Bonshtein Child & Family Guidance Unit. First.In: Hypnosis: Theories. above all. arrived on a fellowship at Jean Martin Charcot's hospital. Israel ABSTRACT The main aim of the present paper is to discuss how intersubjectivity can be applied to hypnosis. Three splits are described: a) psychoanalysis splits off from brain science. Sigmund Freud. through case stories. abandons the myth of the isolated mind. Koester and P. Intersubjectivity is the sharing of subjective states by two or more individuals. Nahariya. Next. Israel and The psychotherapy study program. I discuss how these splits can be healed. It could be interesting to look backward…. The assumptions are based on theoretical and empirical from neuroscience. Inc. Adopting an intersubjective perspective in psychoanalysis means. the Viennese physician who founded Psychoanalysis. . the paper reviews the relationship between hypnosis and psychoanalysis. the paper presents the main assumptions of the intersubjective approach and how it is used in hypnosis. Western Galilee Hospital. b) psychoanalysis splits off from hypnosis and c) splits occur within psychoanalysis. This is surprising. His meeting with Josef Breuer. although it was actually a book about hypnosis. therapist's tone of voice. We can begin our journey by reviewing each of those splits. As a Jew who spoke about sexuality as the main inner motivator of children and adults – he was isolated from the mainstream of psychiatry. Psychoanalysis is saturated with suggestive processes. Due to the lack of effective research methods at that time. a prominent Viennese physician who was 14 years Freud’s senior. Despite his announced abandonment of hypnosis as a clinical technique in 1896. but only its authoritative style. Freud had previously acquired an interest in hypnosis as a medical student. Psychoanalysis Splits off from Hypnosis The official explanation Freud gave for abandon hypnosis was that he wanted to work with defense mechanisms and encourage the emergence of transference. The third was an internal split (actually. The development of psychoanalysis since Breuer and Freud's pioneering work reveals three main split offs. He worked on his own at first. 1991. which was another reason for abandoning this method in favor of psychoanalysis. his special interest soon shifted to the psychopathology of hysteria. "Studies in hysteria" (Breuer and Freud. Freud was not sure about his qualifications as a hypnotist. which he called psychoanalysis. As I see it. Psychoanalysis Splits off from Brain Science I believe that Freud consciously chose to move away from neurology and found a new discipline.146 Udi Bonshtein Salpetrie`re. in late 1885. 1988). In fact. Hypnosis was both mysterious and personally unsettling for him. until science would be able to investigate the mind. Freud maintained an interest it throughout his career (Gravitz. 1984). many splits) within psychoanalysis. Gravitz & Gerton. Freud never abandoned hypnosis. hypnosis and psychoanalysis have more similarities then differences. Freud.the split between psychoanalysis and brain science and the split between psychoanalysis and hypnosis. therapeutic setting (lying on the couch. which is generally considered as the formation point of psychoanalysis. replacing it with a more permissive form of hypnosis. Freud saw this split as temporary. 13). 1895). he chose a different method of learning about human subjectivity. including free-association. One can ask if lying on a couch and offering free associations is not a variation of hypnosis. He preferred to do this by using free associations. Another reason for Freud's choice to found a new discipline was the sociopolitical atmosphere in Vienna. Two of them are externals . He had originally intended to study neuropathology in Paris. gradually winning over colleagues (Gay. Let us take now a careful look at that time. dividing it into many divisions and schools. p. but because of his personal bonding with Charcot (the mentor he called his ‘‘great teacher’’. led to their co-authored essay. 1914/1957. routine of time) and suggestivity of . since Freud seems to have been a creative therapist who was very successful in hypnotizing his hysteria patients. He abandoned brain research in favor of the subjective point of view establishing psychoanalysis. since transference emerges very powerfully during hypnosis. and engaged in some clinical applications. One can ask the same thing about transference. which are important to every hypnotists' training and daily work. For Freud (1921/1922). I will focus on one of the main lines of development in psychoanalysis: the shift from an intrapersonal ("one-person") psychology to interpersonal ("two-person") psychology (Berman. reciprocal affective currents. abstinence and anonymity toward an interactive vision of the analytic situation that places the analytic relationship. In clinical practice. like the previous one. In essence. Pierre Janet was a pioneering French psychiatrist and philosopher in the field of dissociation and traumatic memory. 1997). p. Freud hardly mentions him (Breuer is the one who gave credit for some of Janet's contributions in "Studies in Hysteria"). It is unlikely that Freud did not know about Janet's contribution. in Genesis creation occurs trough separation (or splits): God divided the light from the darkness. according to Freud. Moreover. defense mechanisms and the like. This split. Despite the similarities of some of his ideas to those of Freud (some consider him the true founder of psychoanalysis. served the developmental and consolidation of psychoanalysis as an independent discipline. he said. It takes the form of a broad movement away from classical psychoanalytic theorizing grounded in Freud's drive theory. mainly Charcot and Janet. more . but this is not the place to discuss this issue. Freud owed a great debt to the hypnotherapists of his time. the hypnotic subject played a passive dependent role. ‘‘Transference . 1905/1953). 2003). conflictual impulses (primary processes). He studied under Charcot and managed Charcot's Psychological Laboratory while Freud was there. He further maintained that hypnosis is a manifestation of libidinal regression in which the patient undergoes temporal regression to an infantile dependent relationship (Freud. the goal of psychoanalysis in our day is most often described as the establishment of a richer.The Relational (Intersubjective) Approach to Hypnosis 147 psychoanalytic theories (Bonshtein. objection. These splits served a necessary developmental function. . toward models of mind and development grounded in object relations. Even in the Bible. 51). . While the goal of psychoanalysis in Freud's day was rational understanding and control (secondary processes) over fantasy-driven. in the foreground. It was. using psychoanalytic conceptualizations such as transference. During the past 15 years. Splits within Psychoanalysis The many splits within psychoanalysis occurred because different practitioners defined the borders of the field differently. He was one of the first people to draw a connection between events of the subject's early life and his or her present-day trauma. there has been a vast change in psychoanalysis. there has been a corresponding movement away from the classical principles of neutrality. as he preceded Sigmund Freud in some ways). then. In 1890 he compared hypnosis to the relationship between parent and child (Freud. the theory and practice of hypnosis developed in parallel with psychoanalysis. these attributes that facilitated the subject's acceptance of the therapist's suggestions. 1890/1953). the effects of hypnosis derived from the overarching construct that they were basically transferential phenomenon. can give you the key to an understanding of hypnotic suggestion’’ (Freud. 1910/ 1957. men from women and the like. with its powerful. the day from the night. and he coined the words ‘dissociation’ and ‘subconscious’. the upper waters from the lowers waters. 1993). Some scientists believe that mirror neurons might be very important in imitation and language acquisition. but more like an organizer of human experience. the essential developmental pathways of psychoanalysis are reflected in the theory hypnosis and its clinical implications. Present psychoanalytic objectives seems to fit in with modern approaches to hypnosis. valued and cared about. These neurons may be important for understanding the . Theory is no longer a truth on its own. but hypnotists have become more favorably disposed to psychoanalysis. What today's analysis provides is the opportunity to freely discover and playfully explore one's own subjectivity. according to Mitchell. in your pace… Easily. In fact. Integrating these paths into hypnosis will rely on new evidence about the neurological basis of hypnosis and seeing hypnosis as a mutual occurring process between two subjects: the hypnotized person and the hypnotist.148 Udi Bonshtein authentic sense of identity (Mitchell. The healing of the rift in psychoanalysis was achieved by adopting a meta-theoretical point of view. What the patient needs. a whole network of neurons (neuronal assembly) is activated when an action is observed. which combines interpersonal and intrapersonal psychologies. basically. personally engaged. 2004). In the human brain. Rizzolati & Craighero. A mirror neuron is a neuron which "mirrors" the behavior of another animal or human. Over the years. but it is beginning to do so. And now. These neurons were first discovered by Giacomo Rizzolatti and his research team in Italy in the early 1990s. is not clarification or insight so much as a sustained experience of being seen. of "hard" psychoanalytic concepts are used (as in the HypnoAnalytic approach). by firing both when the animal (or human) itself acts and when it observes the same action performed by another. The professional hypnosis literature contains many interpersonal and intersubjective considerations. while investigating primate motor cortex (see Rizzolatti et al. this is happening right now. psychoanalysts have become more antagonistic towards hypnosis.. and psychotherapists uses empirical findings to advance theoretical and clinical work. Brain researchers uses psychoanalytic concepts to investigate human subjectivity. safety and softly… You can come to here and now… Healing the Splits Psychoanalysis and brain science are meeting again those days. mirror neurons have been found in the premotor cortex and the inferior parietal cortex. one's own imagination. We can see the subjective and objective points of view join together in the inter-disciplinary field called neuropsychoanalysis. In fact. Rather. It is generally accepted that no single neuron can be responsible for any phenomenon. More detailed information on this topic can be found in Balugani (2008) and Jamieson (2007). allowing us to make more flexible use of it. Here I focus on one of the new and most promising discovery of recent years: mirror neurons. The split between hypnosis and psychoanalysis has not healed yet. 1996. and. While in traditional psychoanalytic thought (such as Freudian theory) human beings are motivated by sexual and aggressive drives. Some preliminary evidence connects ToM and hypnosis demonstrating that the same brain regions and modules are involved in both (Bonshtein. THE RELATIONAL APPROACH Adopting a relational (intersubjective) perspective in psychoanalysis means giving up what Stolorow and Atwood (1992) call “the myth of the isolated mind”. introspective. the gene expression/protein synthesis cycle. feelings. empathic. like the theoretic assumption in the psychoanalytic relational field. in this view. relationalists argue that the primary motivation of the psyche is to be in relationships with others.The Relational (Intersubjective) Approach to Hypnosis 149 actions of other people. including their beliefs. and account for their behavior. Rossi and Rossi (2006) proposed that mirror neurons may function as an interface mediating among the observing consciousness. and reflective functions to hypnosis leads us closer to the relational perspective on hypnosis. It is very close to my view of hypnosis as a shared subjective state and to Winnicott's potential space. Intersubjectivity is the sharing of subjective states by two or more individuals. motivation is determined by the systemic interaction of a person with his or her relational world. The term "theory of mind" refers to the ability to represent mental states of others or one self. which I consider in more detail in below. Individuals attempt to re-create these early learned relationships in ongoing relationships that may have little or nothing in common with those early . is a process involving two active partners. Figure 1. Relational psychoanalysis began in the 1980s as an attempt to integrate the detailed exploration of interpersonal interactions and the notion of ideas about the psychological importance of internalized relationships with other people. As a consequence early relationships. A dwarf saxophone player or a female face? Therefore. Linking absorption. We begin with a short review of the relational approach and then examine its implications for hypnosis. intentions or knowledge. Hypnosis. shape one's expectations about the way in which one's needs are met. and brain plasticity in therapeutic hypnosis and psychosomatic medicine. and contribute to our Theory of Mind (ToM) skills. in preparation). Relationalists argue that personality emerges out of the matrix of early formative relationships with parents and other figures. usually with primary caregivers. or dangerous idea or belief about the self that the projecting person cannot accept. What is projected is most often an intolerable. The therapist's subjectivity and specific encounter with the patient's subjectivity is crucial in that view. Projective identification is believed to be a very early or primitive psychological process and is understood to be one of the more primitive defense mechanisms. This is a process that generally happens outside the awareness of both persons involved. Some basic concepts that can be used in relational hypnosis are projective identification. In the post-modern age there is no place for one and only one truth (e. The primary significance of those theories is that the therapist's subjectivity is important as a diagnostic or theraputic tool. In the mother-infant relationship. as demonstrated in figure 1: One can see a dwarf saxophone player or a female face at any time. and have a communicative quality. For relational analysts. attunement. each of whom bring his unconscious to the situation. Both are possible. the object then becomes a container that holds what has been projected into it. With the development of the intersubjective approach in psychoanalysis (Berman. as occurs in projection) in such a way that his behavior towards those onto whom he projects part of himself evokes the thoughts. This re-creation is called enactment. Truth is relational and context-dependent. 1997). Consequently. Yet it is also thought to be the basis from which more mature psychological processes like empathy and intuition are formed. The mother constitutes a container for the projected parts of the infant. containment. Projective Identification Melanie Klein (1946).150 Udi Bonshtein relationships. the can no longer be . the unconscious drive that is seen by the therapist as is hiding from the patient's consciousness). feelings or behaviors projected. They believe that this helps the patient break out of the repetitive patterns of relating to others that maintain psychopathology. painful. the term "container" is associated with the development of the concept of projective identification. the patient and the therapist. in addition to focusing on facilitating insight. In the treatment room there are two subjects.. When a part of the self is projected into an object. who first introduced the term. projective identification brings about a change in the psychic reality of the receiver of the projection. transitional space and selfdisclosure. The affective and mental condition of a mother capable of taking in what has been projected and remaining with it is called 'reverie'. while her followers (especially Bion) considered it as an interpersonal phenomenon. psychotherapy works best when the therapist focuses on establishing a healing relationship with the patient. In the therapeutic situation the therapist serves as a container. Projective identification is defined as a phenomenon in which a person projects a part of himself into another object (not onto it. considered it as an intrapsychic phenomenon. enactment.g. the infant projects into the mother parts of the self that are intolerable and suffused with anxiety. with mutual (but not symmetric) relations. This re-creation of relational patterns serves to satisfy the individual's needs in a way that conforms with what was learned as an infant. Containment In psychoanalytic theory. She contains what is projected. The recipient is influenced by the projection and begins to behave as though he or she in fact actually has the projected thoughts or beliefs. Self Disclosure Self-disclosure is the act of revealing more about ourselves to others: what we feel. for example. but rather a mixture of projected parts of the patient with denied and split-off parts of the therapist. Hypnosis. For Stern. neither subject nor object but some of both. but attunement takes emotional resonance and recasts it into another form of expression. however. shape one's expectations about the way in which one's needs are met. Attunement Affect Attunement is Stern's (1985) conceptualization of a sharing or alignment of internal states in the domain of intersubjective relatedness. Freud. Early relationships. although still a very controversial one. Attunement differs from empathy in that attunement occurs largely outside of awareness and almost automatically. Both empathy and attunement share emotional resonance. dream. In psychotherapy the patient is the one who reveals his or her inner life. Transitional Space The concept of ransitional space is a condensation of Winnicott's ideas of potential space and transitional phenomena (Winnicott. In relational psychoanalysis. Potential space is the overlapping space between two individuals. is a transitional phenomenon which occurs in transitional space. while aspects of empathy require conscious cognitive mediation. self-disclosure serves as a useful therapeutic tool. . Enactment is the recreation of relational patterns serves to satisfy the individual's needs in a way that conforms to what they learned as an infant. In this space we find transitional objects and transitional phenomena. 1971). Enactment Enactment has become a central concept in psychoanalytic understanding of the therapy process.The Relational (Intersubjective) Approach to Hypnosis 151 considered empty. but actually discloses himself to his patients to a great extent. usually with primary caregivers. The reactions of the therapist to the patient in many cases are not merely the result of the patient’s projective identification. imagine. Relational psychotherapists argue that the primary motivation of the psyche is to be in relationships with others. wordless experience that he describes as attunement based on his observational work. insists that the psychoanalyst must be neutral and anonymous. It is a distinct form of affective transaction in its own right. Individuals attempt to recreate these early learned relationships in ongoing relationships that may have little or nothing to do with those early relationships. sometimes even another sensory modality. for many reasons (as Winnicott himself thought about psychoanalysis). the subjective sense of self is something that arises about of a kind of mutual. and the like. think. 1995. 1963. giving up all her accomplishments. mentioned earlier). Banyai (1998) further identified two different working styles of hypnotists: one a physical-organic style characterized by proximity. Sandor Ferenczi (1909). with one child. 2005). as is Ferenczi's description of paternal hypnosis. as opposed to a analyticalcognitive style. has focused almost exclusively on changes occurring within the hypnotized person. an exercises. Traditional approaches focused either on the hypnotist or on the subject's hypnotic states. From this point of view the two participants affect each other consciously and unconsciously. Since researches focused on either the hypnotist or the subject. Case vignette 1: Ruth is a 30-year old hi-tech worker. characterized by distance and reason. warmth and being very personal with the subject. etc. involving a paradigms shift equivalent to the main shift in psychoanalysis. I listened very carefully to what she "said". As in the case of anxiety disorders (some consider anxiety management difficulties as the basis of trichotillomania). Owing to the important recognition that hypnotic responsiveness – as measured by standardized scales is a stable personality trait. 1982. more recently. Haley. emphasizing the hypnotists' skilled and sometimes even virtuoso technical manoeuvres (Barber. Van Dyck. Livnay calls this the hypnotist trance (Livnay. . which led to complete cessation of her habit. which she likened to Ferenczi's (1909) description of a maternal hypnotist. which she likened to Ferenczi's description of a paternal hypnotist. the intersubjective school is inspired by research on infants non-verbal communication. in contrast. In this initial stage Ruth needed to feel that she had someone to lean on. Rather. in the first stage of therapy I am more authoritative. When I became more permissive and acceptive she regressed back to her starting point..person hypnosis"). She came to therapy due to a severe case of trichotillomania (compulsive hair pulling). who considers hypnosis in an interactional framework. Historically. Banyai (1998) described this split as reflected in the fact that clinicians using hypnosis as a therapeutic tool tend to follow the mesmeric tradition. hypothesized a distinction between 'maternal' and 'paternal' hypnosis. understanding that my paternal stance had been a response to her archaic needs at that phase. which in turn inspired research on the hypnotize-hypnotist dyad. we can consider hypnosis an interpersonal process ("two-person hypnosis". they attributed hypnotic effects to only one of them ("one. and started to deal with more affective issues.e. Erickson) or on the hypnotizability of the subject (such as Charcot and the authors of the modern hypnotic susceptibility scales). on only one of the individuals participating in hypnosis). From the relational point of view there is no need to limit ourselves by focusing attention on either the hypnotist or the subject (i. I used that stage to gave her "homework".). married. Since she had already had some ineffective treatments in past. compelling data have been accumulated on the differences in people's susceptibility to hypnosis (Hilgard. Such research has been conducted by Eva Banyai and her collegous at their laboratory in Budapest. At the next stage I became more flexible. the hypnosis literature has concentrated either on the skill of the hypnotist (such as Mesmer or. Experimental investigation. 1980. didactic and serve as an information supplier. 1996). 1986).152 Udi Bonshtein THE RELATIONAL APPROACH TO HYPNOSIS Empirically. according to the integrative hypnotic-CBT model (Bonshtein et al. and sensitive hypnotists can gain an advantage by paying attention to their inner mental life during hypnosis. accepting and "maternal". This phenomenon has been called "joint rhythmic movements". or in covert processes (e. in Winnicott's term. "potential space"). I played the song to the group at the end of the sharing. one of the participants began to share a personal experience.g. .g. p. their relationship and their actual physiological. These findings accord with the mirror neuron hypothesis described above. The hypnotist emphasizes his/her own feelings. joint movements of the limbs when the subject enacts motor suggestions) and postures (e. they may correct different regulatory deficiencies. Each partner provides meaningful stimulation for the other and has a modulating influence on the other's arousal level" (1985. in the case of a patient. all the periphery of my perception field became blurry.The Relational (Intersubjective) Approach to Hypnosis 153 In addition to the paternal and maternal styles. absorbing unbearable feelings from her and the rest of the group (which also experienced trance a state). .. be viewed as a relationship that develops between two or more organisms as their behavioral and physiological systems become attuned to each other. 1985. breathing and electromyographic activity). The hypnotist almost wishes to participate in the realization of the desires and ideas of the hypnotized subject. during an experiential intersubjective workshop under my guidance. It is almost indifferent to the hypnotist if the hypnotized subject’s desires and ideas are realized or not. Field states. a swaying motion of the hypnotist's body has been observed in synchrony with the subject's breathing. I felt pain and sadness. My experience crystallized into a song – lyrics and music. "Attachment might . . Different styles of hypnosis may help meet the subject's various needs. Banyai and her colleagues (1985. There is evidence that in both animals and humans social emotions and interactions are accompanied by marked neurophysiological and hormonal changes (Reite & Field. Banyai and colleagues' findings indicate that these styles are not as stable as they seemed first. which I tried to integrate into communicative a domain. or if the hypnotized person has independent initiatives. and. behavioral and subjective experiential changes during the mutual interaction between them. Hypnotists who usually use a maternal style may sometimes show signs that do not fit into this style. 415). In the lover-like style hypnosis is built mainly on erotic attraction. Brazelton et al. Since music has great affective and emotional qualities and can be used as a projective and expressive vehicle (or. calling it a gift from me to the speaker. My emotional experience was very powerful. The same is true for paternal hypnotists (Gosi-Greguss et al. In the sibling style hypnosis is based mainly on equality. Case vignette 2: Some years ago. 1974). The interaction synchrony appears either in overt movements (e. 1998) noticed that similar physiological changes seemed to appear in the hypnotist and subject and concluded that the development of hypnotic process is influenced by the personal characteristics of both the hypnotist and the subject. My mind generated a variety of images. 1985).g. 1993). I became attuned. When hypnosis is sufficiently deep.g. The feelings and emotions aroused by the hypnotized person are most important for the hypnotist. Stern. posture mirroring). These phenomena are usually involuntary and outside of awareness. Such mutual regulatory functions can be found in parent-infant interactions (e. in a trance state. The atmosphere is an intimate one.. The hypnotist places emphasis on togetherness.. and accepts this person's independent initiatives. Banyai (2002) described two more styles of hypnosis: sibling style and lover-like style.. someone who can really see you. Ferenczi preceded his time with an open approach including disclosing the therapist's feelings and attitudes to the patient.154 Udi Bonshtein The effect was amazing. She was an attractive girl. This authentic response of mine opened the door for Jean to progress considerably in therapy. During a session in which she minimized her difficulties. People cried. although some people might consider it controversial. 1988). I have coined the word "countertranceference" to describe the hypnotist's trance and subjective experience during hypnosis. I said: "I am not proud of it. 1983. allowing myself to become absorbed in my memories of having an ill sibling. indicating a powerful emotional experience and leading us to more effective work. Case vignette 3: Jean is a 16 year-old girl whom I met while she was hospitalized. while remaining strong and stable enough to support and direct the healing journey. After some silence she replied. or more generally. There is a great debate about self-disclosure and sharing the therapist's countertransference with the patient. 1987. Ok? What would you do if you got a zero on an exam?" I thought about it. "Suppose you were a student who is really care about his grades. Several writers have proposed the careful use of disclosure and sharing of countertransferential feelings with the patient (e. 1979. with tears in my eyes. and suppose your grandfather is dying. going as far as free-associating to one's unconscious motives after making a countertransferentially based error in therapy (Gorkin.g. Many clinicians emphasize the importance of the therapist allowing himself or herself to become more aware of his/her countertransference as well as other feelings. 1987). Here too. Gill (1988) emphasized the need to carefully elicit the patient's reaction discerning what it is and how he or she experiences the therapist's disclosure. 1988). yet caution about the complexities and dangers of sharing them with the patient. with the aim of demonstrating a productive use of countertransference. a therapist's emotional entanglement with a client. 1984. One of the foremost figures in the research and delineation of therapist trance and the interactional aspects of the hypnotic situation has been Diamond (1980. countertransference is the redirection of a therapist's feelings toward a client. with a complex clinical picture. Epstein & Feiner. I will describe one aspect of her treatment. and (probably due to projective identification) I felt a sudden sadness. 1987. Wollstein. but I am assuming that I was not telling about my sadness to anybody". keeping my own needs away in fronts of a "real" pain of somebody else. including dissociative conditions and suspected psychotic states. UTILIZING COUNTERTRAN(CE)SFERENCE While transference is the redirection of a client's feelings from a significant person to a therapist. including pain and uncertainty. "Why you are saying you are not proud of it?" she said. I stated that it could be very frustrating to act as if everything is all right when you want someone to notice you are lonely. The group was silent. He mentioned the hypnotherapist's need to gather up the courage to experience and tolerate the patient's unconscious affects and images within himself. Gorkin. . can she see her activity develop until a clear picture? "I feel as if you opened a curtain for me" she says gratefully. After some productive work. by asking a title to the first encounter she was making. It was clear to me that my feelings were actually her feelings. so I "digest" them for her. Whenever a therapist considers sharing or disclosing. slowly lowered her stress level. During the initial moments of the session she "got lost". On the other hand. suffered from severe social anxiety. distancing them by telling her about another person I knew who felt very distressed when . At this point I induced relaxation indirectly. Livnay (1995) found that patients with severe personality disorders are those who are most likely to put him into a trance state. this must be done with the patient's needs in mind. She had been previously diagnosed as having a low-borderline personality organization level. having difficulty in focusing: "It takes so much time…I don’t know from where to begin…I am talking about just one activity I need to. The second issue is whether self-disclosure serves the patient or the therapist. encouraging her to use her imagination. and giving up – my hurt rate increased and I felt a great amount of anxiety. Case vignette 4: Sara. in Banyai's terms (1992). After containing her fears. At the first stage I gave her a preliminary suggestion about focus and limit time investment at work. by being attuned to her inner rhythms (which in turn gave me the opportunity to free-associate the story I told her). Although disclosure of countertransference has occasionally been used with very disturbed patients (Racker. some patients can be eager for role reversal. and I have 30 more to make ready!" she terrified stated. losing. Her muscles seemed to be a little more relaxed and she smiled at me. "How can I work for just 45 minutes?" she keeps asking herself. The main issues include patient's level of personality organization and who needs the self-disclosure (patient or therapist). questions have been raised about when they are appropriate. I tried to serve as an organizer for her. helplessly. Searles. On the other hand. a 40-year-old woman. thriving whenever there is real. and many find the therapist's self-disclosure insulting or even a destructive attack on their own subjectivity. Being in supervision or therapy is recommended for enhancing awareness of the therapist's own motives and unconscious wishes and needs. using a story and self-discloser material. Many authors have cautioned about therapists' improper use of sharing or disclosure for their own narcissistic. These states very often bring him into contact with a more mothering style. Diamond (1983) stressed the need for the therapist to have reached a high level of integration. This caution must be weighed against overintellectualization and the loss of the benefits of spontaneity. trying hard to go out and work in her profession as a kindergarten art teacher. patients with poor personality organization can have serious difficulties accepting the therapist's subjectivity. I asked for more titles. Diamond (1983) has cautioned against using it with patients with a poor level of organization. playfully.The Relational (Intersubjective) Approach to Hypnosis 155 When is Sharing and Self-disclosure Appropriate? While many clinicians gain great advantages from sharing and self-disclosure. including constantly checking the basis of one's motivation for speaking and acting. Pacing and leading her through my tone of voice. Self-disclosure must be based on a high level of maturity and self-awareness on the therapist's part. 1979). aggressive or dependency needs. intimate sharing. 1953. She functioned at a very low level. In those moments I felt like a mother calming a distressed baby. If she connects those titles between them. I began to feel her twisting and fighting and myself as despairing. . New York: Jason Aronson.A. 97-108). P. H.A. É. presence or touch.A. Hoogduin. (eds) Issues on Hypnosis (p. (1988). L. Misra. 1991). Today's evidence from neuroscience and experimental hypnosis support the hypothesis of unconscious attunement and rhythmic resonance between hypnotists and their patients. empathy and precise affective recognition of the patient. with unlimited amounts of trust.two people who create each other continually and mutually. Contemporary Hypnosis. W. The view of hypnosis as a context-dependent. using an amusing illusion to dispel his fear.I. The interactive nature of hypnosis: Research evidence for a socialpsychobiological model. Communication in different styles of hypnosis. see Freud. M. Bion. É. (1985). . Meszaros. Gibson.. Contemporary-Hypnosis. Bányai.R. R. as a Winnicottian potential space. and the way he used the imagery of the audience in their underwear. Berman. & Csokay. I. REFERENCES Balugani. Barber. voice.C. mentalrepresentations. Spanos. E.L. Relational psychoanalysis: A historical background. Waxman.I. After some more organizing work. J. as well as the intended work (future projection). SUMMARY Hypnosis can be seen as a two person phenomenon . M.): Modern Trends in Hypnosis (p. The trance state. Skilled hypnotherapists can use their mental states (such as images.I.P. In D. (1980). such as social role-playing or sociocognitive theory (Kirch. (1997). (2002). reminiscent of reminds the initial affective atmosphere between mother and child (as Freud himself claimed. Learning from Experience. In: C. de Berk. 25(1): 29-38. 23: 4-9. 1991. 1890). 1991. É.156 Udi Bonshtein giving his lectures. Hypnosis and the unhypnotizable. American Journal of Psychotherapy. C. which make it possible for him/her to respond easily to mother's rocking. (1962). 15(1): 52-64. Interaction between hypnotist and subject: A social psychophysiological approach. Bányai. dreams. interpersonal phenomenon is based on well-known theoretical models.A. Basker (eds. 1–19). American Journal of Clinical Hypnosis.D. Bányai. (2008). I gave her positive and reinforcing suggestions. Schaap. One of the interesting directions for further investigation is the curative aspects of attunement. reframing the work she already done as very successful. London: Plenum Press. Wagstaff. feelings and thoughts) as therapeutic and/or diagnostic tools. Nijmegen Cure & Care Publishers. is a very powerful therapeutic tool. 51(2):185-204. (Preliminary report). New York. Embodied simulation and imagery at work in hypnosis: Ericksonian psychotherapy and its uniqueness. I can take a risk hypothesize that the infant's brain is equipped with mirror-neurons and great hypnotic susceptibility. & Golan. M. 130–243). Diamond. P. (1980). Breuer. L.). Thomas. (1914/1957). The possibility chooses of knowing and the unconscious suggestion. An hypnotic induction technique to induce therapist trance: The client-as-therapist. Ferenczi.). U. Norton & Company. B. Accessing archaic involvement: Toward unraveling the mystery of Erickson's hypnosis. Five lectures on psychoanalysis. Three essays on the theory of sexuality. International Journal of Clinical and Experimental Hypnosis. (1895/1937).).J. In M. S. New York: Holt.).. The interactional basis of hypnotic experience: On the relational dimensions of hypnosis. The standard edition of the complete psychological works of Sigmund Freud (Vol. Sihot-Dialogue. IL: Charles C. In B. Essential papers on countertransference (pp. M. & Trans. (1909/1965). S. In J. 22(4): 193200. The standard edition of the complete psychological works of Sigmund Freud (Vol. .). Strachey (Ed.J. Shaar. Lewis & L. The standard edition of the complete psychological works of Sigmund Freud (Vol. The origins of reciprocity: The early mother-infant interaction. & Freud. & Feiner. American Journal of Clinical Hypnosis. 282-303). New York: Nervous and Mental Diseases Publishing. Hariman's (Ed. (Hebrew) Bonshtein. Strachey (Ed. I. Strachey (Ed.. In J. Freud. M. Rosenblum (eds. M. London: Hogarth Press. S. A. London: International Psycho-analytical Press.).B. International Journal of Clinical and Experimental Hypnosis. The standard edition of the complete psychological works of Sigmund Freud (Vol.J. (1910/1957). 11. Brazelton. & Trans. M. London: Hogarth Press.The Relational (Intersubjective) Approach to Hypnosis 157 Bonshtein. 36: 141-156. International Journal of Clinical and Experimental Hypnosis. 14. (1983). (1984). W. Epstein. Freud. The Therapeutic Efficacy of the Major Psychotherapeutic Techniques (pp. London: Hogarth Press. (2005). 35: 95-115. S. 177–178). 18(1): 79-80.J. & Main. Studies in hysteria. pp. Contemporary Hypnosis. The therapist's contribution to treatment. (1988). S. (2003). Strachey (Ed. It takes two to tango: Some thoughts on the neglected importance of the hypnotist in an interactive hypnotherapeutic relationship. Group psychology and the analysis of the ego. and M. G. Shor. 282– 302). Who wants to control the habit? A multidimensional hypnotic model of smoking cessation. J. & Trans. Diamond. Koslowski. pp. Psychical (or mental) treatment.. The Nature of Hypnosis: Selected Basic Readings (p. 69-73). U. On the history of the psychoanalytic movement. 1–66). S. New York University Press. Diamond. Freud. 7. 7. Gay. New York: Wiley. Freud: A Life for Our Time. The Effect of the Infant on its Caregiver. M. In: R. In J. S. In J. & Trans. (1987).. Freud.J.E. (1988). pp. New York. T. H. Orne (eds). 27: 13. The client-as-hypnotist: Furthering hypnotherapeutic change.). Diamond. In J. Comments on hypnosis. Diamond. (1974).. (1890/1953). Wolstein (Ed. (1988). Freud. Springfield.T. 28: 197-207. Rinehart and Winston. 9– 55). (1921/1922). London: Hogarth Press. New York: W. pp. (1905/1953). The Neuroscience of Observing Consciousness & Mirror Neurons in Therapeutic Hypnosis. Philadelphia: Lippincott. (2007). et al (Eds.).. Haley. H.R.. The interpersonal paradigm and the degree of the therapist's involvement.). 7–17). Varga. (1963). & Field T. Racker. Wolstein (Ed. In Envy and Gratitude. E. In W. In S. Hypnosis in the historical development of psychoanalytic psychotherapy. M. (1996).A. Gosi-Greguss. Annual Review of Neuroscience. (2004). and Other Works: 1946-1963.158 Udi Bonshtein Gill. In S. Mitchell. Kirch. US: Oxford University Press. et al. (1993). M. (1987). Gravitz. Livnay. Theories of hypnosis: Current models and perspectives (pp. A.. M.F. (2003). Hypnotist styles as reflected in standardized hypnosis experiments. (1984). Livnay. Bolcs. Paper presented at the 6th European Congress of Hypnosis. 27:169-192. American Journal of Clinical Hypnosis. H.H. M. (1946).): Strategies of Psychotherapy. Munich: M. In B. & Gerton.C. The Psychobiology of Attachment and Separation. (1991). Notes on Some Schizoid Mechanisms.). In J. New York Jason Aronson... New York. 3: 131-141. 1977. J. Haley (ed. Peter. (1991).): Munich Lectures on Hypnosis and Psychotherapy (pp. New York: Guilford. Countertransference and related subjects. Rossi. New York. When Erickson Meets Freud: The Therapist Trance and Countertransference as Resources for the Hypnotherapist. 152-155). M. M. (1986). K. Rhue (Eds. Klein. The uses of Countertransference. Rhue (Eds.A. 14-20 August 1993. Vienna.). (Ed). (1979). 439-465). 79-86). & Craighero. Clinical hypnosis: A multidisciplinary approach (pp. Vienna: MedizinishPharmazeutlische Verlag. 48(4): 263278 Searles. S. International Universities press.. & Rossi. (1995). Theories of hypnosis: Current models and perspectives (pp. In E. NY. The social learning theory of hypnosis. L. G. E. Premotor cortex and the recognition of motor actions. Cognitive Brain Research. (1988). I. M. Gorkin. G. Austria. How hypnotist and subject maneuver each other. (1996). A. New York University Press. S. A. Banyai. 19–42). In B. New York.J. Gravitz. New York: John Wiley and Sons. (eds. New York: Basic Books. Orlando: Academic Press. Stiftung. Lynn & J. Early theories of hypnosis: A clinical perspective. Hilgard. New York: Dell. International Journal of Psychoanalysis. Smith (Eds. Divided Consciousness: Multiple Controls in Human Thought and Action. The Therapist Trance as a Generator of Associative Techniques in Therapy. Hope and Dread in Psychoanalysis. K. Rizzolatti G. (1953).E. L.G.I. (2006). Essential papers on countertransference (pp. Rizzolatti. Reite M.304-338). 34: 313-324. New York: Grune and Stratton.) (1985). Lynn & J.I. New York: Guilford. Hypnosis and conscious states: The cognitive neuroscience perspective.. Wester & A. The countertransference neurosis. The mirror-neuron system. .W. S. E. Jamieson.C. et al (Eds): Hypnosis Connecting Disciplines: Proceedings of the 6th European Congress of Hypnosis (pp. L.. Erickson. D. Stern. (1991). London: Routledge. Wolstein (Ed. Lynn & J. 37-47). Stolorow.).).(1998). N. R. Van Dyck.). Essential papers on countertransference (pp. Zeig (ed. D. G. The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology.. New York: Guilford. G.W. (1991). Rhue (Eds. and semantics in hypnosis: A nonstate. Winnicott.K. N. Contexts of Being: The Intersubjective Foundations of Psychological Life. D. NJ: The Analytic Press. . Ericksonian approaches to hypnosis and psychotherapy (p. Lynn & J. Theories of hypnosis: Current models and perspectives (pp. (1992). In S. New York. New York: Guilford.). Wagstaff. In J. (1982). New York: Brunner Mazel. belief. 339-354). R. (1971). Wollstein. 324-361). Theories of hypnosis: Current models and perspectives (pp. New York University Press. B. Hillsdale.The Relational (Intersubjective) Approach to Hypnosis 159 Spanos. A sociocognitive approach to hypnosis. Compliance. The pluralism of perspectives on countertransference. In S. How to use Ericksonian approaches when you are not Milton H. sociocognitive perspective. & Atwood. Rhue (Eds. (1985). New York: Basic Books. E. 362-369). In B. Playing and Reality. . Australia In memory of my mother. The capacity to set aside an instrumental set finds a clear counterpart in current neuroimaging and EEG studies of dissociated control in hypnosis. This account finds further support in recent studies on the roles of these mutually inhibitory neural networks in differing patterns of regulation of peripheral physiology. suggested behaviours are characteristically accompanied by a diminished sense of effort and personal agency while suggested experiences. D. Agnes Fraser Jamieson ABSTRACT In hypnosis. Tellegen (1981) defined the trait of absorption as arising from the interplay of two mutually inhibitory mental sets. Dissociated control theory is a cognitive neuroscience account of hypnosis that emphasises functional disconnections (dissociations) within the predominantly anterior brain networks. Tellegen pointed to distinctive roles for the instrumental and experiential mental sets in psychophysiological self-regulation in order to explain the importance of the trait absorption in mediating the mixed pattern of results in earlier biofeedback studies. Chapter 6 HYPNOSIS. Inc. The consequent ability to adopt an experiential set has a clear counterpart in the recent discovery of a characteristic brain network during quiescent mental activity.In: Hypnosis: Theories. which strongly contradict objective reality. R. Jamieson University of New England. These findings provide an important foundation from which to . ABSORPTION AND THE NEUROBIOLOGY OF SELF-REGULATION Graham A. appear to be accepted without conflict. Koester and P. the instrumental and the experiential mental sets. Neuroimaging studies of suggestions used to induce hypnotic analgesia show strongly overlapping activations with the loci of this network which generates core aspects of internally focused self experience. Delisle ISBN 978-1-60456© 2009 Nova Science Publishers. Research and Applications Editors: G. which implement cognitive control. Profound alterations in the ongoing experience of the self outside the hypnotic context (labelled by Tellegen as absorption) are a key predictor of a person’s ability to experience suggested distortions of reality. The Supervisory Attentional System (SAS) model of Norman and Shallice (1986) elegantly summarises key elements of the thinking which guided these efforts. 1974). According to this model the selection of routine responses is the outcome of an automatic and unconscious competition amongst fixed action schemata (neural networks . At the same time Tellegen and Atkinson (1974) reported the development of a ‘paper and pencil’ personality scale which correlated significantly with hypnotic susceptibility. Meanwhile. “total attention involving a full commitment of available perceptual. They described absorption as a state of. Jamieson understand the unique contributions of absorption and hypnosis in effective practices of self-regulation.162 Graham A. p. This feature of hypnosis was labeled by Shor (1959) as loss of Generalized Reality Orientation (GRO) and identified as a primary dimension of hypnotic experience in his influential 3-factor theory of hypnosis. Similar observations had been made by other observers going back to the nineteenth century. The items on this scale (developed from a series of similar early attempts) asked about the occurrence of a range of unusual or trancelike alterations in experience in daily life. focusing on the construct of imaginative involvement. 274). following the advances in the measurement of individual differences in hypnotic ability which led to the Stanford and Harvard scales psychological researchers sought to identify the personality and ability characteristics which predisposed an individual to high (or low) hypnotizability. HYPNOSIS AND THE SUPERVISORY ATTENTIONAL SYSTEM Influenced by this lead. The one notable exception to these null findings was the biographical interview work. imaginative and ideational resources to a unified representation of the attentional object” (Tellegen & Atkinson. a number of neurophysiological researchers began to search for evidence of the involvement of the brains systems of attentional control in the various phenomena of hypnosis. Although Shor interpreted this feature of hypnosis as an expression of a loss of contact and concern with everyday reality (indeed with the very psychological framework required to focus on that reality) others (for example Milton Eriksen) interpreted this as the expression of the development of an intense attentional focus leading to the exclusion of otherwise distracting or irrelevant stimuli from conscious awareness. Abstracting from the content of several items (and likely influenced by contemporary ideas in the hypnosis literature) Tellegen and Atkinson (1974) fatefully defined the trait measured by their scale as “absorption”. motoric. INTRODUCTION One of the most characteristic features of experience during hypnosis is the loss of awareness of the immediate environment and a strong focus on the communication (words) of the hypnotist and/or the experiences they suggest. conducted by Josephine Hilgard and her associates (Hilgard. Despite an intensive effort from the late 1950s to the early 1970s with virtually every psychological measure available these efforts were largely fruitless (a situation which remains essentially unchanged to this day). 1974. Hypnosis. 1935) is without doubt the classic selective attention task in experimental psychology and has been employed in more publications than any other paradigm in the field (MacLeod & MacDonald. 1997). At the level of cortical dynamics this corresponds to a weakening of the influence of prefrontal task set representations on more posterior cortical processing.. Crawford et al.g..g..g. called contention scheduling is implemented predominantly in posterior cortical regions. This process. have been interpreted as further support for this view (e.. the color-name “red” printed in green) with the color-name. 1999). Therefore.. According to Woody and Bowers hypnosis is characterized (at least in part) by dissociation between conscious volitional control implemented by the SAS and unconscious automatic control implemented by contention scheduling. This is implemented by the SAS which monitors the activation of task relevant schema and modulates their activation to bias the contention scheduling process in favour of the current task set. a phenomenon which some have considered to be a paradigm case for the role of focused attentional control in the production of hypnotic responses. Ray. Woody and Bowers argued. However flexible. Task set representations are stored in anterior cortical regions. Indeed over several decades a number of studies have reported evidence of a positive relationship between hypnotizability and or the hypnosis condition and increases in EEG theta power (e. for access to various response systems. if not loss. the color-name “red” presented in red) or incongruent (e. Woody and Bowers (1994) employed the SAS model in a very different way to understand another key aspect of hypnotic experience that of effortlessness or non volition in the generation of hypnotic responses. thus the source of top-down attentional control is activity in elements of a far frontal attentional network. 1953). which may be congruent (e. In the Stroop task participants view color-name stimuli presented in an actual color. which would distinguish high from low hypnotically susceptible individuals particularly during hypnosis.g. or when responding to specific suggestions such as hypnotic analgesia. These researchers therefore searched for evidence of activity within the anterior cortical networks believed to implement top-down attentional control. 2000). The Stroop task (Stroop. Ishii et al. otherwise known as ‘the classic suggestion effect’ (Weitzenhoffer. Participants must respond to either the color-word or the actual color. In work with the electroencephalogram (EEG) interest focused on the theta frequency band (4-7 Hz) due to the role of theta in tasks demanding mental concentration or effort (e. Evidence for this model of hypnotic responding requires a decrease (not an increase) in the efficiency of selective attentional control in hypnotized high susceptibles and a corresponding decrease in functional connectivity between cortical regions responsible for implementing top-down attentional control. Absorption and the Neurobiology of Self-Regulation 163 mapping specific inputs to specific outputs). A shift from the former to the latter should be evidenced by a decrement (rather than an improvement) in performance on those very tasks which are paradigm cases of executive attentional control.. of SAS control and a shift toward contention scheduling. The Stroop effect is evidenced by slower reaction times (and typically a greater error rate) when responding to incongruent than .g. if the experience of non volition in hypnosis is veridical it must be accompanied by a reduction. 2000). non-routine responses require current goals to guide the selection of task appropriate but often weak schema mappings against the competition of much stronger automatic mappings. On the Norman and Shallice account a volitional response is a paradigm case of attentional control implemented by the SAS.. In addition increased prefrontal cortical activation reported in PET studies of hypnotic analgesia suggestion. Nordby. Cohen and Carter. distinct from the effect of hypnosis per se. Collectively this evidence points very strongly towards a decrease in the efficiency of top-down SAS control of Stroop induced response conflict in the hypnotized condition for high susceptible individuals.164 Graham A. 2004). Pollard and Nitkin-Kaner (2006) also found that high susceptibles were able to use these specific suggestions to modulate Stroop interference but could do so both with and without undergoing a hypnotic induction procedure.. Gruzelier (e. with specific suggestions hypnotized high susceptibles were better able to control Stroop induced response conflict than were lows. In this case focused attention becomes a prerequisite for subsequent frontal inhibition. Current models of the Stroop effect emphasize co activation of competing responses driven by different features of the stimulus (the color-name and the color of the word. in response to suggestion. Thus it appears that. Earlier a series of neuropsychological studies conducted by Gruzelier and his colleagues indicated decreased performance on tasks affected by prefrontal lesions (such as letter fluency see Gruzelier and Warren. Shapiro. 1998) has consistently interpreted these findings as evidence for a decrease in frontal cortical activation brought about by hypnosis. Donovan and MacLeod (1988) found an increase in Stroop color naming reaction times (although high susceptibles were better able to make use of further specific suggestions to reduce Stroop conflict).g.. Hugdhal.e. incongruent. Subsequently Raz. (1988) found that. Fan and Posner (2002) found that high susceptibles were able to eliminate the Stroop effect by means of specific hypnotic suggestions. 1993) during the hypnosis condition. When these are congruent there is little response conflict. Sheehan. (1997) found higher errors in hypnotized participants with higher hypnotic susceptibility using a Stroop type task. rigorously assessed for hypnotic susceptibility and found a significant interaction between hypnotic susceptibility and hypnosis condition in Stroop error rates (with errors rising specifically for high susceptibles in the hypnosis condition). However. Kaiser et al. when the task requires a response to the color of the word on incongruent stimuli additional top-down (SAS) control is required to bias response competition in favor of the weaker color response pathways (Botvinick. respectively). Egner and . Jamieson congruent stimuli. Crawford and Gruzelier (1992) proposed a synthesis of their respective focused attention and frontal inhibition accounts of hypnosis in which the hypnotic induction first engages and directs the focus of frontally mediated attentional processes followed by a gradual inhibition of frontal activation and finally a shift to a more posterior mediated flow of mental activity. An important feature of the Stroop effect is that it is greater when responding to the color of the stimulus then when responding to the color-name. Recently Raz. Jamieson and Sheehan (2004) employed a classic version of the Stroop task in a very large sample. A similar logic is employed in many Stroop type tasks subsequently developed in the experimental literature. color naming) trials. However Sheehan et al. Likewise when the task is to respond to the color-name over learned and highly automatic word reading schema easily out compete schema activated by the color of the word in the contention scheduling process for access to motor response systems. Jasiukaitis and Spiegel (1999) also reported greater Stroop errors in hypnotized high susceptibles. Studies of hypnosis (without further suggestion) and hypnotic susceptibility using the Stroop task have shown that high susceptibles in the hypnosis condition show a significant decline in multiple indices of the efficiency of Stoop performance on high conflict (i. particularly by those higher in hypnotic susceptibility. Kirsch. there are effects in hypnosis which suggest enhanced control of conflicting or distracting competition for attentional resources. Stenger and Carter (2000) were readily able to distinguish regions of brain activation related to cognitive control from those related to conflict-monitoring using the Stroop paradigm in an fMRI scanner. As conflict between competing response tendencies rises (indicating a greater likelihood of an incorrect response or error) so does activation in the dACC which in turn triggers an increase in control related activation in lateral PFC task set representations which then brings about a flexible adjustment of topdown attentional control of competing response processes (Botvinick. a deep midline anterior cortical structure. Miller and Cohen. Using this model MacDonald. Absorption and the Neurobiology of Self-Regulation 165 Raz (2007) have also attempted a synthesis of their recent divergent Stroop and hypnosis findings by pointing to the distinction between the effects of hypnotic induction and specific hypnotic suggestions in their respective results. Cohen. This represented a contrast between high and low control demand conditions respectively and revealed significant activation in the left dorsolateral prefrontal cortex. While there are several leading accounts of cognitive control and/or the executive functions of the anterior cortex arguably the most clearly specified and empirically studied is the conflict-monitoring model developed by Cohen and associates (Cohen. when it appears in hypnosis. However activation in these task set representations is dynamically modulated by feedback about the level of conflict between competing response tendencies. They presented congruent or incongruent Stroop stimuli preceded by an instruction to name the color-word or to name the color in which the word appeared. 2004. 2000). 2004). is not underpinned by the activity of frontal attentional control networks but is enabled precisely as a consequence of the disengagement of these networks (see also Jamieson and Sheehan. On their account hypnosis is characterized by a disengagement of anterior mediated SAS control processes which in turn allows the development of sustained iterative processing loops in the absence of (more usual) disruption by frontal attentional control networks. According to this model activity in task set or goal representations located in the lateral prefrontal cortex (PFC) biases competition between competing responses much as described in the SAS model.Hypnosis. CONFLICT-MONITORING AND COGNITIVE CONTROL Despite its historical importance both to the development of cognitive neuroscience and modern hypnosis research today the SAS model fails to provide a detailed account of cognitive control. The second contrast was made in the post stimulus period and was between incongruent (high response conflict) and congruent (low response conflict) . For example the SAS performs both monitoring and control functions and the deficits caused by frontal lesions indicate the key role of anterior cortical networks in their implementation but beyond this the model has little to say as to where or how they are implemented in the anterior cortex or how these functions are related. Two different contrasts were performed. In many respects this proposal by Egner and Raz may be considered as almost the inverse of that put forward by Crawford and Gruzelier 15 years earlier in that a sustained attentional focus. 2004). The first contrast was performed for the post instruction interval and was between the color naming instruction and the color-word naming instruction. Specifically response conflict is monitored by the dorsal Anterior Cingulate Cortex (dACC). Aston-Jones and Gilzenrat. Cohen and Carter. Williams. Jamieson stimulus events respectively. They conducted an event related fMRI study of high and low hypnotically susceptible participants in both hypnotized and non hypnotized conditions performing a Stroop paradigm requiring color naming or color-word naming responses to congruent and incongruent Stroop stimuli. Weiss and Miltner (2004) between motor cortex and frontal cortical sites in hypnotized high susceptibles experiencing hypnotic analgesia. Further EEG evidence (again from the high frequency gamma band) in support of a functional disconnection between and within anterior cortical regions in hypnosis has been reported by Croft. However when activity levels were examined in conflict related regions of interest a classic interaction effect was found between hypnotic susceptibility and hypnotic condition. The conflict-monitoring model functionally and anatomically fractionates monitoring and control functions and clearly specifies the relationship expected between them. The absence of a similar pattern in the control related activation strongly suggests a breakdown of functional connectivity between conflict monitoring and control processes and their respective anterior cortical regions rather than between anterior and posterior cortex as suggested in the initial formulation of dissociated control theory. In addition to strong experimental support from neuroimaging studies this model has largely been generated and tested around the Stroop task and similar response conflict paradigms making it an obvious choice for the further investigation of changes in cognitive control and the functional role of anterior cortical networks in hypnosis. A similar breakdown in EEG gamma band coherence was found by Trippe. Haenschel and Gruzelier (2002) who found that the correlation between ACC . In this study Egner et al. There was no effect present for activation in the control related region of interest for high or low susceptibles in either hypnotized or non-hypnotized conditions. We found that coherence in the gamma band (closely associated with the binding of discrete cortical processes into an integrated neural ensemble see De Pascalis. In this case conflict related activation occurred exclusively in the dACC. Conflict related activation in dACC rose in high susceptibles in hypnosis but actually dropped in low susceptibles demonstrating reduced efficiency in the control of response conflict in hypnotized highs. No such breakdown in cortical functional connectivity was observed for low susceptibles or for the homologous right hemisphere connection between Fz and F4. This is contrary to the expected relationship between conflict and control related activations where increased conflict detection should lead to an up regulation in control related activation. (2000) high versus low conflict contrasts revealed significant activations in dACC and a color naming versus color-word naming contrast identified significant activation in left inferior frontal gyrus (IFG). By comparison high and low susceptibles generating analgesia by attentional distraction (the mechanism proposed for hypnotic analgesia by proponents of the focused attention account of hypnotic phenomena) did not show this effect. Egner. (2000) in order to identify the specific mechanism of the dissociation in attentional control believed to occur in hypnosis. 2007) declined between recording sites reflecting activity in dACC and left IFG (electrodes Fz and F3 respectively) for high susceptibles in the hypnotized condition. (2005) sought to directly assess functional connectivity between cortical regions through EEG coherence. Similarly to MacDonald et al. Jamieson and Gruzelier (2005) adopted a strategy similar to that used by MacDonald et al. We recorded EEG from the same participants performing the identical task under hypnotized and non-hypnotized conditions on a separate occasion away from the MRI scanner.166 Graham A. (2005) that hypnotized highs showed greater conflict related activation in dACC while performing the Stroop task. However an earlier negative going component of the brains response to errors. An often overlooked finding from EEG research on cognitive control in hypnosis comes from the work of Kaiser et al. It is likely then that functional connectivity from dorsal to rostral ACC plays a key role in the translation of detection of the likelihood of an error (arising from post error response conflict) into the mobilization of an adaptive change in top-down control to reduce the likelihood of error on subsequent trials. Luu and Posner. approximately 100 milliseconds post error response. one studied correct responses the other error responses. . (1997) found that a later positive component the error related positivity or Pe. (1997) who examined averaged event related potentials (ERP’s) to error responses on their Stroop type task (see discussion of their behavioral results above). Consistent with the findings of Egner et al. Although significant we are currently extending our sample prior to a journal submission. the error related negativity or Ne. Meta analyses of imaging studies strongly support a functional division between dorsal and rostral segments of the ACC with dorsal activations more closely associated with cognitive and behavioral tasks and rostral activations more closely associated with affective and motivational manipulations (Bush. In our most recent data on this topic. Note that due to the timing of its peak. Firstly the finding of an increased Ne independently supports the finding of Egner et al. (2005) that is increased dACC responsiveness to the detection of response-conflict in hypnotized high susceptibles. one utilized fMRI the other EEG. gathered in conjunction with Croft. If correct this suggests two things. These error related ERP’s play an important role in the brains detection of and response to errors in task performance and have been the subject of intense investigation and theorizing from this perspective (Falkenstein. the Ne cannot be generated by feedback from the actual error response itself. Kaiser et al. 2000).Hypnosis. we have also found a significant reduction in the Pe in hypnotized highs and further a significant increase in the Ne in this same condition. was not affected. Absorption and the Neurobiology of Self-Regulation 167 sourced gamma and subjective pain experience broke down for higher susceptible individuals in the hypnosis condition. 2004). 2002). Both sets of results were produced from a Stroop paradigm. Hammond and Findlay. Secondly. 2001).. (2005) it appears that the earlier monitoring part of this adaptive control circuit is intact (if anything it is hypersensitive) in hypnosis but that the later part of the control network is disrupted due to a dissociation between monitoring and control functions within and between key anterior cortical regions in hypnotized high susceptibles. Although controversial the account of conflictmonitoring in cognitive control has recently been powerfully extended to cover electrophysiological error responses by modeling the Ne as generated by the dACC post response detection of conflict between the intended correct response and the executed incorrect response (Van Veen and Carter. the earlier unconscious Ne response is generated in dACC and the later Pe more closely associated with conscious awareness of error and corrective behavioral responses) appears to be generated in rostral ACC. Cleary. which appears to be closely related to the emotional experience of making an error (the so called “oh crap” response) and to the magnitude of subsequent behavioral corrections (Nieuwenhuis et al. If the conflict-detection account is correct then the enhanced Ne in the present findings has precisely the same functional interpretation as the increased dACC activation reported by Egner et al. is diminished in high susceptibles in hypnosis. (2002) may provide initial evidence of this wider possibility. Subsequent meta analyses have shown that an identifiable network of (functionally connected) brain regions is more active in a variety of “resting state” control conditions than effortful cognitive processing (Raichle et al.. 2001). Faymonville et al. I have argued above that hypnosis is closely associated with a specific type of disruption to one of these principal networks. These distinct functional networks are mutually inhibitory. which combines the new imaging technologies with the EEG.168 Graham A.. (2003) conducted an investigation of the functional connectivity of a dACC region in . While there remains deep disagreement and controversy rapid progress has been made which no truly contemporary hypnosis researcher should ignore. Conclusions from this work are necessarily more tentative but even at this point important new directions and the beginnings of new advances can be clearly identified. It is plausible then that hypnosis is also associated with some form of modulation of the alternative network engaged during other forms of effortless experience. However just as ubiquitous. but much less commented on. Data from PET studies of hypnosis conducted by Faymonville et al. Whist this circuitry is far from identical for disparate tasks there are common identifiable themes (sketched above) involving a dynamic interplay between dACC monitoring. For many traditional cognitive paradigms key components of the circuitry of cognitive control have been mapped along with their dynamic functional connectivity. An early finding within imaging studies of effortful cognitive activity (the antithesis of the experience of hypnotic responding) was a ubiquitous activation within the dACC relative to various “control”conditions. The dorsal and rostral divisions of the ACC are critical nodes in each network. Jamieson TWO MODES OF SELF-REGULATION Over the last fifteen years the new discipline of cognitive neuroscience. principally a breakdown in functional connectivity between monitoring (dACC) and control functions within the anterior cortex and the consequent effects of this on the integrated control of other brain-mind functions. at least in part. However just as the seemingly discrete discipline of cognitive neuroscience has itself spilled over into the most recent development of cognitiveaffective-social neuroscience so to related research in hypnosis is now pointing to the necessity for a wider integration with social and affective neuroscience in the understanding of hypnosis.. important aspects of the change in mental organization which occurs in hypnosis can also be understood within this emerging theoretical framework. Provocatively a previous meta analyses has also identified a mutually inhibitory relationship between activation in dorsal and rostral ACC in cognitive and affective paradigms respectively (Bush et al. the rigorous experimental paradigms of cognitive psychology and the mathematical modeling of connectionism. was a consistent deactivation of several other brain regions (including the rACC) in the same experimental contrasts. 2000). has grown and flourished principally focusing on the issue of cognitive control. Within this same time period the work described above has shown that. implementation of one excludes implementation of the other. (2003) and by Rainville et al. prefrontal task set representations and top-down control of more posterior perceptual and motor control functions. That is just as there appears to be a broad pattern of functionally interconnected regions (with important common nodes) implementing effortful cognitive control there arguably appears to be a broad but systematic alternative pattern of brain activations and connections closely associated with effortless experience. including rACC and regions of the posterior cingulate cortex and parietal association areas. decision making and goal directed behavior”. They conducted a Psychophysiological Interaction (PPI) analysis which found regulatory interactions with key nodes of the “resting state” network. 2003. Qualls and Sheehan (1981) attempted to understand the factors underlying the success (and failure) of biofeedback training.Hypnosis. Tellegen (1981) described experience as being organized around two discrete and mutually exclusive mental sets. in psychophysiological (as distinct from cognitive) self-regulation (see also Woody and Szechtman. 2007). They also reported a network which featured rACC. 1981. Critchley (2005) has himself observed the likely integration of these central networks of somatic regulation and the networks regulating active cognitive processes and resting self-focused mental states respectively. Absorption and the Neurobiology of Self-Regulation 169 which activity co-varied with the analgesic effects of hypnotic suggestions to relive a positive affective experience. voluntary and effortful planning. realistic. that of absorption (Ott. Unlike with cognitive control I cannot offer a systematic theory of these findings but I suggest they are closely tied to the role of hypnosis. lateral PFC . Hennig and Vaitl. High absorption individuals were readily able to lower muscular tension if allowed to adopt their preferred self-regulatory style of focusing their awareness on self generated inner experiences. and what are more widely known as trance states. High and low absorption ability (the ability to engage in trance like experiences in daily life) is closely related to the ease and effectiveness of two very different styles (and associated strategies) of psychological and somatic self-regulation. Nagai et al.. 2004) have identified distinct networks of brain regions (each spanning across a range of higher cortical midbrain and brain stem structures) engaged in the regulation of phasic sympathetic nervous system activity and in the regulation of tonic parasympathetic nervous system activity. posterior cingulate and parietal association cortex. These findings led Tellegen (1981) away from his earlier account of absorption as strongly focused attention to a fundamental redefinition of the trait. When instructed to adopt this approach low absorption individuals failed to lower (and actually raised) their level of muscular tension. Activation in each network is mutually inhibitory and the dorsal and rostral ACC play a fundamental role in each. mutually inhibitory networks of cognitive. He (Tellegen.222) describes the instrumental set as “a state of readiness to engage in active. Across a series of important studies they found that individuals’ level of trait absorption was a critical predictor of the success or failure of disparate self-regulation strategies. Rainville et al. 2005). Looking at electromyograph activity (muscle tension) they found that low absorption individuals could learn to lower muscle tension through biofeedback protocols but that when instructed to use this same approach high absorption individuals not only failed but actually increased their state of muscular tension. The consistent nodes in the activation networks related to these additional components of hypnotic experience in both studies also appear as principal nodes in the meta analyses identifying the resting state network. A recent series of neuroimaging studies conducted by Critchley and colleagues (Critchley et al. p. Absorption has been found to play a critical role in the success of different psychological strategies for somatic self-regulation. Reuter. (2002) used self report ratings of the experience of absorption during a hypnosis procedure to identify a network of brain regions in which activation co-varied systematically with this experience. affective and somatic self-regulation bring us full circle to a psychobiological construct with deep roots in hypnosis research. A description which is immediately recognizable as active cognitive control implemented by the dACC.. the instrumental-mental-set and the experiential-mental-set. Growing evidence for two functionally distinct. M. REFERENCES Botvinick. That is. map and explain (Sheehan and McConkey. P. 8. 2008). 1982). Luu.D. G. a very different mode of organization with its own characteristic patterns of functional connectivity. 4. If continued vigor is shown by researchers and supported by funding bodies. M. Trends in Cognitive Sciences. Aston-Jones. For example. In MI Posner ed. psychophysiological and related somatic states.S. 71–90). p. 1981. Cohen.. Davis and Howe. Cohen.170 Graham A. experience and selfregulatory organization and to adopt the other. 215-222. 539-546. when circumstances permit. sensory or imaginal [that] may occur … a tendency to dwell on rather than go beyond the experiences …[which] have a sense of effortlessness and involuntariness” (Tellegen. Jamieson and posterior cortical networks described by cognitive neuroscience and known to be disrupted in high susceptibles during hypnosis. (2000). .. C. G.S. & Gilzenrat. 222). to set aside an instrumental set and adopt instead an experiential mental set. & Posner. & Carter... central and peripheral systems of self-regulation. Tellegen described the experiential set as “a state of receptivity or openness to experiencing whatever events. 2005) and other elements of heart rate variability (Diamond. A systems level theory of attention and cognitive control. By contrast. Conflict monitoring and anterior cingulate cortex: an update. However. He further emphasized the role of affective processes in the experiential-mental-set. Cognitive and emotional influences in the anterior cingulate cortex. J. the principal social role of hypnosis has always been and remains the self-regulation of psychological. Tellegen then conceptualized absorption as a predisposition. Cognitive neuroscience of attention (pp. The mutual engagement between cognitive neuroscience and hypnosis research as outlined here has already proven most fruitful in this regard. Bush. (2004).. (2004). Therefore. New York: Guilford Press. ventricular arrhythmia (Taggart et al. from a contemporary cognitive-affective-social neuroscience perspective. Trends in Cognitive Science. M. recent studies have demonstrated the important role of hypnosis and hypnotic susceptibility in the self-regulation of stress-related endothelial dysfunction (Jambrik et al. CONCLUSION The distinctive character of the changes in experience that accompany hypnosis (at least in high susceptibles) remain one of the most important features for hypnosis researchers to comprehensively catalogue. experience and self-regulatory mechanisms.D. 2005). the future collaboration of hypnosis with systems-level neuroscience research holds the great promise of uncovering the full nature of these underlying psychological. he described absorption as the predisposition and ability to inhibit or disrupt one of two major patterns of neural functional connectivity. the study of hypnosis must not only include but also extend beyond the purely psychological level of analysis. J.M. 0 Heart rate variability as a quantitative measure of hypnotic depth. 138-156. Errors.. Neuropsychological evidence of reductions on left frontal tests with hypnosis. In M Ullsperger and M Falkenstein. Contemporary Hypnosis. (2002). Ukai... K. S. Phase-ordered gamma oscillations and the modulation of hypnotic experience. R. (1998). A. Attention and disattention (hypnotic analagesia) to noxious somatosensory TENS stimuli: fMRI differences in low and highly hypnotizable individuals. L. Z. Phillips.H. T. Hypnosis and conscious states: The cognitive neuroscience perspective (pp. pp.D. Harrington.H. 221– 227 Jamieson. 216.R. Delgueldre.S. & Santarcangelo. P. hypnosis and 40 Hz oscillations. Fox. In G. G. G. (1993).J. 27.L. G. 93-101. 11. T. Brain.. Williams. Gruzelier. Egner. 56. Max Planck Institute for Cognitive Neuroscience.. (1974). (2003). Jamieson (Ed). R. J. J. P. L. M. (2005). 255 – 262. Roediger. 55. Conflicts. Critchley. J. R. H. Psychological Medicine. C. (1999). Ghelarducci. Absorption and the Neurobiology of Self-Regulation 171 Crawford. Leipzig. Falkenstein. International Journal of Clinical and Experimental Hypnosis. O’Doherty. T. S.. S44.. 52. (2005). T. Josephs. J. Jambrik.J. (2004).. De Pascalis V. Ishii.5-14. 22. & Dolan. 1–18.. Egner. Diamond.. & Gruzelier. (2003). International Journal of Psychophysiology. 67-89). 5-23. Hypnotic modulation of flow-mediated endothelial response to mental stress. (2000). Medial prefrontal cortex generates frontal midline theta rhythm. S. Maquet.W..-K.. J. (2008). K. International Journal of Psychophysiology. C. K. H.. A midstream view of the neuropsychophysiology of hypnosis: recent research and future directions. . Shinosaki. 29-50).. Sebastiani. A. 227-266). 17. Hilgard. 46. (1992). In G.E. Imaginative involvement: Some characteristics of the highly hypnotizable and the nonhypnotisable. Zanini.G. 2139– 2152.. O. C... (2007).. & Sheehan. L. et al. J. Current Opinions on Performance Monitoring. & Gruzelier.. H.. 675–679. Gruzelier. S. Contemporary Hypnosis Research (pp.D. Dewar. E. Picano. Luxen. A working model of the neurophysiology of hypnosis: A review of evidence. Lamy. 101-108. & Howe. Increased cerebral functional connectivity underlying the antinociceptive effects of hypnosis.C. 232-249. International Journal of Clinical and Experimental Hypnosis.Hypnosis. Daugherty. Cognitive Brain Research.H. B. In E Fromm and M Nash. J.. Hypnosis decouples cognitive control from conflict monitoring processes of the frontal lobes. O. Jamieson (Ed)...J. International Journal of Clinical and Experimental Hypnosis. M. Horton. 15. eds. & Gruzelier. G. Cipolotti. An empirical test of Woody and Bower’s dissociated control theory of hypnosis..D. 10.. S. J.. Davis. Human cingulate cortex and autonomic cardiovascular control: converging neuroimaging and clinical evidence.. Cognitive control processes and hypnosis. Pain perception. (2007). E. Hypnosis and conscious states: The cognitive neuroscience perspective (pp. & Downs III. and the Brain. A. Croft. & Raz. & Warren. Neuroreport. & Laureys.J. (2004).. ERP correlates of erroneous performance. B. Crawford. Shallice. New York: Oxford University Press. Del Fiore. Hirsch-Downs. 969-978.. C.A. J.. Haenschel. Guilford Press. M. New York: Oxford University Press. NeuroImage. New York. A.J.E. Mathias. 23... J. eds. Neuroimage. Faymonville. Jamieson. R. A. hallucinogen effects. 301-313. M. 24. Attention to action: Willed and automatic control of behaviour. New York: Plenum Press. 45. Y. Miller.. 14. and positive symptoms: Epistasis between 5HT2a and COMT polymorphisms. Blom. Effects of hypnotizability on performance of a Stroop task and event –related potentials. (2000) Dissociating the role of dorso-lateral prefrontal cortex and anterior cingulate cortex in cognitive control.C. Snyder. P. J.. American Journal of Psychotherapy. Schwartz. R. A.. Nagai.J. 137B. Hypnosis modulates activity in brain structures involved in the regulation of consciousness. 243–251.. Davidson. Kirsch. P. & Gruzelier.R. B. Shapiro (Eds. & Shulman.. Hypnotic suggestion and the modulation of Stroop interference. Sheehan. Cohen. (1959).J.D. 582-602.R. Jamieson Kaiser.H. American Journal of Medical Genetics (Neuropsychiatric Genetics). (2005). 1-18). Strategy manipulation and the stroop effect in hypnosis. Raz. C. H. C.. J. Archives of General Psychiatry. Donovan. P. Vol.W.. 288. Erlbaum. T. Annual Review of Neuroscience. Haenschel. Nieuwenhuis. Jasiukaitis.172 Graham A. Y. 59. M. R. & McConkey..) Consciousness and self-regulation. (2001).B. J. Trends in Cognitive Sciences.E. (1999). Neuroimage. Suggestion Reduces the Stroop Effect. Sheehan. J. C.. 676–682.K. D.. G. (1982).P. Trimble.. 13. Perceptual and Motor Skills.Z. J.. MacLeod. Bushnell. Blom. K. W. Ray. J. 98.M & MacDonald. D. & Vaitl. Ridderinkhof. Raichle.. E. I. Hypnosis and event related potential correlates of error processing in a stroop.L. Norman. In R. W. Journal of Abnormal Psychology. A.W. MacLeod. A.. & Shallice. 4. 455-460. 38. 215-222. W. (1988). Hypnosis and experience: the exploration of phenomena and process. Hugdhal. 752-760.4 (pp. 97. (2001).M. Activity in ventromedial prefrontal cortex covaries with sympathetic skin conductance level: a physiological account of a “default mode” of brain function. C. 88.J. 29-32. Raz A.. (1986).J. D. 22.. 27. Proceedings of the National Academy of Sciences U S A. 887-901. International Journal of Clinical and Experimental Hypnosis.. Shor. Critchley.. 17.. P. D. A default mode of brain function.E. Hofbauer.E. An integrative theory of prefrontal cortex function. EEG concomitants of hypnotic susceptibility. Rainville. Nordby... 167-202. 383-391.type paradigm: A test of the frontal hypothesis. Gusnard.A. & MacLeod. Hillsdale N. Evidence for a common biological basis of the Absorption trait.. & D.. Duncan. Shapiro T. U. K. E. H. (1997). S.. M.. Journal of Cognitive Neuroscience. J. M. (2001). H. K. Reuter. . Stenger.D.A. S. & Carter. P. T. R. Baldeweg. Psychophysiology. Powers. Pollard.. & Spiegel. (2002). (2004). G. 1155-1161. Featherstone. (2000). 819-830. G. & Cohen.K. G.A. V. A.D. Error-related brain potentials are differentially related to awareness of response errors: evidence from an antisaccade task. Hennig. 1835-1838. Interdimensional interference in the Stroop effect: uncovering the cognitive and neural anatomy of attention.. & Kok. Hypnosis and the concept of generalized reality orientation. Barker.. International Journal of Psychophysiology. J.M. & Price. Psychological Science. MacDonald. (1997). & Dolan. A. 91-95. (2006). & Nitkin-Kaner. P. M. D. Ott. R. Science. D. Fan J and Posner MI (2002). a trait related to hypnotic susceptibility. E. K. Redfern. R. Lynn & J. Hypnosis and conscious states: The cognitive neuroscience perspective (pp. Openness to absorbing and self-altering experiences: Absorption. Batchvarov. (2004). A. 52-79). Tellegen. U.. 376–383. Studies of interference in verbal reactions. (1953). (1981). G. Journal of Cognitive Neuroscience.R. 18. K. 14. Dissociation: Clinical and theoretical perspectives (pp. Van Veen. Anästhesiologie & Intensivmedizin. Journal of Experimental Psychology. The timing of action-monitoring processes in the anterior cingulate cortex. A. The Effect of Mental Stress on the Non-Dipolar Components of the T Wave: Modulation by Hypnosis. Woody. V. Burgess. 268-277. New York. Motivation. & Carter. (2005). (2002). 110.H. James. Hypnotisch-induzierte Analgesie Mechanismen. & Atkinson. Grune and Stratton. Sutton. Hnatkova. M. Journal of Abnormal Psychology. (1994).M. Department of Psychology. J. Hypnotism: An objective study in suggestibility.H...). A frontal assault on dissociated control. Jamieson (Ed). Weiss. Absorption and the Neurobiology of Self-Regulation 173 Stroop. University of Essex. 45... (1935). Weitzenhoffer. 241-255). Taggart P. 643-661. (2007). J. & Szechtman. & Bowers. E. 642-647. (1974). W. W.N. T. Reviewed by Professor Adrian P. Birmingham UK. 593-602. New York: Oxford University Press. A.S. 67.. Rhue (Eds. 83. 217-226. Journal of Experimental Psychology: General. Colchester. UK. and Hypnosis. New York: Guilford. Woody. & Miltner. Malik. C. C... In G. Aston University.Hypnosis. In S. and by Dr Nick Cooper. A. Trippe. V. To See Feelingly: Emotion.. P. A. Practicing the two disciplines for relaxation and enlightenment: Comment on ‘Role of the feedback signal in electromyograph biofeedback: The relevance of attention’ by Qualls and Sheehan. & Joseph. Tellegen. Psychosomatic Medicine. H. .. . Koester and P. Tallabs G* The Free Institute of Science. Research and Applications Editors: G. Mass Anxiety Hysteria and Mass Motor Hysteria. osé Revueltas 2748. Mirror neurons * Email: felipetallabs@msn. Inc. D. Empathy. Fundamental differences are presented from the two variants of MPI. Mass Anxiety Hysteria. However. as well as a possible mirror neuron system that could be the cornerstone of symptomatology transmission. Monterrey. R. Evidence has emerged that the cultural context is of utmost importance in the mechanism of both variants of Mass Psychogenic Illness. there is an underestimated variable that relates both conditions even in a more meaningful manner. This study presents evidence that the neural mechanism of hypnosis is a fundamental prerequisite for the environmental context to exert pressure and provoke the onset of MPI.com . 64740México ABSTRACT Mass Psychogenic Illness (MPI) is typically defined as the collective occurrence of a constellation of similar physical symptoms and related beliefs. and which can be divided in two possible conditions. Chapter 7 THE NEUROPHYSIOLOGY OF HYPNOSIS IN MASS PSYCHOGENIC ILLNESS Felipe A. Mass Motor Hysteria. Mass Anxiety Hysteria and Mass Motor Hysteria. the role of empathy is assessed as a part of the mechanism of suggestibility during MPI.In: Hypnosis: Theories. Keywords: Hypnosis. Col Alta Vista Sur. and this is the neurophysiology of hypnosis. for which there is no plausible pathogenic explanation. Delisle ISBN 978-1-60456© 2009 Nova Science Publishers. peudoparesis. Colligan and Murphy. ranging from general anxiety symptoms like dizziness. 1952) or any other belief. 1970). The difference is that in Mass Anxiety Hysteria (MAH). The first consists of episodes featuring some or all the symptoms of acute anxiety. there was almost no history of previous prolonged stress or tension. 1978). these epidemics. But whatever the form of the specific case.176 Felipe A. 1973). A wide variety of crazes. 1987). such as pseudo seizures. 1966) whilst MAH seems to be the result of momentary suggestibility triggered by a situation where attention is focalized (contracted) into a perceived danger. (Bebbington et al. the belief is created at the same time that the first symptoms appear in the case 0 or first subject. Kerchkoff and Back. demonstrating alterations in motor function. anesthesia (Lee and Acherman. 1987). palpitation. panic and abnormal group beliefs have been labeled as mass hysteria... Ikeda. Tan. Watson and Bausher. Regarding the nature of the perceived danger.) Another common feature of MMH and MAH with conversion and hypnotic paralysis is the fact that MMH is the result of a long exposure to stress that could not be avoided (Knight et al.. It is relevant also that MAH lasts only for hours whilst MMH can last from weeks to years.. could be a mysterious gas (Wong et al. trances. However. Wessely comments: “The common feature of the stressors underlying outbreaks of mass motor hysteria is an inability on the part of the subject either to comprehend the true nature of the threat or have the ability to avoid it” (Wessely. 1979. 1996). etc. Tallabs G INTRODUCTION Collective psychogenic illness has been reported since the Middle Ages. 1980. 1982. Teoh et al. Small and Nicholi. 1980.. 1983) to more specific symptoms like seizures. reciting poetry (Dhadphale and Shaikh. an insect plague (Bartholomew. agitation. even demons (Huxley. headaches. Stahl and Lebedun. running. There exists no satisfactory definition of mass hysteria. This inability to comprehend the nature of the stressor mentioned by Wessely is the cause of the cultural interpretation of the stressor into a . there is always a “mythical” belief on a source that causes the phenomena. Interesting to note is the fact that this time difference is similar to the difference found between hypnotic paralysis and conversion paralysis. agitation terror (Acherman and Lee. (This will be explained further in section 3. 1982). nausea. and such accounts have continued to appear all the way up to our time. 1963. which in turn raises the level of anxiety. abdominal pain. whereas in Mass Motor Hysteria (MMH) there is a previous belief in the cause. 1982. It has been argued that in cases where anxiety-like symptoms (mass anxiety hysteria) are predominant. McEvedy and Beard. A detailed assessment of modern mass hysteria symptoms suggests that two broad groups may be identified. 1994). hyperventilation.. 1983). laughing and twitching. Many forms of behavior had been described. anxiety. possession (Teoh and Yeoh. 1965. anxiety and pseudoneurological (Ali Gombe et al. just to name a few. 1974. pseudo paresis and all sorts of pseudoneurological phenomena. Colligan et al. Small and Borus. which is always present in the cases where hysteria symptoms are predominant (Wessely. 1983. fainting. 1975. hallucinations. However there are cases in which both sets of phenomena are present. while definitely of a pathological order are certainly psychosocial phenomena rather than manifestation of individual mental Illness. 1965. The second group consists of episodes involving symptoms more recognizable as hysterical in nature. Theoretical models of group behavior have been designed to be applied to all forms of group behavior. After the onset of this rupture a state of transmarginal inhibition is set. In experimental settings. depends upon social interaction occurring between the initial case preceding the outbreak and the rest of the group. and such isolations prevents adequate verification of perceived threats (Festinger. Pavlov was most excited when he found that in all those dogs which had experienced the collapse. Theories of mass hysteria spreading mechanisms have also involved the analogy between the spread of mass hysteria and the spread of an infectious disease. Gruenberg. He suggested the existence of a “complexity” in crowd psychology that provoked emergent behaviors observable only in groups. All the dogs had met the frightening experience with initial fear and excitement. 1941) describes what happens to the conditioned behavior when the brain is “Transmarginally” stimulated by aggression or fear beyond its capacity for showing its habitual response. 2002). The unitary approach to group behavior started with LeBon (1895) who saw crowd behavior as more than the sum of single behaviors. This is only possible if the subject 0 has high status in the group. STRESS AND HYPNOTIC TRANCE In 1924 some of Ivan Pavlov’s dogs accidentally became trapped in their cages when the Nerva River flooded St Petersburg.The Neurophysiology of Hypnosis in Mass Psychogenic Illness 177 comprehensible. culturally manufactured danger. stupor and collapse. specifically when observing the difference of spread that occurs in MAH and MMH. If a belief is to be propagated and sustained over a prolonged period of time. some were in a state of severe inhibition. those who do not witness the outbreak are never affected. and those who ignore it will be immune. In Mass Anxiety Hysteria. those who accepted the fantasy idea will succumb to the epidemic. One of Pavlov’s most important findings (Pavlov. those who reject it will be resistant. social networks facilitate the spread of the symptoms. 1974). all the recently implanted conditioned reflexes had been abolished. The spread of Mass Motor Hysteria however. transmission of the outbreak is commonly along a “line of sight”. . Pavlov was able to imprint on them new patterns of behavior” (Sargant. when they were swimming around the very tops of their cages. It is this universality that prevents such models from becoming complete explanations. they were dramatically rescued by a laboratory attendant who brought the dogs out under the water to safety. It has been proposed that group reality replaces external reality. According to Penrose (1952) also Back (1971). The strain on the nervous system had been so intense that the fearful excitement aroused had resulted in a final emotional collapse. He called this state “rupture in higher nervous activity”. 1957). But after their rescue. it must be relevant to the group and all involved in the epidemics should be able to identify with the initial case or subject 0’s behavior. This particular danger provides the features of the condition itself (symptoms). What is evident is that in MMH. 1950. The water entered Pavlov’s laboratory and reached nearly to the top of the cages containing the dogs. “it was as if the recently printed brain-slate had been suddenly wiped clean. subjects with high prestige were found to be the most effective models of contagion (Bartholomew and Wessely. Towards the end. Absorption is a state of highly focused attention with a total involvement in a single dimension of experience. therefore a proneness to be influenced by suggestion develops. Kaplan and Bloom. Janet (1907) described this as a ‘retraction in the field of consciousnesses. they came from either the observing person or the observed one. memory or ideation (Tellegen and Atkinson. A person under instructions of hypnosis ‘is fully absorbed in only one or two aspects of awareness. cognitive dissociation and somatoform dissociation. Hypnosis can be explained as a controlled and structured dissociation (Kaplan.178 Felipe A.. 1990.. The notion that empathy between two people is related to a state of shared physiology is not new. The individual suddenly takes notice of events and influences around him to which he would normally have paid little or no attention. 1984. (2002) provided hard evidence of this by comparing several conversion patients with control subjects on measures of hypnotic susceptibility. Koopman et al. however most of the literature generated by the study of empathy is taken from a single person perspective. but never both of them. and although it has generated physiological measurements (Di Mascio et al.. is a fundamental part of the social fabric of emotion. Malmo et al. Tallabs G According to Pavlov. 1996). This retraction requires the relegation of material to the periphery of consciousness where it no longer impinges on awareness. Conversion patients were significantly more responsive to hypnotic suggestion than controls. which normally would not have influenced them emotionally or intellectually. 1960). This focalization excludes other experiences that should normally be present in conscious awareness. people become open to the uncritical adoption of thoughts and behavior patterns present in their environment. Suggestibility is an increased responsiveness to environmental cues (real or perceived) and is a main characteristic of hypnosis. The individual becomes susceptible to influences in the environment to which he was formerly immune. This aspect of hypnosis is considered a dissociation of content (Spiegel. 1995) However little empirical evidence existed that could relate hypnotic susceptibility to conversion (Frischolz et al. THE ROLE OF EMPATHY IN MASS ANXIETY HYSTERIA Empathy defined as the ability to perceive accurately another person’s feelings. 1990.. 1974. however this important result awaits independent replication. In this “hypnoid” state of brain activity. Frankel. like perception. Marmar et al. 1985) with a state of excessive focal concentration and relative suspension of peripheral awareness (absorption) and suspension of critical contextual evaluation (suggestibility) (Spiegel and Cardena. 1992) until Roelofs et al. 1990). and is thought to result from the heightened focal awareness through absorption. Butler et al. This can cause a great increase in suggestibility. this state of brain activity is similar to that seen in human hysteria. The narrowing of attention results in a diminution of higher order critical capacities. 1992). and therefore is less likely to critically judge or evaluate the meaning of the experience’ (Spiegel. 1957. 1955. . Spiegel. 1988. 1994. 1992). Evidence of the relationship between severe traumatic events and development of dissociative symptomatology is considerable (Spiegel. providing a bridge between one person’s feelings and those of another. As mentioned earlier.The Neurophysiology of Hypnosis in Mass Psychogenic Illness 179 Physiology has always been perceived as something private. such focalization can be produced by the continuous perception of certain danger (real or not). specifically a Mass Anxiety Hysteria fast spreading epidemic. Vaughan and Lanzetta. however such absorption of attention was also “catalyzed” by an unavoidable future of a mathematics test. at this moment the stress rises (the class was already under stress because of the future test). The observation of the sick student’s behavior provides to the class a confirmation that the teacher’s belief might be a reality. 2002). most Mass Psychogenic Illness studies consider that the symptoms begin spreading from high status students (Bartholomew and Wessely. As I mention in the introduction. thus. the essence of empathy is interpersonal. suggestibility is defined as the suspension of critical contextual evaluation. Stress and lack of proper sleep cause the student to feel sick. That is exactly what happens during MPI. Earlier that morning the stench of the nearby factory fumes had reached the school. and can only be possible when attention is focalized. This is evidence of the direct relationship between empathy and MPI. real or perceived. and during the experiencing of empathy. We can then reformulate the definition of empathy as: The ability to detect emotional information. 1989. In the previous scenario it was a possible toxic gas threat. thus the cognitive experience and the physiological experience are now coupled. then the reality of that person becomes consensual reality. McHugo et al. as well as autonomic arousal on the part of the observer (Dimberg. developing dizziness and nausea. If the level of empathy with the student 0 is high enough. He finally throws up in front of the class and complains of difficulty breathing. and thus physiological information transmitted by another person’s behavior. 1983) and even the physiological response of two people can evidence a considerable relatedness and linkage (Levenson and Ruef. Nevertheless. must be a fundamental element for the development of suggestibility during MPI epidemics. High status students provoke higher levels of empathy in their schoolmates. the teacher nervously comments to her class that the student’s condition must be a result of the morning fumes. Once absorption of attention is present. 1980). Consider the following scenario of an MPI epidemic. Orne (1959) defined suggestibility as an increased responsiveness to social (environmental) cues. which caused an above normal level of stress. the physiological response caused by an empathic observation of the student 0. triggers a suspension of critical contextual evaluation. the physiological response of an individual can be understood in terms of basic social processes (Cacioppo and Petty. A high status student is under stress because of an impending math test the following day. where single reality becomes consensual reality the mechanism of hypnosis is fundamental. There is a belief in an urban area Middle school that a nearby industrial complex releases fumes into the air that might be toxic. 1985. 1992). From this definition we can also define a level of empathy as: The level of accuracy to perceive and reproduce another person’s physiological state related to emotions. 1982. At the same time empathy gives them a physiological model of the first case or student 0 feelings. a state of suggestibility develops. However the role of empathy in MPI is still a theoretical formulation since no studies to date have thoroughly assessed it. . However. This is evidence that observing the emotional display of another person can result in similar emotional displays. it seems feasible that the physiological response triggered by empathy. Lanzetta and Englis. However let’s describe a possible scenario in order to clarify the role of empathy in a real life scenario of MPI epidemics. In this moment. Such enhancement could certainly obstruct effective functioning of the cognitive subdivisions which are suddenly disregarded by this pathological feedback circuit. However. Nevertheless. Teachers that experience episodes of MAH regularly complained of being unable to control the discipline in their classrooms. Based upon Wessely (1987). must be leading to the induction of the onset of the symptoms. This led to the “Insecure Teacher Inducer Hypothesis”. there are similarities with hypnotic-induced conditions like induced anesthesia. involving few students. Another fundamental difference between MAH and induced conditions is precisely the fact that MAH is environmentally shaped rather than induced. Most of such cases were mild. there is no stress during hypnotically induced conditions. 2005) that in hypnotizable subjects the amygdalaanteriorcingulate cortex-orbitofrontal cortex connections were enhanced by a trauma-induced long-term potentiation (LTP) in the feedback circuit between the affective subdivisions of ACC and OFC and the amygdala. line of sight Absent Under 18 Changes in motor function Usually identified Weeks to years slow present Any age It is interesting to note the similarities that exist between Mass Motor Hysteria and Conversion paralysis as well as with Mass Anxiety Hysteria and hypnotic induced paralysis respectively. See Table 1. recent data obtained by the author in questionnaires applied to a government elementary school district in an urban area of the city of Monterrey in northeast Mexico (yet to be published) provide evidence that some teachers were prone to experience MAH cases with regularity. however. MAH Symptomatology Initial case Duration Spread Preexisting tension Age-Group MMH Acute anxiety Rarely identified Hours(may be repeated) Rapid. Table 1. leading to a dysfunctional processing of motor behaviors (among others) that finally provokes the onset of the symptoms of conversion paralysis. As I have mentioned earlier there is no evidence of a previous stressing environment in MAH cases. however.Felipe A. SIMILARITIES WITH CONVERSION AND HYPNOTIC PARALYSIS All forms of Mass Psychogenic Illness may be considered an interaction between the individual and its social group. there is stress in the beginning of the event. Tallabs G 180 MMH AND MAH. . a factor related to behaviors of insecurity in the teacher during a stressful situation. I speculated elsewhere (Tallabs. Stress seems to be fundamental for the suggestibility state to develop during MAH. According to this hypothesis. which triggers the onset of the symptoms. This difference provides different characteristics to the onset of both conditions. but very repetitive. These results evidence the fact that certain personality traits in teachers might induce episodes of MAH. which seems to be fundamental in MAH. the nature of this interaction differs between MAH and MMH. Also during MAH. I believe that this “response facilitation” is just an element of the mechanism of empathy. In this type of behavior.The Neurophysiology of Hypnosis in Mass Psychogenic Illness 181 When a teacher complains about the discipline in his/her classroom. 1953. They discovered a system of neurons that behave like a mirror (Rizzolati et al. for example. 1999). Resonance behaviors appear to be present in humans also. and this can be expressed not only in words but in facial and body expressions. Once children feel the insecurity of the adult figure. 1953). An example of this is the capacity of young children to imitate mouth and manual gestures (Meltzoff and Moore. Actions that seem to be related to some degree of empathy can be contagious. leaving a void of an adult figure in the classroom. a teacher’s comment like the one in the proposed scenario “must be the result of the morning fumes” then you have all the elements for the beginning of a MAH epidemic. a feeling that anything might happen. So according to this hypothesis. an individual repeats overtly in a quasi automatic way a movement made by another individual (in this chapter I will only deal with this sort of behavior. This sort of teacher is not really in control of the children’s behavior. as if made by subjects watching the action. This type of response provides an adaptational advantage to the individual . et al. This is a stress of being unprotected. 1988). like induced pseudoneurological syndromes in experimental conditions. This stress is different to that of repressive environments so common during MMH. a group of Italian neuroscientists headed by Giacomo Rizzolati and Luciano Fadiga made a transcendental discovery for the neurosciences. This would mean that MAH could be in certain occasions an induced condition. For all these actions there is no need to postulate a comprehension of the observed actions. Tinbergen N. they play a fundamental role in establishing communication with adults. In infants. the teacher is failing as a leader. MAH onset might benefit from an indirect inducer person. 1995). A thoroughly studied example is displayed by shore birds when alarmed. many students may experience a sense of indefensibility. The most typical example of resonance behavior is found in the imitative behavior observed in different species of animals. Such state of unsafeness is an excellent condition to produce suggestibility. It is hard to believe that at such an early age there is understanding of the meaning of the observed gestures or conscious desire to repeat them. smiling produces a tendency to respond with smiling. The term “response facilitation” was proposed to describe this kind of behavior (Byrne. These sorts of behaviors can also be observed in adult humans. They refer to these behaviors as “resonance behaviors”. what is of utmost importance in this case is that the action emitted by one or two birds can act as a release signal (Rizzolati. a state of unsafeness. not more complex types of resonance). RESONANCE BEHAVIORS AND SYMPTOM TRANSMISSION IN MMH At the end of the last century. This “contagious” behavior does not require necessarily an understanding of the action. Typically one or a few birds start wing flapping. If you add to this. then others repeat the action and eventually the entire flock begins flight (Thorpe W H. A teacher should be most of all a problem solver for the children.. The most usual response to the sight of someone yawning is to yawn. laughing is well known to be contagious. 1977). such actions simply releases in the observers the seen action. this “mirror” neurons were found to represent observed actions. they also differ in fundamental aspects. However. the behaviors observed in MMH are limb related and thus must be dependent on a mechanism to overcome such “inhibition”. such inhibition can be overriden. It is then hypothesizable that OFC is in charge of this “spinal inhibitory modulation”. This modulation. like a yawning “infection”. let’s look at the mechanism that facilitates the overriding of the inhibition. But whatever the differences. one person’s reality becomes consensual (group) reality. smiling and yawning. a belief is introduced by a third party. 1995) such modulation replicated the observed movements (Fadiga et al. which is the neurophysiology of hypnosis. CONCLUSION There are two different neuropsychological mechanisms that correspond to Mass Anxiety Hysteria and Mass Motor Hysteria. 1995). thus it was speculated as a mechanism to prevent the overt replica of an observed action (Baldissera et al. This would allow then for the motor system to physically reproduce the information of the observed action by the influence of the corresponding mirror system. nevertheless. My hypothesis is that such inhibition is the result of hypnotic-like suggestion. it could not be the case if it was a purely spinal condition. as mentioned in the introduction. the OFC could override any inhibition in order to correspond to the irregular level of empathy required by the situation during MMH. then.. Now..e.. 1969. So it makes sense to speculate that during suggestibility. 2005) that OFC is an area that is responsible for suggestibility. In MAH. and behaviors become quite involuntary. emotion and motor inhibition of spontaneous movements (Kaada. It is known that the Orbitofrontal Cortex (OFC) of the brain controls adequate responses to environmental stimuli (Kolb and Whishaw. because of the psychological stress present in MMH. Ludens et al. which are strongly related to empathy and do not suffer from such type of “inhibition” modulation because they are dependent on cranial nerves not spinal nerves. just like the contagious wing flapping (escape) mechanism to a bird flock. which is a main characteristic of hypnosis. Tallabs G inserted in a society. thus. otherwise. OFC is also implicated in action. 1995) but in an “inverted mirror” fashion. In 2001 it was discovered that there was a modulation of spinal excitability during observation of actions in humans. This would mean that during MMH. is an increased responsiveness to environmental cues. it would not be easily overridden. So how do the behaviors observed during MMH come to be “contagious”. further research is required to dilucidate the exact range of its functional characteristics. 2001). Damasio. however. a teacher. and if the level of empathy with the first case is high enough. 1999). In contrast with the behaviors previously mentioned: laughing. these models are only a variation of the same phenomenon. was opposite to that occurring when the recorded muscles were actually executing the observed action (Lemon et al.. attention is focalized in the condition of the first person to become sick. i. the behaviors observed during MMH epidemics are far from being a regular occurrence of human societies. It is logical to speculate that the “inverted mirror” spinal inhibition is originated in the motor cortex. Suggestibility.182 Felipe A. 1998. This . I have speculated elsewhere (Tallabs. and although they are closely related. the reality of such belief is confirmed by empathic observation of a defined symptomatology. Social Science and Medicine 5. a suggestion. Journal of Sociology and Psychology 1. During MMH. in other words. there is a long history of a stressful environment in the group. Bebbington E. Bartholomew R (1994) Taranstism.. Craighero L. 302-307. Koopman C. 1990) and it is in charge of attention focalization. Cavallari P. Jasiukaitis P. These two areas are fundamental elements for the mechanism of hypnosis. however. Baldissera F. however. Hopton C. The American Journal of Psychiatry 153. Lee R L (1978) Mass Hysteria and Spirit Possession in urban Malaya. 281-306. 1988. 461468. most of the time related to a repressive environment within the group. Extensive research on the neural correlates of MAH will have to be undertaken. Such focalization causes a suggestion and the override of the spinal “motor inhibition” in order to respond to a level of empathy required by this extraordinary situation. Butler L. there is an empathic response to a first case. Wessely S (2002) Protean nature of mass sociogenic illness: From possessed nuns to chemical and biological terrorism fears. Psychological Medicine 24. specifically the Anterior Cingulate Cortex (ACC) and the Orbitofrontal Cortex (OFC). Pardo et al. Stress focalizes attention in the empathic response to the observed behavior. Ali Gombe A. What is definitely behind both variations of Mass Psychogenic Illness is the engagement of frontal brain cortex areas. REFERENCES Ackerman S. Similar to MAH.The Neurophysiology of Hypnosis in Mass Psychogenic Illness 183 triggers a suspension of critical evaluation. We can speculate that such group suggestion is the cause of the communicated symptomatology. 42-70. the mechanism observed in MAH although similar to hypnotic paralysis. 190-194. Community Medicine 2. McDermott N (1996) Mass Hysteria: One syndrome or two? British Journal of Psychiatry 168 (5) 633-635. Lockett H I. OFC as mentioned earlier is in charge of suspension of critical evaluation as well as motor inhibition. does not involve motor behavior. Back K (1971) Epidemiology versus Cartesian dualism. ACC has been found to be selective of attentional demands (Posner et al. British Journal of Psychiatry 180. Fadiga L (2001) Modulation of spinal excitability during observation of hand actions in humans. 24-30. a strict school discipline. . Guthrie E. Spiegel D (1996) Hypnotizability and traumatic experience. European Journal of Neuroscience 13. Bartholomew R E. 300-306. It is then likely that ACC and OFC are areas strongly involved during MMH and MAH. The mechanism seen in MMH is rather similar to the one observed during conversion paralysis. British Journal of Psychiatry 180. there is not any environmental suggestion present. Bartholomew R. dancing mania and demonopathy: the anthro-political aspects of mass psychogenic illness. i. Madeley R J (1980) From experience: epidemic syncope in jazz bands.e. This allows the corresponding mirror system to exert a direct influence in motor areas otherwise blocked to its influence. Wessely S (2002) Protean nature of mass sociogenic illness: From possessed nuns to biological terrorism fears.. Duran D. 300306. 184 Felipe A. Tallabs G Byrne R (1995) The Thinking Ape: Evolutionary Origins of Intelligence. Oxford University Press. Cacciopo T J, Petty R E (1983) Social psychophysiology: A source-book. New York: Guildford Press. Colligan M, Murphy L R (1979) Mass Psychogenic Illness in organizations. Journal of Occupational Psychology 52, 77-90. Colligan M, Pennebaker J, Murphy L (1982) Mass psychogenic illness: A Social Psychological Analysis. Lawrence Erlbaum: Hilsdale, New Jersey Dadphale M, Shaikh S (1983) The mysterious madness of Mwinilunga. British Journal of Psychiatry 142, 85-88. DiMascio A, Boyd R, Greenblatt M, Solomon H C (1955) The psychiatric interview: A sociophysiologic study. Diseases of the nervous system 16, 4-9. Dimberg U (1982) Facial reactions to facial expressions. Physchophysiology 19, 643-647. Festinger L (1950) Informal social communication. Psychological Review 57, 271-282. Frankel F H (1990) Hypnotizability and dissociation. American Journal of Psychiatry 147, 823-829. Frischholz E J, Lipman L S, Braun B G, Sachs R G (1992) Psychopathology, hypnotizability and dissociation. American Journal of Psychiatry 149, 1521-1525. Gruenberg E M (1957) Socially shared psychopathology. In: Exploration in Social Psychiatry (ed. A. H. Leighton, J. A. Clausen, R. N. Wilson) pp 201-299. Travistock Publication: London. Huxley A (1952) The demons of Loudun. Harper and Brothers, New York. Ikeda Y (1966) An epidemic of emotional disturbance among leprosarium nurses. Psychiatry 23, 152-164. Jeanet P (1907) The Major Symptoms of Hysteria. London: MacMillan. Kaada B R (1960) Cingulate, posterior orbital, anterior insular and temporal pole cortex. In: J Field (ed.) Handbook of Physiology. Baltimore, M D: Williams and Wilkins, vol 2. Kaplan H I (1985) Dissociative disorders. In: H I Kaplan, B J Sadocks (eds) Comprehensive Textbook of Psychiatry. Baltimore, MD: Williams and Wilkins, 942-957. Kerckhoff AC, Back K W, Miller N (1965) Sociometric patterns in hysterical contagion. Sociometry 28, 2-15. Knight J A, Friedman T I, Sulianti J (1965) Epidemic hysteria: a field study. American Journal of Public Health 55. 858-865. Kolb B, Whishaw I Q (1998) Fundamentals of Human Neuropsychology. New York: W H Freeman and Company. Koopman C, Classen C, Cardena E, Spiegel D (1995) When disaster strikes, acute stress disorder may follow. Journal of Trauma and Stress 8, 29-46 Lanzetta J T, Englis B G (1989) Expectations of cooperation and competition and their effects in observers` vicarious emotional responses. Journal of Personality and Social Psychology 56, 543-554. Le Bon G (1895) The Crowd. Reprinted (1960). Viking: New York. Lee R L, Ackerman S (1980) The sociocultural dynamics of mss hysteria. Psychiatry 43, 7888. Lemon R N, Johansson R S, Westling G (1995) Corticospinal control during reach, gasp and precision lift in man. Journal of Neuroscience 15, 6145-6156. The Neurophysiology of Hypnosis in Mass Psychogenic Illness 185 Levenson R W, Ruef A M (1992) Empathy: A Physiological Substrate. Journal of Personality and Social Psychology 63 (2) 234-246. Luders H O, Dinner D S, Morris H H, Wyllie E, Comair Y G (1995) Cortical electrical stimulation in humans: the negative motor areas. Advances in Neurology 67:115-119. Malmo R B, Boag T J, Smith A A (1957) Physiological study of personal interaction. Psychosomatic Medicne 19, 105-119. Marmar C R, Weiss D S, Schlenger W E, Fairbank J A, Jorda B K, Kulka R A, Hough R L (1994) Peritraumatic dissociation and post-traumatic stress in male Vietnam theatre veterans. American Journal of Psychiatry 151, 907-909. McEvedy C P, Beard A W (1970) Royal Free epidemic: a reconsideration. British Medical journal. i, 7-11. McHugo G J, Lanzetta J T, Sullivan D G, Masters R D, Englis B G (1985) Emotional reactions to a political leader’s expressive displays. Journal of Personality and Social Psychology 49, 1513-1529. Meltzoff A N, Moore M K (1977) Imitation of facial gestures by human neonates. Science 198, 75-78. Orne M T (1959) The nature of hypnosis: artifact and essence. Journal of Abnormal Social Psychology 58: 277-299. Pardo J, Pardo P, Janer K, Raichle M E (1990) the anterior cingulated cortex mediates processing selection in stroop attentional conflict paradigm. Proceedings of the National Academy of Science, USA 87: 256-259. Pavlov I P (1941) Lectures on conditioned reflexes, Vol 2, Lawrence and Wishart: London. Penrose L S, (1952) On the objective study of crowd behavior. H Lewis: London. Posner M I, Petersen S E, Fox P T, Raichle M E (1988) Localization of cognitive operations in the human brain. Science 240: 1627-1631. Rizzolati G, Camarda R, Fogassi L, Gentilucci M, Luppino G, Mantelli M (1988) Functional organization of inferior area 6 in the macaque monkey: II. Area F5 and the control of distal movements. Experimental Brain Research 71, 491-507. Rizzolati G, Fadiga L, Fogassi L, Gallese V (1999) Resonance behaviors and mirror neurons. Archives Italiennes de Biologie 137, 85-100. Roelofs K, van Galen G P, Keijsers G P J, Naring G, Moene F, Sandijk P (2002) Hypnotic susceptibility in patients with conversion disorder. Journal of Abnormal psychology 111 (2) 390-395. Sargant W (1994) The mind possessed: A physiology of possession, mysticism and faith healing. The Lippincott Company: New York. Small G, Borus J (1983) Outbreak of Illness: mass hysteria or toxic poisoning? New England Journal of Medicine 308, 632-635. Small G, Nicholis A (1982) Mass Hysteria among School children. Archives of General Psychiatry 39, 721-724. Spiegel D (1984) Multiple personality as a post-traumatic stress disorder. Psychiatric Clinics of North America 7, 101-110. Spiegel D (1990) Hypnosis, dissociation and trauma: hidden and overt observers in repression and dissociations. In: JL Singer (ed.) Repression and Dissociation: Implications for Personality Theory, Psychopathology, and Health. Chicago IL: University of Chicago Press, 121-142. 186 Felipe A. Tallabs G Spiegel D (1992) The use of hypnosis in the treatment of PTSD. Psychiatry Medicine 10, 2130. Spiegel D (1992) The use of hypnosis in the treatment of PTSD. Psychiatry Medicine 10, 2130. Spiegel D, Cardena E (1990) New uses of hypnosis in treatment of post-traumatic stress disorder. Journal of Clinical Psychiatry (October supplement): 39-43. Spiegel D, Hunt T, Dondershine H E (1988) Dissociation and hypnotizability in posttraumatic stress disorder. American Journal of Psychiatry 145, 301-305. Stahl S M, Lebedun M J, (1974) Mystery gases. Journal of Health and Social Behavior. 15, 44-50. Tallabs F (2005) Functional correlates of hypnotic and conversion paralysis: A neurophysiological hypothesis. Contemporary Hypnosis 22 (4) 184-192. Tan E S (1963) Epidemic hysteria. Medical journal of Malaya 18, 72-76. Tellegen A, Atkinson G (1974) Openness to absorbing and self-altering experience (absorption) a trait related to hypnotic susceptibility. Journal of Abnormal Psychology 83: 268-277. Teoh J, Soewondo S, Sidharta M (1975) Epidemic hysteria in Malaya. Psychiatry 38 258-267. Teoh J, Yeoh K (1973) Cultural conflict and transition: epidemic hysteria and social sanction. Australian and New Zealand Journal of Psychiatry 7, 283-295. Thorpe W H, (1953) Learning and Instincts in Animals (2nd Ed) London. Methuen and Co. Ltd. Tinbergen N (1953) Social Behavior in Animals. London. Methuen and Co. Ltd. Vaughan K B, Lanzetta J T (1980) Vicarious instigation and conditioning of facial expressive and autonomic responses to a model’s expressive display of pain. Journal of Personality and Social Psychology. 38, 909-923. Watson N (1982) An outbreak of hysterical paraplegia. Paraplegia 3, 154-157. Wessely (1987) Mass Hysteria: Two syndromes? Psychological Medicine 17, 109-120. Wong S W, Kwong B, Tam Y K, Tsoi M M (1982) Psychological epidemic in Hong Kong I: Epidemiological study. Acta Psychiatrica Scandinavia 65, 421-436. Reviewed by: Prof Anarbol Lopez, Center for Applied Psychology Address: Espinoza 854 Pte, Monterrey N.L. México. In: Hypnosis: Theories, Research and Applications Editors: G. D. Koester and P. R. Delisle ISBN 978-1-60456© 2009 Nova Science Publishers, Inc. Chapter 8 RELAXATION, MEDITATION, AND HYPNOSIS FOR SKIN DISORDERS AND PROCEDURES* Philip D. Shenefelt Department of Dermatology and Cutaneous Surgery University of South Florida, Tampa, Florida, USA ABSTRACT Relaxation, meditation, and hypnosis can help calm and rebalance the inflammatory immune response, which in turn can ameliorate inflammatory skin disorders. The relaxation response has been shown to help rebalance immune functioning. Mindfulness meditation has been shown to enhance the response of psoriasis to ultraviolet light treatments. Hypnosis has been shown to decrease inflammation and discomfort in a number of skin disorders and to improve the patient's attitude about having the condition. Hypnosis has also been shown to be more effective than relaxation alone in alleviating inflammatory skin disorders. Psychocutaneous hypnoanalysis permits diagnostic evaluation as to whether psychosomatic issues are initiating or exacerbating specific skin disorders. If psychosomatic issues are present, hypnoanalysis also permits treatment by reframing the initiating event in a way that defuses the negative emotional charge associated with it. Rapid induction hypnosis followed by deepening and then self-guided imagery has also been effective in alleviating anxiety and discomfort associated with dermatologic procedures. * A version of this book was also published as a chapter in Mind-Body and Relaxation Research Focus, edited by Bernardo N. De Luca, published by Nova Science Publishers, Inc. It was submitted for appropriate modifications in an effort to encourage wider dissemination of research. 188 Philip D. Shenefelt INTRODUCTION Our skin provides extensive contact with and protection from the outside world. The skin and the nervous system develop side by side in the ectoderm of the fetus and remain intimately interconnected throughout life. Cutaneous sensory nerves provide the largest sense organ of the body and are also vital to skin protection and health. There is a significant psychosomatic or behavioral component to many skin disorders. This interaction permits interventions such as relaxation, meditation, and hypnosis to have positive impacts on many cutaneous diseases. Stress is epidemic in modern life. According to an Associated Press poll conducted in November 2006 (Lester 2006), roughly 75 percent of people in the United States, Australia, Canada, France, Germany, Italy, South Korea, and the United Kingdom said that they experience stress daily. See Table 1. In modern industrial societies, factors increasing stress included multiple jobs, long commutes, and increasingly complex technology, both at work and at home. The tense or anxious feelings often associated with having too much to do, too many bills to pay, not enough time, not enough money, health concerns, or family life situations were commonplace. Those earning higher incomes frequently cited their jobs as the leading stress factor, while for those earning lower incomes it was most commonly finances. With an increased emphasis on consumerism and easy credit in the United States, finances were most commonly named as the most frequent stress factor. Our current culture has many other stressful aspects, such as information overload and encouragement of activity overload. In less stressed Spain 61 percent experienced daily stress, while in even more laid back Mexico less than 50 percent experienced daily stress. Table 1. Most important cause of stress in person’s life in percent (sample of about 1000 in each country, margin of error 3%, “other” and “not sure” omitted) modified from Associated Press poll (Lester 2006) Job Finances Health Family life Australia 35 27 14 24 Canada 32 28 19 13 France 30 30 20 13 Germany 37 18 25 15 Italy 33 19 20 13 Mexico 20 38 15 12 South Korea 33 28 13 12 Spain 34 15 23 19 United Kingdom 26 32 15 19 United States 26 34 15 16 Stress can trigger or aggravate many inflammatory skin diseases (See Table 2) and by adding to suppression of the immune response, chronic stress can increase susceptibility to skin cancer (Saul, Oberyszyn, Daugherty et al 2005). Stress and anxiety or anger can feed on each other in a harmful positive feedback loop of increasing distress. The skin serves as a massive sensory organ intimately connected with the nervous system. In addition, neuropeptides released by the sensory nerve fibers activate neuropeptide receptors on skin Relaxation, Meditation, and Hypnosis for Skin Disorders and Procedures 189 cells to induce inflammatory activities. Cholinergic sympathetic fibers innervate the eccrine sweat glands and control sweating. Thermal sweating occurs globally in the skin, while emotional sweating is accentuated on the forehead, palms, soles, and axillae. Sweating can be measured by galvanic skin resistance (GSR). Adrenergic and cholinergic fibers innervate the arrector pili muscles, causing hairs to stand up. This occurs both with exposure to cold and with a strong sudden emotional fear reaction. Adrenergic fibers innervate the cutaneous blood vessels. Alpha adrenergic receptors mediate vasoconstriction, while beta adrenergic receptors mediate vasodilitation, controlling cutaneous blood flow. Emotional embarrassment can cause facial blushing, while fear can cause facial pallor. Skin temperature is related to cutaneous blood flow (Chu, Haake, Holbrook et al, 2003). Table 2. Emotional Triggering of Dermatoses in 4576 Patients Diagnosis Hyperhidrosis Lichen simplex chronicus Neurotic excoriations Alopecia areata Warts, multiple & spreading Rosacea Pruritus Lichen planus Dyshidrotic hand dermatitis Atopic dermatitis Factitial dermatosis Urticaria Psoriasis Traumatic dermatitis Dermatitis not otherwise specified Acne vulgaris Telogen effluvium Nummular dermatitis Seborrheic dermatitis Herpes simplex / zoster Vitiligo Pyoderma / bacterial infection Nail dystrophy Cysts Warts, single / multiple Contact dermatitis Fungal infections Basal cell carcinoma Keratoses Nevi % Triggered 100.0 98.5 97.5 96.4 94.9 94.1 85.7 81.8 75.8 70.2 69.2 68.1 62.3 55.6 55.6 55.3 54.7 51.8 40.6 35.7 33.3 29.1 28.5 27.0 17.4 15.3 8.7 0 0 0 Modified from Shenefelt: Arch Dermatol 2000; 136: 393-399, Table 1, p. 394 Time Sec d-2 wk Sec 2 wk days 2d Sec d-2 wk 2d Sec Sec Min d-2 wk Sec days 2d 2-3 wk days d-2 wk days 2-3 wk days 2-3 wk 2-3 wk days 2d d-2 wk N/A N/A N/A Conversely. social interactions. rosacea. affecting inflammatory processes in the skin. aphthous stomatitis. chemicals. or psoriasis can induce or aggravate depression in susceptible individuals (Gupta and Gupta 2003). alopecia areata. Stress hormones influence the immune system. Reducing acute and especially chronic stress through nonpharmacologic methods can help calm inflammatory skin disorders and rebalance the immune response. Habits (CNS conditioned responses) can be influenced by stress and determine skin exposure to environmental hazards such as ultraviolet light. Shenefelt The central nervous system (CNS) also mediates hormone release through the hypothalamus with its actions on the pituitary and other endocrine glands. atopic dermatitis. seborrheic dermatitis. aggravation of existing skin conditions. lichen planus. Table 3. psoriasis. and behavior. factitial (intentional) trauma. lichenification (thickening in response to rubbing). Manipulation of normal or diseased skin can result in excoriations (damage from scratching). Deep Relaxation Categories of Methods Primarily Physical • Breathing • Progressive muscle relaxation • Yoga stretching • Biofeedback—requires equipment Primarily Mental • Autogenic suggestion---a special sequence of self-hypnosis • Hypnosis and self-hypnosis • Imagery and relaxing self-talk • Meditation ƒ Concentrative—one simple stimulus or mantra ƒ Mindfulness---quiet observation with detachment . Melanocytes are stimulated by melanocytestimulating hormone to produce more melanin.190 Philip D. Robles et al 2002). herpes simplex recurrences. physical injury. leading to stress. and others are exacerbated by excessive stress (Zane 2003). alopecia areata. The interactions of the CNS and the immune system were well reviewed by Kiecolt-Glaser et al (Kiecolt-Glaser. Skin and hair are influenced by thyroid and sex hormones. telogen effluvium. Chronic skin disorders such as acne. The stress reducing techniques can be divided into primarily physical and primarily mental (Smith 2005). McGuire. vitiligo. See Table 3. atopic dermatitis. and temperature extremes. Skin diseases also can affect self image. the appearance of the skin and hair can have a significant impact on self image (in the CNS) and social interactions. and subsequent dyspigmentation or scarring. Many inflammatory skin diseases such as acne. The various types of meditation may broadly be divided into concentrative meditation where the focus is on one object such as a candle flame or mandala. followed by those of the next adjacent body area until all areas of the body have been covered. or toes with intentional muscle tensing followed by relaxation. head. He showed using biofeedback instrumentation that excess muscular tension was present in many psychosomatic disorders. It is more commonly used to induce meditative trance but also can be used as a hypnotic induction. hyperhidrosis (Duller and Gentry 1980). The basic method is to be in a seated or recumbent position and start at the hands. Progressive muscular relaxation was developed by Edmund Jacobson (1929). while the recumbent position is preferred if the patient desires to drift off to sleep for a nap or at bedtime. They are an efficient and effective means of reducing stress. sound. MEDITATION Various forms of meditation have been used since antiquity. The relaxation should be maintained for 5 to 25 minutes for optimal benefit. The most common mechanism is through influencing immunoreactivity (Tausk 1998). The resulting calming effect can improve the psychosomatic aspects of skin disorders. shifting from more shallow and rapid chest centered breathing to deeper and slower diaphragmatic abdominal breathing. or mantra and mindfulness meditation where the focus is on emotional nonattachment but broad awareness of many objects.Relaxation. while the mindfulness trance maintains external awareness while remaining calmly centered. Patients who have low hypnotic ability may be especially suitable for this type of relaxation training utilizing EMG biofeedback. other sensations. Both may involve entering a trance. The western paradigm for healing tends to look at the “how” of disease. Intentionally tensing and then relaxing the muscles decreased emotional distress and the resulting calmness and relaxation reduced psychosomatic symptoms. and Hypnosis for Skin Disorders and Procedures 191 RELAXATION Breath relaxation has been practiced for centuries. sounds. Breath relaxation can induce trance. psoriasis (Benoit and Harrell 1980) and urticaria. atopic dermatitis. The sitting position is preferred if the patient desires to realert after the progressive muscular relaxation. Progressive muscular relaxation can be used by itself for treatment and prophylaxis of psychosomatic components of skin disorders. image. or thoughts. It may induce a hypnotic or meditative trance and is one of the methods of hypnotic trance induction. lichen planus. The concentrative trance reduces external awareness. Biofeedback of muscle tension via EMG can enhance teaching of relaxation. examining the subsystems involved and the means to repair and cure or control the problem with a short . The basic method is to focus on the breath and to intentionally slow and deepen breathing. word. dyshidrotic dermatitis (Koldys and Meyer 1979). There are parallels of concentrative meditation to internally focused hypnotic trance and of mindfulness meditation to alert awake hypnotic trance. Meditation. It has been an aspect of some yoga traditions and has been used in the Lamaze method of natural childbirth. neurodermatitis. The adjacent body part muscles are then tensed and relaxed. Biofeedback assisted relaxation can have a positive effect on inflammatory and emotionally triggered skin conditions such as acne. Mindfulness meditation has also been used extensively for stress reduction. including stress reduction. closing your eyes. pruritus. and stretching yoga combined with at half day of meditation and daily homework of 45 minutes taped guided meditation or 30 minutes of meditation on their own helped them to develop nonjudgmental.192 Philip D. alopecia areata. Hypnosis may improve or clear numerous skin disorders. Jon Kabat-Zinn (1991. . One form of generic concentrative meditation was introduced by Herbert Benson (1975) to induce what he termed the relaxation response. trichotillomania. Examples include acne excoriée. glossodynia. pain or pruritus reduction. We all experience spontaneous mild trances daily while absorbed in watching television or a movie. remain sitting quietly for a few minutes. say the word “one” to yourself (concentrative mantra meditation trance induction). examining the systems and supersystems involved and the means to restore or rebalance the system with a long term focus (Otani 2003). 1994) has been a major proponent of this methodology. It involves guiding the patient into a trance state for a specific purpose such as relaxation. herpes simplex. He developed the Mindfulness-Based Stress Reduction program. or habit modification. and acceptance. lichen planus. It involves sitting in a quiet place. and vitiligo (Shenefelt 2000). Maintain the concentrative meditation for 10 to 15 minutes. With each exhalation. urticaria. post-herpetic neuralgia. He also performed a study (Kabat-Zinn 1998) with randomization of psoriasis patients undergoing ultraviolet B (UVB) or psoralen plus ultraviolet A (PUVA) light treatments into two groups. moment to moment awareness. Let any distracting thoughts or sensations drift away ignored like clouds in the sky. After appropriate training. reading a book or magazine. They both use the trance phenomena but with different conceptual approaches and different types of emphasis. then with your eyes open. atopic dermatitis. Hypnosis arose in the western cultural milieu while meditation arose in the eastern cultural milieu. attention monitoring. See Table 4. letting your muscles loosen and relax. dyshidrotic dermatitis. psoriasis. When you finish. Patients in the mindfulness meditation tape group reached the halfway point in clearing and the clearing point significantly more rapidly than the controls for both UVB and PUVA treatments. breathing evenly through your nose and becoming aware of the breath (breath relaxation trance induction). Maintain a passive attitude. ichthyosis vulgaris. Shenefelt term focus. starting at your feet and working upward (progressive muscular relaxation trance induction). employing mindfulness mediation and hatha yoga. Hypnosis can also reduce stress. it has been adapted for medical use. The health benefits of the relaxation response have been extensive researched with positive results in areas such as cardiovascular health. furuncles. HYPNOSIS Hypnosis is a tool with many useful dermatologic applications. those listening to mindfulness meditation tapes and those who were controls. rosacea. congenital ichthyosiform erythroderma. neurodermatitis. or other focused activity. hyperhidrosis. nummular dermatitis. awareness of body sensations. verruca vulgaris. while the eastern paradigm for healing tends to look at the “what” of disease. erythromelalgia. Originally associated with Buddhism and in particular Zen. The 8 week course had weekly 2 hour classes where techniques of breath. first with your eyes closed. anxiety and pain associated with dermatologic procedures. self-hypnosis. to promote healing. We may induce the trance state using guided imagery. Skin disorders reported responsive to hypnosis. The purpose of medical hypnotherapy is to reduce suffering. Trance has been used since antiquity to assist the healing process. and termination of the trance state for a specific purpose. but most can obtain some benefit from hypnosis. and Hypnosis for Skin Disorders and Procedures 193 we may intensify this trance state and use this heightened focus to induce mind-body interactions that help to alleviate suffering or to promote healing. meditation techniques. Some people are more highly hypnotizable. relaxation. or hypnosis induction techniques.Relaxation. gene coding for the amino acid valine on both alleles . Table 4. deepening. maintenance. or to help the person alter a destructive behavior. At position 148 in this enzyme. One biological factor that has been associated with degree of hypnotizability is the catechol-o-methyl-transferase gene. others less so. deep breathing. Low hypnotizability is to a large extent hard-wired into individuals' brains and tends to be consistent over time as measured by the Hypnotic Induction Profile (Spiegel and Spiegel 2004). Randomized Control Trials (representing strong evidence of effectiveness) o Hypnotic relaxation during procedures o Verruca vulgaris o Psoriasis Nonrandomized Control Trials o Atopic dermatitis Case Series o Alopecia areata o Urticaria Single or Few Case Reports (representing weak evidence of effectiveness) o Acne excoriée o Congenital ichthyosiform erythroderma o Dyshidrotic dermatitis o Erythromelalgia o Furuncles o Glossodynia o Herpes simplex o Hyperhidrosis o Ichthyosis vulgaris o Lichen planus o Neurodermatitis o Nummular dermatitis o Post-herpetic neuralgia o Pruritus o Rosacea o Trichotillomania o Vitiligo Hypnosis is the intentional induction. Meditation. Quantitative EEG findings by Freeman et al (Freeman. Shenefelt (homozygous) is associated with a four times more rapid degradation of dopamine and lower hypnotizability compared with gene coding for methionine on both alleles (homozygous) with slower degradation of dopamine and medium hypnotizability.5-7. restricted and focused attentiveness. Laurys. Further discussions of the definitions of hypnosis are available in Crasilneck and Hall (1985) or Barabasz andWatkins (2005). Hypnosis may also help to reduce stress. including verruca vulgaris (warts). Bloch (1927) and Sulzberger (1934) used suggestion to treat verrucae successfully. selective wakefulness. Stress reduction through the relaxation response that accompanies hypnosis alters the neurohormonal systems that in turn regulate many body functions. PET subtraction studies by Faymonville et al (Faymonville. In their study. or underrate the true capabilities of hypnosis.194 Philip D. overrate. Barabasz. Skin disorders that have responded to hypnotherapy are discussed below. Recent evidence from EEG studies and positron emission tomography (PET) studies comparing brain activity in the same individual when alert and when in trance lend support to the theory that hypnosis is a describable altered state of consciousness rather than simply a social compliance with expectations. hypnosis may be used to help control stress exacerbated harmful habits such as scratching. reduce symptoms such as pruritus. The precise definition of hypnosis is still somewhat controversial. and heightened suggestibility. improve recovery from surgery. Marmer (1959) defined hypnosis as a psychophysiological tetrad of altered consciousness consisting of narrowed awareness. 2000). Heterozygous coding for valine and methionine is associated with medium to high hypnotizability (Lichtenberg. . The mechanisms by which hypnosis produces improvement in symptoms and in skin lesions are not fully understood. or psychosomatic aspects of skin diseases. pruritus. presumably related to cerebral activity. BachnerMelman R. Gritsenko et al. or SHSS:C scores ) compared with low hypnotizables at parietal and occipital sites during hypnosis and also during waking relaxation. (Tausk 1998) For skin disorders.5 Hz) activity for high hypnotizables (based on Stanford Hypnotic Susceptibility Scale. Skin diseases responsive to hypnosis are described in the relatively old book by Scott (1960) and in the chapter on the use of hypnosis in dermatological problems in Crasilneck and Hall (1985). It can also be used to provide immediate and long term analgesia. Hypnosis can hasten the resolution of some skin diseases. Form C. Grossbart and Sherman (1992) include hypnosis as recommended therapy for a number of skin conditions in an excellent resource book for patients. Koblenzer (1987) also mentions some of the uses of hypnosis in common dermatologic problems. pain reduction mediated by hypnosis localized to the mid anterior cingulate cortex. Degueldre et al 2000) demonstrated specific areas of the cerebral cortex with higher bloodflow during hypnosis and others with lower bloodflow. skin pain. Suggestion without formal trance induction may be sufficient in some cases. and facilitate the mindbody connection to promote healing. Barabasz et all 2000) in a study of hypnosis versus distraction effects on cold pressor pain showed significantly greater high theta (5. There are many myths about hypnosis that distort. Hypnosis can help regulate bloodflow and other autonomic functions not usually under conscious control. See Table 5. Mentioning hypnosis to patients will allow the practitioner to gauge the patient's receptiveness to this treatment modality. preparing. hypnosis can decrease suffering and morbidity from skin disorders with minimal side effects. soothe. Hypnotic trance sequence during medical hypnotherapy. ability to obtain a response where other treatment modalities have failed. Scott 1964. and actually perform the hypnotherapy are similar to or less than those for screening. Trance induction Rapid.Relaxation. or a play or by using some other distractive process that employs the imagination (Olness 1986). Patient selection is an important aspect of successful medical hypnotherapy. Barabasz and Watkins 2005). Induction of the hypnotic state in adults is achieved by methods that focus attention. Scott 1963. Table 5. and hypnoanalysis (Scott 1960. direct suggestion. The time needed to screen patients.-Eyeroll Slow. Hartland 1969). and ability of patients to self-treat and gain a sense of control when taught self-hypnosis reinforced by using audiotapes or mp3s. educate them about realistic expectations for results from hypnosis. Meditation. Hypnosis facilitates supportive therapies (ego-strengthening). Supportive (ego-strengthening) therapies include positive suggestions and posthypnotic suggestions for self-worth and effectiveness. Disadvantages include the practitioner training required. With proper selection of disease process. the low hypnotizability of some patients. patient. Practitioners who prefer to refer patients to hypnotherapists or who desire further information about training in hypnotherapy may obtain referrals or training information from the American Society of Clinical Hypnosis or similar professional organizations. and educating patients about cutaneous surgery and then actually performing the surgery. symptom substitution. and provider. and/or produce monotony or confusion (Crasilneck and Hall 1985. costeffectiveness. a movie. the negative social attitudes still prevalent about hypnosis. and the lower reimbursement rates for cognitive therapies such as hypnosis when compared with procedural therapies such as cutaneous surgery. The hypnotic state may be induced in children by having the child makebelieve that he or she is watching television. and Hypnosis for Skin Disorders and Procedures 195 MEDICAL HYPNOTHERAPY Hypnosis can be used to reduce stress and psychological or behavioral impediments to healing.-Progressive relaxation or other method Trance deepening Trance work (one or more) Ego strengthening Direct suggestion Indirect suggestion Hypnoanalysis Relaxation for procedures Trance termination Some advantages of medical hypnotherapy for skin diseases include nontoxicity. Reinforcement can be achieved by recording an . skin discomfort from pain. burning sensations. "may" is used below to qualify recommendations that are based on weak evidence.P.P. verbal expression of feelings. Hypnoanalysis may help patients with skin disorders unresponsive to other simpler approaches.Philip D.S. anxiety. direct suggestion may produce sufficiently deep anesthesia to permit cutaneous surgery. C.S. One of my patients who had persistent erythema nodosum for 9 years with no apparent physical trigger factors had resolution of the lesions after hypnoanalysis (Shenefelt 2007). method of hypnoanalysis for root causes • • • • • • • Conflict Organ language Motivation Past experiences Active identification Self punishment Suggestion MEDICAL HYPNOTHERAPY FOR TREATING SPECIFIC SKIN DISORDERS Until recently.O. reports of the effectiveness of hypnosis on specific dermatologic conditions were mostly based on one or a few uncontrolled cases.A. and insomnia.A. In highly hypnotizable individuals. Since the validity of such findings await further confirmation. or meditation. The trend toward more controlled trials has produced more reliable . Autonomic responses in hyperhidrosis. method of identifying seven trigger or exacerbating psychosomatic root causes is slightly modified from the method well described in Ewin and Eimer (2006). another physical activity. blushing. nail biting or manipulating. Table 6. Uncovering the trigger or exacerbating factors and neutralizing the associated negatively charged emotion often leads to the resolution of the psychosomatic aspects of the problem. Using hypnoanalysis. artwork. Shenefelt 196 audiocassette tape or mp3 that the patient can use subsequently for repeated self-hypnosis. Symptom substitution replaces a negative habit pattern with a more constructive one (Scott 1960). pruritus. For example. Posthypnotic suggestion and repeated use of an audiocassette tape or mp3 by the patient for self-hypnosis helps to reinforce the effectiveness of direct suggestion.S. Verrucae can be induced to resolve using direct suggestion (see below). Other activities that can be substituted for scratching include athletics. results may also occur much more quickly than with standard psychoanalysis (Scott 1960).M. The strengthened ego is better able to deal with psychological elements that inhibit healing.O. and hair pulling or twisting (Scott 1960). Direct suggestion can also reduce compulsive acts of skin scratching or picking. The C.S. See Table 6. such as grasping something and holding it so tightly for a half minute that it almost hurts. and some forms of urticaria can also be controlled by direct suggestion. Direct suggestion during hypnosis may be used to decrease stress.M. can be substituted for scratching. Remarkable clearing of congenital ichthyosiform erythroderma of Brocq in a 16 year old boy was reported following direct suggestion for clearing under hypnosis (Mason 1952). Nine patients had total regrowth of scalp hair. scratching. posthypnotic suggestions. A 33 year old man with a negative self image and recurrent multiple Staphylococcus aureus containing furuncles since age 17 was unresponsive to multiple treatment modalities. For atopic dermatitis. Although three patients had only slight increase in hair growth and one had no change. and tension. hypnosis can be a very useful complementary therapy that can decrease the needed amount of other treatments. Stewart and Thomas (1995) treated 18 adults with extensive atopic dermatitis who had been resistant to conventional treatment with hypnotherapy that included relaxation. The results were statistically significant (p < 0.01) for reduction in itch. Meditation. Reduction in severity of dyshidrotic dermatitis has been reported with using hypnosis as a complementary treatment (Tobia 1982). The list of responsive skin conditions below is not all-inclusive. In a small clinical trial of medical hypnotherapy with five patients having extensive alopecia areata. Stepanek 1991). One patient was instructed to remember the word "scar" whenever she wanted to pick her face and to refrain from picking by saying "scar" instead. Revenstorf and Wörz 1991). and instruction in self-hypnosis. Pharoah. and . Similar though less spectacular results were confirmed with two sisters aged eight and six (Wink 1961). Patient use of topical corticosteroid decreased by 40% at 4 weeks. to the point where some individuals can use the flaring of their dyshidrotic dermatitis as a barometer of their stress levels. direct suggestion for skin comfort and coolness. Scott et al 1992). and with 34 year old father and his four year old son (Kidd 1966). and may sometimes have an effect on the condition itself. direct suggestion for non-scratching behavior. Hypnosis and self-hypnosis with imagined sensations of warmth. only one patient showed significant increase in hair growth. although randomized controlled trial results are still not available for most skin disorders. Stress is a known common trigger factor for dyshydrotic dermatitis. and Hypnosis for Skin Disorders and Procedures 197 information (Kaschel. Posthypnotic suggestion was successful in reducing or stopping the picking associated with acne excoriée in two reported cases (Hollander 1959).Relaxation. sleep disturbance. 50% at 8 weeks. ego strengthening. tingling. Hypnosis may be an appropriate treatment for the picking habit aspect of acne excoriée in conjunction with standard treatments for the acne itself. with a 20 year old woman (Schneck 1966). and 60% at 16 weeks. hypnosis did improve stress and psychological parameters in these five patients (Harrison PV. Vanderlinden. Stress plays a significant role in the exacerbation of atopic dermatitis. Deconinck et al 2006). A number of case reports describe improvement of atopic dermatitis in both children and adults as a result of hypnotherapy (Twerski and Naar 1974). stress management. and another 3 patients had better than 75 percent regrowth. Based on these case reports. all 21 patients with severe alopecia areata had improvement of anxiety and depression with hypnotherapy. hypnosis may be potentially very useful as a complementary therapy in addition to emollients. I have had similar success in one case (Shenefelt 2004). In a larger clinical trial (Willemsen. There is one case report of successful treatment of erythromelalgia in an 18 year old woman using hypnosis alone followed by self-hypnosis (Chakravarty. Permanent resolution occurred. cold. In a nonrandomized controlled clinical trial. Hypnosis may be appropriate as a complementary supportive treatment for the psychological impact of having alopecia areata. Some cases of neurodermatitis have resolved and stayed resolved with up to 4 years of followup using hypnosis as an alternative therapy (Kline 1953. Tausk and Whitmore (1999) performed a small randomized double-blind controlled trial using hypnosis as adjunctive therapy in psoriasis with significant improvement only in the highly hypnotizable subjects and not in the moderately hypnotizable subjects. Zachariae. especially if there is a significant emotional factor in the triggering of the psoriasis. complementary use of hypnosis may help to end the chronic susceptibility to recurrent infection. Collison 1972. Shenefelt heaviness brought about dramatic improvement over 5 weeks with full resolution of the recurrent furuncles (Jabush 1969). Oster. Hypnosis can be quite useful as a complementary therapy for resistant psoriasis. Sacerdote 1965. Hypnosis may modify and lessen the intensity of pruritus (Scott 1960). Lehman 1978). Tobia 1982). and spring (Schneck 1954). Stress is a definite exacerbating factor in lichen planus. Reduction of pruritus and resolution of lesions of nummular dermatitis has been reported with use of hypnotic suggestion (Scott 1960. Stress is a common trigger or exacerbator of hyperhidrosis. but in unusually resistant cases with significant psychosomatic overlay. Another case of severe psoriasis of 20 years duration resolved fully with a hypnoanalytic technique (Waxman 1973). hypnotic suggestion may be useful as a complementary therapy for reducing the frequency of recurrence. Stress is a common exacerbating factor in psoriasis. Winchell and Watts 1988. The patient also improved substantially from a mental standpoint. In another case of extensive severe psoriasis of 20 years duration marked improvement occurred using sensory imagery to replicate the feelings in the patient's skin that he had experienced during sunbathing (Frankel and Misch 1973). A man with chronic myelogenous leukemia had intractable pruritus that was much improved with hypnotic suggestion (Ament and Milgram 1967). With organic disease. Pain from herpes zoster and post-herpetic neuralgia can be reduced by hypnosis (Scott 1960. Itching typically increases with stress. Tobia 1982). A reduction in the frequency of recurrences of herpes simplex following hypnosis has also been reported (Bertolino 1983). hypnosis may give temporary relief from pain. Conventional antibiotic therapy is the first line of treatment for furuncles. Discomfort relief from herpes simplex is similar to that for postherpetic neuralgia (see below). Hypnosis and suggestion have been demonstrated to have a positive effect on psoriasis (Kantor 1990. The vascular blush component of rosacea has been reported to improve in selected cases . winter.198 Philip D. A 33 year old man with ichthyosis vulgaris which was better in summer and worse in winter began hypnotic suggestion therapy in the summer and was able to maintain the summer improvement throughout the fall. Stress is a major factor in increasing scratching or picking in these patients. Oral pain such as glossodynia may respond well to hypnosis as a primary treatment if there is a significant psychological component (Golan 1997). Pruritus and lesions of lichen planus may be reduced in selected cases using hypnosis (Scott 1960. Hypnosis may be useful as a complementary therapy for postherpetic neuralgia. Tobia 1982). A 75 percent clearing of psoriasis was reported in one case using a hypnotic sensory-imagery technique (Kline 1954). Bjerring et al 1996). Hypnosis or autogenic training may be useful as adjunctive therapy for hyperhidrosis (Hölzle 1994). In cases with an apparent emotional stress trigger factor. Vickers 1961. Hypnosis may be a useful complementary therapy for trichotillomania. MEDICAL HYPNOTHERAPY FOR REDUCING PROCEDURE STRESS AND ANXIETY Hypnosis can reduce stress. Gottlieb and Hackett 1972. Stress was a trigger factor. while none of the control group had improvement (Surman. Williams and Gwynn 1990. Stenstrom and Johnston 1988. as well as reducing postoperative discomfort. Tobia 1982). needle phobia. A recent study that showed negative results was criticized for using a negative suggestion of not feeding the warts rather than a positive suggestion about having the warts resolve (Felt. Hypnosis may be appropriate as a complementary supportive treatment for the psychological impact of having vitiligo. Tasini and Hackett 1977. In 15 patients with chronic urticaria of 7. Surman. anxiety. Barabasz 1987). Logan et al 1999) used selfguided imagery content during nonpharmacologic analgesia on 56 nonselected patients referred for percutaneous interventional procedures in the radiology procedure suite. Ewin 1992. Noll 1988. Noll 1994). Fick et al (Fick. Stankler 1967). Hypnosis has been proved to be helpful as a complementary or alternative therapy for warts. Lang. with decreased medication requirements reported by 80 percent of the subjects (Shertzer and Lookingbill 1987). A . An 11 year old boy had an urticarial reaction to chocolate that could be blocked by hypnotic suggestion so that hives appeared on one side of his face but not the other in response to hypnotic suggestion (Perloff and Spiegelman 1973). Tobia 1982). Two cases of urticaria responded to hypnotic suggestion in one study. and Hackett 1973). Several reports of successful adjunctive treatment of trichotillomania have been published (Galski 1981. Dreaper 1978. Johnson and Barber 1978. Ullman 1959. A well conducted randomized control study resulted in 53 percent of the experimental group having improvement of their warts three months after the first of five hypnotherapy sessions. Morris 1985. Straatmeyer and Rhodes 1983. and Hypnosis for Skin Disorders and Procedures 199 of resistant rosacea where hypnosis has been added as complementary therapy (Scott 1960. Meditation. Stress is an exacerbating factor. Hypnosis may be useful as complementary or even alternative therapy for selected cases of chronic urticaria. One study (Tenzel and Taylor 1969) that tried to replicate the remarkable success reported in Lancet (Sinclair-Gieben and Chalmers 1959) of using hypnotic suggestion to cause warts to disappear from one hand but not the other in persons with bilateral hand warts was unsuccessful. hypnosis with relaxation therapy resulted within 14 months in 6 patients being cleared and another 8 patients improved. Spanos. and pain during cutaneous surgery. Dudek 1967. Sheehan 1978) and failed to be confirmed in a few studies (Clarke 1965. Clawson and Swade 1975.8 years average duration. Reports by Bloch (1927) and Sulzberger (1934) on the efficacy of suggestion in treating verruca vulgaris have since been confirmed numerous times to a greater or lesser degree (Obermayer and Greenson 1949. Spanos. Many reports confirm the efficacy of hypnosis in treating warts (McDowell 1949. but it is unclear whether the recovery was simply spontaneous. Ullman and Dudek 1960. Rowen 1981. Stress can increase blushing. Gottlieb.Relaxation. Vitiligo has improved using hypnotic suggestion as complementary therapy (Scott 1960. Hall and Olness 1998). Ewin 1974. N Y State J Med 1967. but more so with hypnosis. but deep trance is required for hypnotic anesthesia for surgery (Barabasz and Watkins 2005). Barabasz M. Benotsch. New York. and self-hypnotic relaxation. REFERENCES Ament P. and Redd 2000). patients must be mentally intact. New York. heart disease. For most purposes light and medium trance is sufficient. motivated. They concluded that average patients can engage in imagery. but topics chosen are highly individualistic.200 Philip D. and preferably medium or high hypnotizable as rated by the Hypnotic Induction Profile (Spiegel and Spiegel 2004) or Stanford Hypnotic Susceptibility Scale and its variants. . Morrow 1975. L'ipnosi in dermatologia. The hemodynamic stability was significantly higher in the hypnosis group than in the attention and standard groups. Milgram H. making prerecorded tapes or provider directed imagery likely to be less effective than self-directed imagery. Benson H. Minerva Medica 1983. Cost analysis of this study (Lang and Rosen 2002) showed that the cost associated with standard conscious sedation averaged $638 per case while the cost for sedation with adjunct hypnosis was $300 per case. DuHamel. but remained flat in the hypnosis group. structured attention. Lang et al (Lang. with the attention group intermediate. 67:833-835. Drug use was significantly higher in the standard group than in the structured attention and self-hypnosis groups. However. New York. Bertolino R. 831-839. burn injury. Pain reduction mediated by hypnosis localized to the mid anterior cingulate cortex in a study (Faymonville. not resistant. Procedure times were significantly shorter in the hypnosis group than in the standard group. The Relaxation Response. Laureys. Pain increased linearly with time in the standard and the attention group. not psychotic nor intoxicated. Biofeedback and control of skin cell proliferation in psoriasis. Barabasz A and Watkins JG: Hypnotherapeutic Techniques. All 56 patients developed an imaginary scenario. Brunner-Routledge 2005. 2000) conducted a larger randomized trial of adjunctive non-pharmacologic analgesia for invasive radiologic procedures consisting of three groups: percutaneous vascular radiologic intraoperative standard care (control group). Letting the patient choose his or her own self-guided imagery allows most individuals to reach a state of relaxation during procedures. Benoit J and Harrell EH. Fick et al. For hypnosis to be of benefit. for self-guided imagery a moderate or high degree of hypnotizability is not critical to success. Anxiety decreased over time in all three groups. Trichotillomania: a new treatment. I have used this technique with good success in dermatology patients (Shenefelt 2003). Shenefelt standardized protocol and script was used to guide patients into a state of self-hypnotic relaxation. cancer. and chronic back problems (Montgomery. A meta-analysis of hypnotically induced analgesia found that hypnosis has been demonstrated to relieve pain in patients with headache. Int J Clin Exp Hypn 1987. Degueldre et al 2000) using a positron emission tomography (PET). dental problems. 74:2969-2973. 35:146-154. New York. making the latter considerably more cost-effective. 2nd ed. eczema. The imagery they chose was highly individualistic. Effects of suggestion on pruritus with cutaneous lesions in chronic myelogenous leukemia. Psychol Reports 1980. Medical Hypnotherapy. Lutgendorf S. Clarke GHV. New York. Degueldre C. Hypnotherapy for warts (verruca vulgaris): 41 consecutive cases with 33 cures. Chakravarty K. Skin Deep: A Mind/Body Program for Healthy Skin. Berman BD et al. 40:89-96. Lamy M. 45:15-21. Freeman R. Am J Clin Hypn 1974. Ewin D. Chu D H. 2006. Katz S I editors. Illinois. Luxen A. Grossbart TA. 1:643-649. The hypnotic control of blood flow and pain: the cure of warts and the potential for the use of hypnosis in the treatment of cancer. 2003 pp58-88. Misch RC. Orlando.Relaxation. Fitzpatrick's Dermatology in General Medicine sixth edition. 35:1-10. Warner D. 92:12571267. Meditation. 1992. Grune & Stratton. Barabasz M. Loomis C A: The structure and development of skin. Thomas. The charming of warts. and Hypnosis for Skin Disorders and Procedures 201 Bloch B. New York. Int J Clin Exp Hypn 1973. J Invest Dermatol 1965. Santa Fe. Springfield. Clawson TA. Laurys S. Am J Clin Hypn 1975. Duller P and Gentry WD. The adjunctive use of hypnosis in the treatment of trichotillomania: a case report. I M. Am J Clin Hypn 1981. Faymonville ME. Holbrook K. 17:160-169. 220:305310. Recalcitrant warts on the hand cured by hypnosis. The use of hypnosis in the treatment of psychogenic oral pain. Sherman C. Lang EV. Olness K. Suggestion and play therapy in the cure of warts in children: a pilot study. 17:73-78. New Mexico. Am J Clin Hypn 1992. Hypnosis in a case of long-standing psoriasis in a person with character problems. Florida. Erythromelalgia--the role of hypnotherapy. 6:2320-2325. 21:212-130. Klin Wchnschr 1927. Wolff K. Goldsmith L A. Ewin DM. Felt BT. Kohen D. Health Press. 43:137-148. Wart regression in children: comparison of relaxation-imagery to topical treatment and equal time interventions. Br J Dermatol 1980. Hall H. Barabasz A. Use of biofeedback in treating chronic hyperhidrosis: a preliminary report. Condyloma acuminatum: successful treatment of four cases by hypnosis. 145:37-42. 1985. McGraw-Hill. Am J Clin Hypn 1998. Clinical Hypnosis. Galski TJ. Franck G. Dreaper R. Charles C. Pharoah PDP. Acad Radiol 1999. J Nerv Ment Dis 1967. Fick LJ. Am J Clin Hypn 1997. Über die heilung der warzen durch suggestion. 103:143-146. Ewin DM. Haake A R. DelFiore G. Practitioner 1978. 23:198-201. Imagery content during nonpharmacologic analgesia in the procedure suite: where your patients would rather be. Maquet P. Eimer BN. Dudek SZ. 6:2271-2275. Neural mechanisms of antinociceptive effects of hypnosis. Frankel FH. Golan HP. 2nd ed. Benotsch EG. . Eisen AZ. Schmidt W. Am J Clin Hypnosis 2000. Anesthesiol 2000. In Freedberg. Postgrad Med J 1992. Ideomotor Signals for Rapid Hypnoanalysis: a How-To Manual. Swade RH. Logan HL. Austen K F. Hypnosis and distraction differ in their effects on cold pressor pain. Barker S. Med J Austr 1972. 68:44-46. 6:457-463. Hall JA. Scott DGI. 41:130-138. Crasilneck HB. Collison DR. Revised ed. Shenefelt Gupta MA. Grune & Stratton. New York. University of Chicago Press. 43:448-455. Stepanek P. Pain and Illness. New York. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress. Brit J Clin Hypn 1969. Cost analysis of adjunct hypnosis with sedation during outpatient interventional radiologic procedures. Hypnosis in dermatology.202 Philip D. Psychosom Med 1998. Cutis 1979. Gupta AK: Depression and dermatological disorders. Hyperion. Int J Clin Exp Hypn 1953. 64:15-28. . Delimited hypnotherapy: the acceptance of resistance in the treatment of a long standing neurodermatitis with a sensory-imagery technique. pp 233-249. Psoriasis and hypnotherapy: a case report. Jabush M. Excoriated acne controlled by post-hypnotic suggestion. Brief hypnotherapy of neurodermatitis: a case with four-year followup. Stress and psoriasis. 11. Orlando (FL). Kiecolt-Glaser JK. McGuire L. New York. A case of chronic recurring multiple boils treated with hypnotherapy. Rosen MP. Hypnose und haut: trends und perspecktiven. Progressive Relaxation. Therapie der hyperhidrosis. Illinois. 1:2-7. Hautarzt 1994. Kidd CB. Hölzle E. 355:1486-1490. 78:101-105. Psychocutaneous Medicine. Psychocutaneous Disease. Kline MV. 1990. Robles TF et al. Chicago. Marcel Dekker. Logan H. Barber TX. 222:375-382. 60:625632. 24: 219-221. Delacorte. In Koo JYM. Kaschel R. Int J Clin Exp Hypn 1954. Revenstorf D. Johnson RFQ. Section A. Br J Dermatol 1966. Am J Clin Hypn 1978. 35:7-15. Fick LJ. 20:165-174. Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial. Psychoneuroimmunology and psychosomatic medicine: back to the future. Hypnosis. New York. Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA). Lang EV. Lang EV. Harrison PV. Lester W: Stress knows no boundaries. New York. Associated Press poll conducted November 17-26. Koldys KW and Meyer RP. (letter) Br J Dermatol 1991. 46:321-322. Wörz B. 2:318-322. Kantor SD. Lancet April 29. Experim Klin Hypn 1991. 7:65-82. Lee CS editors. Psychiat Quarterly 1969. 1929. 124:509-510. 1:122-123. 1987. There You Are: Mindfulness Meditation in Everyday Life. suggestions. Benotsch EG. pp 1. 1:18-22. Kabat-Zinn J. Spiegel D. Congenital ichthyosiform erythroderma treated by hypnosis. Biofeedback training in the therapy of dyshidrosis. Hartland J. Am J Clin Hypn 1959. Hollander MB. Berbaum ML. 2006. Kline M. Lehman RE. 1994. 2003. Am J Clin Hypn 1978. Cutis 1990. 21:48-51. Jacobson E. Psychosom Med 2002. Kabat-Zinn J. New York. 2000. and warts: an experimental investigation implicating the importance of "believed-in efficacy". Kabat-Zinn J. December 21. Wherever You Go. Hypnotherapy for alopecia areata. Lutgendorf S. Koblenzer CS. 2006 and published in The Tampa Tribune. Radiology 2002. Schneck JM. 3rd ed. Bull Menninger Clin 1949. 7:233-235. Ichthyosis treated with hypnosis. Psychosomatics 1966. Illinois. Springfield. Gritsenko I. J Natl Cancer Inst 2005. Daugherty C. Thomas. 50:131-136. Noll RB. 13:124-126. Am J Clin Hypn 2003. Obermayer ME. Psychosom Med 1949. J Dev Behav Pediatr 1994. Hypnosis-facilitated relaxation during self-guided imagery during dermatologic procedures. Am J Clin Hypn 2003. Treatment by suggestion of verrucae planae of the face. Hypnotherapy of a child with warts. et al. Hypnotherapy for ichthyosis.Relaxation. Thomas. A case of congenital ichthyosiform erythroderma of Brocq treated by hypnosis. Bachner-Melman R. Am J Clin Hypn 1978. Mason AA. A meta-analysis of hypnotically induced analgesia: how effective is hypnosis? Int J Clin Exp Hypn 2000. 9:89-91. 46:239-245. Eastern meditative techniques and hypnosis: a new synthesis. Hypnotherapy in neurodermatitis: a case report. Illinois. Hypnotherapy of warts using the Simonton visualization technique: a case report. 15:170-173. Montgomery GH. Schneck JM. 2:422-423. Hypnotherapy for warts in children and adolescents. pp 122-142. Spiegelman J. Hypnosis in dermatology. Scott MJ. 1960. 1963. Shenefelt PD. 48: 138-153. 20:160-164. Olness KN. Thomas. Illinois. Meditation.Ebstein RP. 45:225-232.23:195-197. Redd WH. Scott MJ. Springfield. 123:913-916. 46:97-108. Exploratory association study between catechol-o-methyltransferase (COMT) high/low enzyme activity polymorphism and hypnotizability. 15:269-272. Springfield. Charles C. Oberyszyn T M. Arch Dermatol 1987. Am J Clin Hypn 1981. Shertzer CL. Hypnotic age regression in the treatment of a self-destructive habit: trichotillomania. Am J Clin Hypn 2004. Am J Clin Hypn 2007. Effects of relaxation therapy and hypnotizability in chronic urticaria. Psychosomatics 1964. Otani A. Am J Med Genetics 2000. Greenson RR. 27:237-240. Psychocutaneous hypnoanalysis: detection and deactivation of emotional and mental root factors in psychosomatic skin disorders. 79(4):95-100. 1959. Dis Nerv Syst 1954. 11:163-164. Shenefelt PD. Am J Clin Hypn 1965. Saul A N. Lookingbill DP. Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée. Hypnotherapy in children. Morris BAP. . 97:1760-1767. Br Med J 1952. 15:211-214. Chronic stress and susceptibility to skin cancer. Shenefelt PD. Hypnosis in Anesthesiology. Influence of psychosocial factors on wart remission. Hypnosis in dermatologic therapy. 5:365-368. and Hypnosis for Skin Disorders and Procedures 203 Lichtenberg P. J Dev Behav Pediatr 1988. Shenefelt PD. Postgraduate Medicine 1986. In Schneck JM (ed): Hypnosis in Modern Medicine. Hypnosis in the treatment of a child's allergy to dogs. McDowell M. Noll RB. Hypnosis in skin and allergic diseases.105. Sheehan DV. Juvenile warts removed with the use of hypnotic suggestion. Marmer MJ. DuHamel KN. Charles C. Am J Clin Hypn 1973. Rowen R. Arch Dermatol 2000. 136: 393-399. 7:249253. Perloff MM. Scott MJ. Sacerdote P. Charles C. 96(6):771-774. Hypnosis in dermatology. Am J Clin Hypn 1985. On the psyche and warts: I. Thomas SE.C. Gwynn MI. Dudek S. & Mindfulness. Effects of psychologic intervention on psoriasis: a preliminary report. Ullman M. Effects of hypnotic. American Psychiatric Publishing. J Am Acad Dermatol 1996. J Am Acad Dermatol 2006. Tenzel JH. 50:245-260. Hypnosis in the treatment of warts in immunodeficient children. Behaviour therapy of psoriasis--a hypnoanalytic and counter-conditioning technique. Watts RA. Psychosom 1969. New York. 2005. Practitioner 1967. Sulzberger MB. 2nd ed. J Am Acad Dermatol 1988. Spanos NP. A critical assessment of the cure of warts by suggestion. Am J Clin Hypn 1972. 28:439-441. Tobia L: L'ipnosi in dermatologia. Williams V. Vickers CFH. Vanderlinden J. Deconinck A. Johnston JC. Med Rec 1934. 140:552-556. Arch Gen Psychiatry 1973. Am J Clin Hypn 1974. Straatmeyer AJ. 21:473-488. Wolf J. Condyloma acuminata: results of treatment using hypnosis. Psychother Psychosom 1999. Oster H. 9:434-436. 73:531-537. Hypnotherapy as a treatment for atopic dermatitis in adults and children. Evaluation of treatment of warts by hypnosis.. Twerski AJ. On the psyche and warts: II. Winchell SA. 495:1-9. A pilot study of hypnosis in the treatment of patients with psoriasis. Waxman D. Am J Clin Hypn 1977. Spiegel D. Silverberg EL. and suggestion in the treatment of warts. placebo. hypnotic suggestion and warts. Relaxation therapies in the treatment of psoriasis and possible pathophysiologic mechanisms. 134:1422-1425. Stankler L. An evaluation of hypnosis and suggestion as treatment for warts. Hypnotic treatment of a child with warts. Congenital ichthyosiform erythroderma treated by hypnosis. Spanos NP. Trance and Treatment: Clinical Uses of Hypnosis. New York. Smith J: Relaxation. pp 51-92. Surman OS.Hypnosis in the treatment of warts. 132:778-783. Surman OS. Taylor RL. Tausk F. Naar R. 2:480-482. Tausk FA. Rhodes NR. Whitmore SE. Minerva Medica 1982. Psychosom Med 1960. 52:109-114. Br J Dermatol 1995. Shenefelt Sinclair-Gieben AHC. Chalmers D. Bjerring P. 18:101-104. Psychosom Med 1988. and salicylic acid treatments on wart regression. Br Med J 1961. Stenstrom RJ. Alternative medicine: is it all in your mind? Arch Dermatol 1998. Gottlieb SK. Willemsen R. 16:202-205. 198:690-694. 19:152-154. 2:743-745. D. Ullman M. Tasini MF. Spiegel H. Br Med J 1961.204 Philip D. Psychosom Med 1959. Postgrad Med J 1973. Hypnosis. 15:12-14. . Hackett TP. Suggestion and warts: a review and comment. 22:68-76. Stewart AC. 2:741-743. Washington. 34:1008-1015. 55:233-237. Zachariae R. Wink CAS. J Am Acad Dermatol 1983. 2004. Treatment of plantar warts in children. Hackett TP. Hypnotherapy in a case of refractory dermatitis. Meditation. Roseeuw D: Hypnotherapeutic management of alopecia areata. The treatment of warts by suggestion. Hackett TP. Lancet 1959. 49:591-595. Psychosom Med 1990. Gottlieb SK. Springer Publishing. placebo. 10:252-257. Kragballe K. Meditation. New York. Lee CS editors. In Koo JYM. pp 65-95. New York. and Hypnosis for Skin Disorders and Procedures 205 Zane LT: Psychoneuroendocrinimmunodermatology: Pathophysiological mechanisms of stress in cutaneous disease. Marcel Dekker.Relaxation. Psychocutaneous Medicine. 2003. . . Yves-Jean Bignon2 and Alain Blanchet3 1 2 Bio-statistics unit. On the other hand. Although the impact of many types of psychosocial intervention have been tested in cancer patients with disappointing results on survival. and has proven to be a great help to terminally ill cancer patients. Inc. pain. we suggest that well-trained hypnotists participate. Koester and P. Research and Applications Editors: G. These trials should explore various dimensions of the patient’s psyche. and appears to be very useful against depression. In most trials. although for prospective trials testing wider endpoints. including physical activity. and biological rhythms. France ABSTRACT Oncology is a domain where hypnosis has a role to play. France Laboratory of Molecular Oncology. Surveys testing hypnosis that include survival as an end-point need still to be performed.In: Hypnosis: Theories. hypnosis has not yet been assessed using appropriate methodology. edited by AnneLaure Léglise. Clermont-Ferrand. Delisle ISBN 978-1-60456© 2009 Nova Science Publishers. Chapter 9 HYPNOSIS AND CANCER: A DEAD-END STORY?* Fabrice Kwiatkowski1. For research purposes. published by Nova Science Publishers. D. treatment side-effects and other symptoms. R. The effect of hypnosis on immunity should also be evaluated since some authors have shown a positive impact on natural killer cell count and activity. It can also prevent distress during invasive medical procedures. promote behaviors known to reduce the risk of relapse. Nancy Uhrhammer2. Sometimes sessions can be performed by nurses and physicians having followed a short course in the technique. hypnosis appears to be superior to standard educational and/or cognitive-behavioral interventions. the impact of hypnosis on patients’ well-being has been well studied. Centre Jean Perrin and University Paris-8 (Saint-Denis). France 3 Department of Psychology. Centre Jean Perrin. since medical treatments are still not sufficient. examine the impact of the alleviating past trauma. It was submitted for appropriate modifications in an effort to encourage wider dissemination of research. . Inc. University Paris-8 (Saint-Denis). preferably practitioners trained in psychology. measures * A version of this book was also published as a chapter in Progress in Circadian Rhythm Research. It can now be proposed to children or adults. diet. including standard prospective randomized trials. nor what happens in the patients’ minds. 2002]. even when the underlying mechanisms are unknown. INTRODUCTION Thanks to Milton Erickson’s considerable work during the 20th century. as illustrated by Erickson in the “February man” [1989]. and its influence on biology can easily be studied. One of the best ways to show the impact of psychosocial intervention is to test it on somatic disease. One of the lessons of this era is that stage practice (public demonstrations) must be separated from clinical practice: an other refers to certain topics that the association with charlatanism has unfortunately rendered off-limits to legitimate investigation. Investigators do not need to know the mechanisms by which the interventions work. and the “hard science” approach using statistics and objective outcomes can now be applied to measure the efficiency of any intervention. with often surprising and reproducible results [Méheust. 2007]. but may evolve each time they are evoked. and may soon understand why hypnosis appears to be so efficient in comparison to other psychosocial interventions1. this does not mean it is considered a standard medical treatment: hypnosis does not “work” in the way that chemical drugs do. Of course. This first step. may eventually be followed by an analysis of what occurs in the black-box. neuroscience is advancing so rapidly that we may be at a turning point in our understanding of brain function. The “patient + hypnotist” couple can be treated as a blackbox by the researcher. however. with statistical analysis of the data and sample numbers appropriate to measure the expected variability of the parameters. Gray. using specific tools. protocols. brings hypnosis into the realm of standard scientific investigation. 2000. hypnosis is currently viewed as an acceptable practice by western medicine [Pirotta. especially in the domain of cancer. methodology in psychosocial sciences has made tremendous progress. Traditional clinical research methods. biology is a convenient context to measure changes. where physicians facing major treatment 1 The contrary is also true: it is very likely that hypnosis will help neurosciences to understand brain functionning. The subjective nature of psychological interventions and objectives. However. and experts. Quinn SO.208 Fabrice Kwiatkowski. Last but not least. the discovery that memories are not recorded once forever. Focusing on measurable symptoms is an appropriate strategy to study the effect of a psychosocial intervention like hypnosis. sheds new light on the “rebuilding” of the past. . Nancy Uhrhammer. Hypnotism today cannot be rejected as mesmerism was in the 19th century when many physicians were involved in this practice. make it difficult to bring this science fully into the realm of “hard” science. 1999. Yves-Jean Bignon et al. Many authors have conducted serious investigations at the frontier of psychology and medicine. This approach. Indeed. Oncology is only just beginning to take advantage of the diverse possibilities of hypnotism. if the results are positive. concerning susceptibility to hypnosis should be collected and new indicators developed in order to facilitate future progress. This makes it possible to compare the impact of different psychological approaches on particular psychopathologies. trials. For example. and to evaluate protocols regardless of content. can be used. There may in fact be no difference between a real psychological change and belief in that change. Most articles found in PsychInfo are also referenced in Medline. hypnosis management. Last column counts the number of articles from Medline where the “publication type” is “trial” but excludes reviews. Special attention should be paid to prospective randomized trials: when they respect the methodological guidelines of evidence-based medicine. In this chapter. A flatter but similar trend appears with the more specialized PsychInfo index (Fig 1. Tsao. 2006. they are considered the most reliable type of proof [Guyatt.1). since biological. except for book chapters that appear only in PsychInfo. . blue columns). Very often the content of these latter [Wild. The other 92 % includes case reports. Rogovick. 2007] either analyze children and adults separately or consider only one population. The medical literature on hypnosis these past decades. followed by a resurgence in the new century (Fig 1. 1995]. This article will focus on these experiments. expert opinions and reviews.Hypnosis and Cancer: A Dead-End Story? 209 difficulties may be more open-minded to look for resources out of their usual domain of competence. violet columns). 2004. Number of articles 80 70 Medline . Ladas.CancerLit PsychInfo 60 Trials (not review) 50 40 30 20 10 -09 05 20 20 00 -04 -99 95 19 -94 90 19 -89 85 19 19 80 -84 0 Time : 5 year periods Figure 1: Evolution since 1980 of the number of articles indexed in Medline/CancerLit and PsychInfo with the keywords “cancer” and “hypnosis”. and notably that concerning cancer (Medline or CancerLit index). 2005. new trials have been published at an average of almost one per year (right columns in Fig. 2005. Since 1980. shows a slowdown of research in this area through the 1980’s and 1990’s. we propose a different approach and to successively analyze: - Research investigating the effect of hypnosis on clinical or biological parameters. 1992. Cook. Rajasekaran. representing 8 % of the literature on the topic “hypnosis and cancer”. clinical and psychosocial factors are evoked. what to measure when hypnosis is used in a trial. and what target the hypnosis sessions should address Beyond biological parameters. . This is the parameter of choice. It is also considered unbiased if two conditions are respected : - no selection is made between causes of death less than 5% of the patients are lost to follow-up. even if they are in remission. This is even truer for those that use hypnosis. 210 - - Research into the impact of hypnosis on the patients’ well-being. Prospective trials on psychosocial interventions are scarce. since the patients are followed all during their disease and long after.Fabrice Kwiatkowski. therefore. Nancy Uhrhammer. 1983]. RESEARCH INVESTIGATING THE IMPACT OF HYPNOSIS ON CANCER ITSELF Results of trials including hypnosis Impact on overall survival As in many prospective trials in cancer. Technical aspects of research on hypnosis with the following main topics : o o o What kind of hypnosis has or should be proposed to patients How biological hypotheses on the etiology of cancer and its evolution may modulate the types of suggestions made during the therapy. first treatment…) and the date of death or last follow-up. overall survival has almost been the sole clinical factor tested in studies of psychosocial interventions in cancer. actuarial) are used to analyse these intervals. For example. 2 Overall survival is the interval between a starting point (date of disease diagnosis. since the latter may not coincide with overall survival and thus cannot be considered a surrogate end-point. the treatment of breast cancer has improved to the point where second or third line treatments offer significant chances of survival even for metastatic patients. Although of poor prognosis. including quality of life. and the statistical analysis separated patients receiving a minimum of ten 1-hour hypnosis sessions within 3 months. its design was inappropriate: it was not a randomized trial. It is likely that the subjects who died shortly after enrolment in the study did not have time to receive the threshold number of ten sessions. recurrence is no longer synonymous with death from cancer. from patients who received less that ten but at least three sessions. Unfortunately. the main clinical end-point is overall survival2. Statistical methods (Kaplan-Meier. overall survival is preferred to disease-free survival. In phase III trials. and any lost patients are equally distributed in the different arms of the trial. anxiety and depression. pain management and the prevention of treatment side effects. The first reference of a trial using hypnosis as a complementary treatment for cancer concerned overall survival [Newton. Yves-Jean Bignon et al. In spite of these flaws. Even so. but were not led to believe that participation would affect the course of their lives. and use the same psychosocial protocol established by Spiegel. it has become obvious that the early enthousiasm could not be sustained by the results. and patients were encouraged to discuss strategies for coping with cancer. and only as a supplementary method to help patients handle pain or anxiety. .92 n = 227 0. and differs from RR in the way it is calculated: if the occurrence of the sign or the disease is less than 20 %. and the slightly significant results in favor of hypnosis have to be questioned. just four prospective trials can be selected from the literature (Fig. The impact of hypnosis alone on the survival of cancer patients is thus a question that has not been yet tested with appropriate methodology. and several prospective trials using hypnosis in cancer patients follow the same model. 2000]. 1989]. favorable Spiegel (1989) Goodwin (2001) Kissane (2007) Spiegel (2007) unfavorable 0. Spiegel [1989. Aside from Newton’s trial.93 n = 122 0. but instead taught patients how to practice selfhypnosis. 2005]. 2). these figures are comparable. (which one is the imagery study?) At the end of the 20th century.96 Total n = 670 0 1 Cox hazard ratios 2 3 Figure 2: Impact on survival of self-hypnosis as a auxiliary treatment (hazard ratios are represented by the circles. only one study testing hypnosis as the main psychological intervention in cancer patients (Hodgkin’s and non Hodgkin’s lymphoma) has been published [Walker. In the intervention group.Hypnosis and Cancer: A Dead-End Story? 211 and this selection may account for the difference in survival. This came to be known as “supportiveexpressive group therapy” [Goodwin. for this chapter we will consider the results of these trials as representative of hypnosis impact. 2000] initiated this kind of protocol.76 n = 86 1.06 n = 235 0. self-hypnosis was taught for pain control. All four studies concern metastatic breast cancer patients. Although these studies did not use standard hypnosis. it integrates the survival delay and is calculated using Cox's regression model. this trial launched a long series of prospective research on psychosocial interventions. 95% confidence intervals are drawn with horizontal lines). To date. Spiegel’s well-known article in the Lancet involved a moderate number of patients (n = 86). hypnosis has mostly been used in association with other educational and/or supportive interventions (mainly group therapy). but was the first description of a significant impact of a psychosocial intervention on the survival of women with metastatic breast cancer: mean survival time after randomization was more than 17 months longer in the intervention group versus the control group [Spiegel. More recent publications confirm the failure of psychosocial 3 Relative-risk (RR) is the ratio of the frequency of a particular sign or disease in a group over the same frequency in a reference group. Hazardratio (HR) is similar to RR except it applies to survival. Odds-ratio (OR) applies to case-control studies. This second trial was also not randomized. although a weak association in the relaxation arm was found between the rating of imagery vividness and clinical tumor regression. Kissane. 1980]. Moreover. Impact on immunity Although many authors underline the importance of immune functions in the evolution of cancer [Kiecolt-Glaser. Recently. But two remarks should be noted : - hypnosis was not the main psychological lever in the supportive-expressive group therapy. 0.55 [0.97 [0. An audiotape was supplied with instructions for relaxation and patients were given a portfolio cartoons to help them visualize their host defenses destroying the cancer cells. 2007a]. 1. data on treatment response is usually obtained routinely. Temoshok. 2002.73. a prospective trial in England tested a technique similar to hypnosis to enhance the response to neoadjuvant chemotherapy in breast cancer [Walker. focusing on the response to treatment. 1998]. going along with Smedslung suggestions. 1999. but a minor one and it consisted in self-hypnosis. very few trials include end-points concerning immunity. 48 in each arm. but not hypnosis. Ninety six patients were accrued. Before the first cycle of chemotherapy. and also because it is obtained more quickly than overall survival data.70] while the global estimate of the impact of the complementary subset (i. The main interest of this study is the originality of the protocol. 2007]. Impact on the response to chemotherapy Most of the time. 2007. patients were taught “progressive muscular relaxation and cue-controlled relaxation” [Hutchings. This means that individual management seemed to reduce the risk of death by half. The conclusion of this brief review of trials “using hypnosis” does not differ from Smedslund’s meta-analysis of psychosocial interventions [Smedslund. Nancy Uhrhammer. The hazard ratio associated with a subset of three trials testing individual interventions was 0. The psychological intervention consisted of relaxation training and guided imagery. 2004] where the authors found no significant advantage of these interventions on overall survival of cancer patients. This idea is attractive. An interesting finding of Smedslund’s meta-analysis is that individual treatments seemed to have a stronger impact on survival than group treatments. Many types of psychosocial interventions have been investigated. since for most types of cancer.43.e.Fabrice Kwiatkowski. it is likely that individual sessions of hypnosis will do much better than group training. and a larger trial may show a positive response. Patients kept a diary in order to evaluate their daily practice duration.27]. After completion of chemotherapy. nine group treatments) was 0. Thus a first global conclusion: hypnosis as the main psychological treatment has never been tested against survival in cancer patients with appropriate prospective methodology. the response to treatment is correlated to overall survival. Yves-Jean Bignon et al. Kwiatkowski. 212 intervention including self-hypnosis to significantly improve survival [Spiegel. no significant difference in pathological or clinical responses was found. There may be at least two reasons for this dearth of information: . A lack of statistical power may have been responsible for the non significance of the main outcomes. anger (p = 0.03) but this response was not sustained at the 3-month follow-up. NK cell count and cytotoxicity were measured at base line. and a significant gain in survival was naturally targeted. Testing immunity in a trial on hypnosis therefore needs to include the measure of a large set of biological parameters (Kwiatkowski. cytokines (IL-2. and as a consequence may make the trial unfeasible because of the associated costs.017). while 28 patients were included (14 per arm) and relaxation with guided imagery was employed as the psychological intervention. Hypnotic guided imagery followed the methods of Simonton [1980]. Standard methodology requires a control arm and the randomized allocation of patients to ensure that no selection and/or confusion bias will interfere with the outcome. their cytotoxic potential. The first study of immunological parameters in a trial tested an “early structured psychiatric intervention” (including relaxation training but not hypnosis) in patients with malignant melanoma. the risk of finding a parameter significant when only chance is at work). 1995].e. 1938]. since it is impossible to guarantee that the parameters followed through time change due to the psychological intervention or to some other uncontrolled cause.. NK counts rose significantly after 8 weeks (p = 0. but with a control arm. cortisol. the study is interesting. immunity is a very large and intricate set of biological processes that interfere with the whole metabolism. The disadvantage of increasing the number of factors studied is the risk of falsepositive conclusions (i. This intervention had a positive and significant effect on the NK lymphoid cell system and found that affective changes but not coping measures showed some significant correlation with immune cell changes [Fawzy. 2000] ? Immunity is a chain of biological processes.013). 1990]. such as E2-microglobulin [Sabbioni. breast cancer at stages 0 to 2 was targeted. tension (p = 0. For 25 stage I-II breast cancer patients. but it dramatically increases the population size necessary to reach sufficient statistical power. and as a chain. IL-6. or other nonspecific markers of activation of cellular immunity. [2008] recently performed a second pilot study using the same pretestposttest kind of design.015) and depression (p = 0. at 8 weeks and at 3 months. hormones (melatonin. The immunological parameter measured was IL-2-activated NK cell activity in blood samples obtained prior to surgery and . Second. Each patient received 8 individual weekly imagery training sessions and were encouraged to practice 3 times a week. Nevertheless. The Bonferroni correction for multiple testing can be used to counter this effect [Bland. 2007b). leptin) that inhibit or activate NK activity. Lengacher et al. The first trial using hypnosis-like approaches used a longitudinal design where patients were their own controls [Bakke et al. They also received relaxation training based on the Jacobson method [Jacobson.Hypnosis and Cancer: A Dead-End Story? - - 213 the main reason is that initial expectations were too high (especially after Spiegel’s positive results).004). 2002]. it has the strength of its weakest link. No change in NK cytotoxicity was observed. The NK lymphocyte fraction increased with improvements in mood on different subscales of the POMS questionnaire: confusion (p = 0. IL-15). As in Bakke et al. It appears difficult to choose the relevant parameters for cancer: number of natural killer (NK)-cells. This kind of design causes problems. Moreover. Impact on circadian biological functions If instantaneous values of biological parameters are relevant as secondary objectives in prospective cancer trials testing hypnosis or other psychosocial interventions. The authors of the present article are undertaking one such trial [Kwiatkowski. Indeed. melatonin and cortisol. significant objective effects of “hypnosis” on NK cells were observed concerning one of the key immune parameters in cancer. SPO² is relatively easy to measure. This is not proof of any effect on disease progression or overall survival.01 and 0. b]. mood. etc. An other hormon. Up to now. For example. In QOL questionnaires. The main clock hormones.05 characterized differences in NK-cell cytotoxicity between the trial arms. temperature and rest/activity cycles. their circadian rhythms (principally the amplitude of rhythms) give a better point of view on metabolism homeostasy: this includes major hormones (melatonin. anxiety. For more detail. each of these characteristics are probed by a few specific questions that combine to give a global estimate of . and a portion of the resistance to chemotherapy [Brahimi-Horn. Nancy Uhrhammer. Finally. can easily be sampled in saliva at different times of the day. the need for more precise scales can occur. etc. four weeks post-surgery. the circadian rhythm of SPO² could be also studied with a portable device recording continuously over a couple of days. the spread of malignant cells. surveys using small sample numbers still have adequate statistical power. cortisol) that rule main immune functions. depression. 2000]. 4 Correlations between QOL and dimensions like depression are easy to understand : depression damages self esteem and social relationships. making them suitable candidates for kinetic studies. including “quality of life” (QOL). because of its crossactivity between adipocytes and immune cells. 2007]. Cellular responses to hypoxia may explain neoangiogenesis. 2007a. blood oxygen saturation (SPO²) could be of interest since it was shown that tumors could be very dependent on the quantity of oxygen available to them from the circulation. especially when testing psychosocial interventions. leptin. with intermediate results expected in 2010. Although both used small sample sizes. Because longitudinal studies of biological parameters are quantitative and most inter-individual variability does not interfere thanks to paired statistical tests. fatigue. in particular for those concerned by psychoneuroimmunology. has recently gain importance in this type of studies. it is often associated with poor sleep. Significant p-values between 0. these trials show the feasibility of small studies of psychosocial intervention and sound immunological end-points. IMPACT OF HYPNOSIS ON PATIENTS’ “WELL-BEING” Patients’ well-being is an imprecise notion which covers a wide range of aspects. circadian rhythms appeared to be a significant prognostic factor for overall survival in metastatic colorectal cancer patients [Mormont. Yves-Jean Bignon et al. These two reports are coherent. using a non invasive infrared electronic device at the surface of the skin. Although QOL is well-correlated to other psychological dimensions4. but suggests a direction of research. no published research has tested the effect of hypnosis on circadian fluctuation in biological functions.214 Fabrice Kwiatkowski. Hypnosis and Cancer: A Dead-End Story? 215 such intervention may be of more benefit for distressed patients [Sheard, 1999; Goodwin, 2005], since most trials have shown a significant rise in mood scores in distressed cancer patients, and also since the level of depression has been found to correlate with worse treatment responses [Walker, 1999]. QOL questionnaires are not always sufficient to study this, because they are intended to illustrate a global perception of life, and thus merge together different effect sources and sacrifice accuracy on individual points. Specialized evaluation tools act as a magnifying glass: they focus on one dimension and thus reduce statistical variability. But they only focus on one topic. Quality of life QOL is now very standardized, and internationally validated questionnaires, including SF36 [Wade, 1992] and EORTC QLQ-C30 [Aaronson, 1993], facilitate correct investigation of this domain. Since some dimensions of these questionnaires are often correlated to more targeted scales (anxiety, depression, mood, coping, pain...), many clinical studies use only a QOL questionnaire. The purpose of this choice is twofold: first, investigators want to limit the number of questionnaires that patients have to answer. This is justified, since filling out dozens of pages often represents a burden to patients already very tired and distressed because of their cancer and treatments. Second, most clinical trials give priority to biological endpoints directly related to the medical treatment. Usually in such cases, the endpoints are survival, response to treatment, and/or toxicity. Although attitudes are changing, considerations of other aspects of patients’ lives are frequently considered secondary, and psychosocial investigations are reduced to a single QOL enquiry. QOL questionnaires are not all alike. Most of the validated ones concern patients that are in rather good shape and can still do (or hope to do) the things healthy persons can do. To assess QOL in elderly or terminally ill patients, more specific questionnaires are required [Mystakidou, 2005]. For example, feelings concerning approaching death or other spiritualexistential questions are not evaluated by standard QOL questionnaires. More recent tools have been developed, such as the MVQOLI [Biock, 1998] or the Qual-E [Steinhauser, 2002, 2004], that may offer better evaluation of the impact of hypnosis for terminal phase cancer or palliative treatments. Unfortunately, these are only validated in certain languages, and their validation in non anglo-saxon cultures may be negative since some questions may be too direct to be acceptable in different cultures. Other aspects of emotional adjustment, measured by mood, positive/negative affect and/or coping scales, are usually correlated to global quality of life, and to depression and anxiety levels. Specific questionnaires may be necessary if the goal of hypnosis is to enhance a particular aspect of adjustment. Else, the use of such questionnaires in trials seems redundant to a QOL questionnaire. Liossi and White [2001] tested the efficacy of four weekly sessions of hypnosis compared to a cognitive-existential management among 50 terminally ill cancer patients in palliative treatment in Greece. Patients in the hypnosis group had significantly higher overall something called quality of life. QOL appears as a result of different influences: a same decrease of QOL index can come from depression itself but also from a severe wound or a life threatening sickness. QOL does not help much to discriminate between possible causes. 216 Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon et al. QOL scores, with lower depression and anxiety scores. Although, as the authors noted, the Rotterdam Symptom Checklist [de Haes, 1990] questionnaire employed was not optimal5, the conclusions are likely valid. If we retain a strict definition of QOL, very few trials of psychosocial interventions have effectively tested QOL among cancer patients. Several studies have measured specific psychological dimensions (emotional functioning, pain, anxiety, depression, etc) but did not take global QOL into account. As Ross et al. [2002] reviewed, only 8 of 38 randomized trials (21%) included a QOL survey. Uitterhoeve et al. [2004] selected 13 trials focusing on QOL, of which 3 (23%) evaluated QOL with validated instruments while the others estimated QOL on scales concerning limited domains of QOL, such as the POMS mood scale, or the HADS anxiety-depression scale. Their findings coincide with Liossi’s, although very few of the selected trials used self-hypnosis (Spiegel et al., Goodwin et al. listed in Fig.2). To conclude, although QOL has not been often tested in the context of hypnosis and cancer, it seems to be improved significantly. Hypnosis appears to be a valuable approach with terminally ill patients, where options beyond pain management are often limited. Managing Anxiety and Depression with Hypnosis Depression may be both a cause and consequence of cancer. It has been suggested that chronic depression could favor the development of cancer. Dalton’s review [2002] showed a moderate relationship between depression and cancer. The global odds-ratio was around 1.2, with a trend toward greater risk when depression was major or chronic: for instance, in Penninx [1998], the odds-ratio was close to 1.9 in a survey of the elderly. On the other hand, cancer may favor depression. In a study of 250 patients with various disease locations, 50% of them presented adjustment disorders, and among these, 20% had major depressive episodes [Derogatis, 1983]. Similar statistics were reported among breast cancer patients Morasso et al [2001], and a prospective study, found an increase of 25 to 33% of affective and anxiety disorders when compared to the general population [Harter, 2001]. According to Ronson [2005], “the vast majority of patients receiving a diagnosis of adjustment disorder actually suffer from either sub-threshold depression or from full or partial presentation of post-traumatic stress disorder... The very fact that an average of 10% of cancer patients have been shown to meet criteria for PTSD might suggest the existence of a specific trauma stress adaptation process in this particular patient population”. Since depression has been found to be correlated to immune response for some cancer types [Lutgendorf, 2008; Steel J, 2007], and to prognosis [Watson, 1999; Hjerl, 2003], it might be important to manage depression in cancer patients. Depression frequently has been suggested to reduce survival because it encourages poor treatment compliance, resulting in disease progression, and also because of it favors a higher rate of suicide [Reich, 2007]. The association between depression, NK count/activity and prognosis suggests that depression could also shorten survival because of weaker immune defenses [Steel, 2007]. Spiegel and 5 This self-report questionnaire comprises four dimensions : physical symptom distress (23 items), psychological distress (7 items: irritability, worrying, depressed mood, nervousness, hopelessness, tension and anxiety), activity impairments (personal and social) and a global verbally labelled 7-point Likert scale about their quality of life ranging from “excellent” to “extremely poor”. Hypnosis and Cancer: A Dead-End Story? 217 Giese-Davis [2003] conclude in a similar manner: “there is growing evidence of a relationship between depression and cancer incidence and progression. Depression complicates not only coping with cancer and adherence to medical treatment but also affects aspects of endocrine and immune function that plausibly affect resistance to tumor progression... Further exploration of possible effects of depression and its treatment on endocrine and immune function on cancer progression itself represents an exciting research and clinical opportunity.” In Ross’s review of 38 surveys on psychosocial interventions among cancer patients [Ross, 2002], 24 trials included evaluation of anxiety and 21 evaluation of depression. Among these, 46% showed a favorable impact of psychosocial interventions on anxiety and 52% on depression. Of the 4 trials including self-hypnosis cited in Figure 2, all reported a positive impact of the interventions on anxiety and/or depression. These findings are consistent with the hypothesis that psychosocial interventions may be more helpful to distressed patients than to others. In contrast, a recent study investigating whether highly distressed patients were more likely to benefit from supportive-expressive group therapy did not conclude positively: patients with different distress levels seemed to benefit similarly from psychological support [Classen et al. 2008]. What about hypnosis and depression? The previous paragraphs suggest that self-hypnosis may have more impact on anxiety and depression than other psychosocial interventions, although this has never been rigorously investigated (i.e. in a randomized prospective trial). The only clinical hypnosis trial in the literature is that of Liossi and White [2001] cited previously. For terminally ill cancer patients, personal hypnosis sessions resulted in significant decreases (p < 0.01) in both depression and anxiety, in comparison to the cognitive-existential control group. Cancer survivors may also be concerned by depression. One trial of 61 women with a history of breast cancer but no detectable disease randomized the women between a hypnosis arm (5 weekly sessions plus self-hypnosis training) and a no intervention arm. Measures were taken at inclusion and after five weeks. Although 15% of the subjects were lost to follow-up or withdrew, significantly decreased depression and anxiety scores were observed in the hypnosis arm [Elkins et al., 2008]. The effect of clinical hypnosis on depressed patients without cancer, however, has been more thoroughly studied. “Cognitive hypnotherapy” was compared to standard cognitivebehavioral therapy, with changes over time measured using Beck’s depression inventory, anxiety inventory and hopelessness scale. The three scores decreased by 5%, 6% and 8%, respectively, and were maintained after 6 and 12-months [Alladin, 2007]. These figures did not reach significance, but they show that hypnosis may represent an alternative to conventional psychotherapy against depression. A study investigating the effect against long-term depressed mood of two strategies: meditation with yoga, versus group therapy with hypnosis (group hypnosis and self-hypnosis training), plus a control group found that 77% and 62% of the meditation and hypnosis groups, respectively, had no depressive symptoms at the end of the follow-up, versus 36% for the control group [Butler et al. 2008]. These results are comparable to the 73% remission rate reported for a combination of antidepressants and psychotherapy [Kocsis, 2000], suggesting that hypnosis could be an approach of choice to manage depression and anxiety for the half of Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon et al. 218 cancer patients who suffer from depression. As stated previously, protocols including personal hypnosis sessions should also be tested, with perhaps even better outcomes. Hypnosis and Pain One of the first reports concerning the use of hypnosis against pain in cancer patients described three cases where the treatment was effective [Milton H Erickson, 1959]. Since its invention, hypnosis has been used to ameliorate pain because this approach was one of the few available. But pain is not a simple symptom. As Kupers et al. [2005] report, “there is compelling evidence that there is a poor relationship between the incoming sensory input and the resulting pain sensation”. Cognitive processes may significantly influence this sensation. This “physical symptom” often requires more than a single pharmacologic medication to resolve, although considerable progress have recently been made in that domain. According to one review of pain and cancer [Zaza, 2002], very often pain has a psychosocial dimension that reflects both social loneliness and psychological distress. Cultural environment also plays a role in the representation of pain and its acceptance, especially today in western countries where it is often easier to be heard by the medical staff if the complaint concerns aches rather than distress. Analgesic drugs have proven to be efficient against most acute pain, especially that related to surgery, but two main domains are left for which complementary means can be required : - short term pain during invasive medical procedures for both children or adults to reduce pain and anxiety. chronic pain during palliative treatments where pain does not respond to pharmacologic medications without high risk side-effects (for example respiratory complications from morphine derivatives). Hypnosis to manage pain during invasive medical procedures Children are less able than adults to rationalize about a given medical procedure, or to correctly anticipate the time it will take and the amount of discomfort that it will generate. When children have had a preliminary experience of pain for a type of procedure, their distress can exaggerate negative memories, which in turn increases distress and fear for the procedure [Butler, 2005]. Children also respond better to hypnotherapy: unlike adults, they are less burdened with cognitive stereotypes, and their boundaries between imagination and reality appear less substantial. Their limit consists rather in their ability to understand what hypnotherapist says, making hypnotherapy inappropriate for children under three years. Children often fidget under trance, while adults stay motionless [Rogovik, 2007]. In their review of the few pediatric controlled trials performed using adequate methodology, Wild and Espie found the results inconsistent, but there were no conclusions of an adverse effect of hypnosis [2004]. In two tests of hypnosis in children and adolescents with cancer undergoing either bone marrow aspiration or lumbar puncture, hypnosis was significantly superior to behavioral techniques to reduce anxiety and pain during the procedure [Zelter, 1982; Katz et al., 1987]. A third study supported these results, with a significant reduction of pain and anxiety in response to either direct or indirect suggestions, Hypnosis and Cancer: A Dead-End Story? 219 and observing that the level of hypnotizability was correlated to the magnitude of the outcome [Hawkins, 1998]. In a protocol in which children and their parents were trained to use both distraction and hypnosis, some patients were highly hypnotizable while others not. Easily hypnotized children showed a significant decrease in pain, anxiety and distress scores with hypnosis; for those not easily hypnotized, distraction significantly reduced observer-rated distress scores [Smith, 1996]. Additional techniques have been studied, with cognitivebehavioral coping skills training (CBCST) giving results nearly as positive as those of hypnosis for 30 pediatric cancer patients undergoing bone marrow aspiration [Liossi, 1999], and attention control doing as well as hypnosis for pain, anxiety and distress in 80 patients undergoing lumbar puncture, although the effect diminished when the patients were switched to self-hypnosis. Lastly, in a trial of pediatric non-cancer patients undergoing voiding cysto-urethrography (VCUG), 44 children who had already had difficulty with at least one VCUG were randomized to routine care or hypnosis. A one hour training session in imaginative selfhypnosis was given to parents and children, which they were asked to practice several times the day before the VCUG. The levels of distress, anxiety and pain were significantly lowered in the hypnosis arm, as was the total procedural time and thus overall costs [Butler et al., 2005]. In adults, relatively few controlled clinical trials have tested the efficacy of hypnosis to reduce pain [Liossi, 2006], perhaps because adults seem more able to face temporary pain related to medical procedures. Nevertheless, fear and discomfort may result in poor cooperation during procedures, leading to usually unnecessary amounts of analgesic and sedatives [Deng, 2005]. A small sample size randomized trial (n = 20) was performed in 2002 by Montgomery et al. on women undergoing breast biopsy. Hypnosis was reported to reduce pain and distress while the effect seemed to be mediated by the pre-surgery expectations of patients [Montgomery, 2002]. The consensus that comes from studies is that hypnosis is a convenient method to reduce pain, anxiety and distress generated by invasive medical procedures, especially when patients and in particular children undergo such procedures several times. The mechanism may be partly indirect, by changing expectations and by permitting the patients (and their parents) not to focus on previous negative experiences. The susceptibility of patients to hypnosis may be a limiting factor, which confirms the standard recommendation to test hypnotizability before including patients in protocols. Not surprisingly, self-hypnosis appears to be less efficient than hypnosis sessions with a therapist. For pediatric trials, measures aimed at reducing the parents’ anxiety are probably also relevant, as the anxiety of children and parents may be correlated. The large variation of hypnotic procedures used has been criticized [Wild and Espie, 2004], but this variety is unavoidable as long as there is no consensus as to the best procedure, if indeed there is one. Meanwhile, the use of treatment manuals to standardize procedures in a trial is recommended, and meets the criteria of the American Psychological Association’s division 12 Task Force for an intervention to qualify as empirically supported therapy. Finally, it is worth noting that although most of these trials involved small samples, usually a stumbling block in clinical research, they achieved their goals and reached significance. This means that the effects were large enough to be reliably measured with a few dozen people, which is not the case for all endpoints. 220 Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon et al. Hypnosis for chronic or persistent pain Most cancer pain is caused by tumor invasion or its pressure on nerves. Medical, radiological or surgical treatments of the underlying lesions are necessary to prevent further damage, and this often controls pain. For various reasons in such cases, complementary therapies are not indicated, and acute pain generally requires analgesics. Long-term use of analgesics, however has many side-effects, whose negative impact increases over time [Deng, 2005]. Patients who develop tolerance to opiates require higher doses and frequent drug rotation. Respiratory side-effects may become a limiting factor. Chronic constipation may lead to laxative abuse and further difficulties with bowel management. Gastrointestinal bleeding may result from the chronic use of non-steroidal anti-inflammatory drugs. Depression is associated with chronic pain and use of opiates. Hypnosis and complementary medicine (such as acupuncture, massage, or herbal therapy) may be good alternatives to increasing drug doses. Hypnosis may also be useful to manage pain generated by long term treatments, especially in cancer patients where treatments are particularly aggressive and last for months. Self-hypnosis training plus group therapy significantly reduced pain in patients with metastatic breast cancer, even more so than group therapy alone [Spiegel, 1983]. Since this initial study, others have confirmed that hypnosis, either alone or in combination with other techniques, can reduce pain. For example, hypnosis was more effective than cognitivebehavioral coping skills training, or attention control in alleviating persistent pain following bone marrow transplantation (BMT) [Syrjala, 1992]. A continuing study of BMT patients confirmed this result while adapting the content (i.e. relaxation training, imagery and/or suggestions) of the individual hypnosis sessions to the patients’ health and desire, although the hypothesis that cognitive-behavioral skills training would boost the effect of hypnosis was not confirmed [Syrjala, 1995]. Both these latter trials observed a non-significant decrease in opiate use. Hypnosis may also alleviate chronic pain in children. One study showed improvement in 80% of children with various pulmonary symptoms (asthma, chest pain/pressure, habit cough, hyperventilation...) including some who had remained symptomatic despite extensive medical treatments. This study did not include a no-treatment arm. Various subjects were worked with the patients who could identify personal objectives they wanted to address, such as school or athletic performance, and specific symptoms to alleviate, including non-pulmonary symptoms such as abdominal pain, headaches and insomnia. Neuropathic pain responds less to analgesics than nociceptive pain, and many patients continue to suffer in spite of medication. Because of the weakness of medical means against neuropathic pain, 60% to 80% of cancer patients in chronic pain seek alternative therapies on their own, with the risk of being taken into scam operations and harmful practices [Deng, 2005]. The efficacy of hypnosis against more temporary pain has been demonstrated, and suggests it may also be effective against chronic neuropathic pain. Clinical trials addressing this issue, however, are lacking. There are several negative consequences of chronic pain. First, it often provokes depression in patients, as well as in their caregivers. Second, there is some evidence that pain inhibits the immune system, which leaves patients more vulnerable to infection and possibly to the cancer itself. Third, the lack of success in pain management may damage the confidence that patients have in their medical treatments, thus lowering their compliance with treatment and in turn reducing its efficacy. We anticipate that in the near future, evidence- or delaying schedules) and compromise the patient’s therapeutic alliance with his physician. the goal of the great majority of clinical investigations is to define the optimal balance between antitumor efficacy and toxicity. neuropathy. and psychological problems more or less related to these symptoms. drugs have to be toxic. Among the four trials. In spite of Richardson’s conclusion. in particular with advanced cancer. Anticipatory symptoms cannot neither be treated by such medications. hot flushes. All trials presented methodological weaknesses. for example. pain is one of the major side-effects of cancer treatments. which made a meta-analysis pertinent. but the effect size was not associated to any probability. nausea and vomiting. A reduction of the amount of anti-emetic medication was also reported in Jacknow but this last outcome was questionnable since delivery conditions of anti-emetic drugs were not at patient’s request in both arms. Three of them concerned pediatric cancer patients. such as monoclonal antibodies. and depression than patients supported by a therapist or the control group [Lyles et al. Hawkins. Hypnosis and Treatment Side-Effects As stated previously. surgery invasive. 1995]. 1994. except in Syrjala. Richardson et al. The use of hypnosis against nausea and vomiting is quite old. three tested the impact of self-hypnosis and Zelter’s one tailored hypnosis. 1982]. where drastic measures need to be taken. The major remaining side effects are pain (see previous section). a result that carried over into the follow-up period. Patient management including hematological follow-up helps avoid major sepsis. In fact. to be efficient. In a study of chemotherapy-related effects. and radiotherapy cannot avoid irradiating normal tissues.. Considerable progress has been done to prevent side-effects. The development of targeted treatments. A universally effective anti-emetic regime is still elusive and the extent of this side-effect varies according to the cytotoxic agent used against cancer. patients practicing relaxation and guided imagery experienced significantly less anxiety. Jacknow. 1991. conducted a meta-analysis on this subject in 2007. chimiotherapy-induced nausea and vomiting still represent a significant problem for cancer patients [Koeller. 1992. Outcomes varied since trials addressed sometimes anticipatory symptoms and some others chemotherapy-induced ones. stereotactically guided radiotherapy and perhaps immunotherapy. fatigue. mainly reduced sample sizes. is beginning to change this situation. Nausea and vomiting Although anti-emetic medications are widely used. Syrjala. nausea.Hypnosis and Cancer: A Dead-End Story? 221 based guidelines on the use of hypnotism for pain management will be available to both patients and clinicians. concluded that hypnotherapy lessened nausea and vomiting. Typically. since they interfere with treatment (by requiring dose reductions. potent anti-emetic medications (5-HT3 receptor antagonists in association with dexamethason) enable patients to better cope with chemotherapy and radiation. Long-term follow-up after hypnosis treatment as well as the effect of hypnosis used over longer intervals should also be addressed in clinical trials [Elkins. we agree with Genuis when he stated in 1995 that the consensus is that hypnosis to manage . 2002]. Richardson et al. They could only find four trials satisfying their selection criterias [Zelter. These symptoms are not without consequence. 2007]. embarrassment. and in trials. fatigue was evaluated weekly on a subscale of the FACIT questionnaire (Functional Assessment of Chronic Illness Therapy) and daily on a visual analogue scale.). Hot flushes concern patients and survivors of various types of cancer. whereas fatigue increased linearly in the control group [Montgomery et al. Hypnosis may be of some assistance when medical treatments fail. Hot flushes were the main end-point of a study previously cited for its findings on depression: a 68% reduction in the frequency and intensity of hot flushes was observed in the hypnosis group [Elkins et al. Hypnosis thus seems to be useful at different moments of cancer management: before. case studies exhibit a much wider range of difficulties that hypnosis may help with.) and psychological troubles (irritation. Yves-Jean Bignon et al. 2001]. nausea and vomiting in cancer patients shows encouraging results but yet not compelling evidence [Genuis. Although trials often target specific endpoints. the competences of theses persons can influence outcomes and issues addressed during sessions. spontaneous and playful and to build a stronger therapeutic relationship with a patient while providing symptom relief” [Liossi.222 Fabrice Kwiatkowski. as shown by the significant improvement of mood scores and sleep quality.. For clinician... the relation between hypnotist and patient. Fatigue The effect of hypnosis on fatigue has not been well studied. The persons who learn hypnosis for management of pain or nausea and vomiting may apply their skills to lessen the distress of insomnia and anxiety. an often underestimated symptom that affects up to 78% of female chemotherapy recipients and 72% of hormonotherapy recipients. to address dysphagia for pills or to enhance their performance in their favourite sport. sometimes shortly trained. But hypnosis includes a large range of practices. These can later appear of importance if significant results are obtained .. [Carpenter. different measures can be taken that qualify the trance. showing that fatigue remained unchanged in the CBT+H arm. Results are encouraging. We agree with Liossi’s conclusion: “hypnosis can be generalized to many circumstances. during and after treatments. 2009]. sense of loss of control. Nancy Uhrhammer. 2008]. and are associated with many physical symptoms (headaches. Hot flushes Hypnosis has begun to be used to treat hot flushes in breast cancer patients. making their control of general interest [Elkins et al.. it can be used by varied professionnals. In one pilot study of cognitive-behavioral therapy plus hypnosis (CBT+H). insomnia. TECHNICAL ASPECTS OF STUDIES USING HYPNOSIS ON CANCER PATIENTS We have reviewed most researches investing the impact of hypnosis on either biological or psychological end-points.. 2004]. Finally. This is to say: always. 1995]. This reduction had an overall impact on.. 2006]. hypnosis is an opportunity to be inventive. paresthesia. or was synchronous with patients’ well-being. Trend analysis was statistically significant despite the small sample size. Besides. palpitations. a good relaxing approach is sufficient for appropriate suggestions to take effect. Erickson’s approach is so widely used today that it is no longer necessary to distinguish between practices: every hypnotist employs more or less Ericksonian hypnosis and there is no need to use the adjective “Ericksonian”. For this reason. meditation [Biegler. a single session to reduce anxiety before an invasive medical procedure). Erickson’s renewal of hypnotism overcame this difficulty. and perhaps prayer. Ericksonian hypnotism is often described as a sort of guided self-hypnosis. 1964]. A study of chronic pain management [Anbar.Hypnosis and Cancer: A Dead-End Story? 223 on the disease itself. 2002]. depression. 2009]. Before Erickson. since the patients’ acceptance was not achieved. relaxation with guided imagery is usually considered a form of hypnosis. more sophisticated approaches and deeper trances are often necessary. though it is not this simple. Sorry Milton ! Erickson also showed that a very deep trance was rarely necessary: most desired effects could be obtained with a light trance. and the aims of therapy rather straightforward: ameliorate pain. as we have done here. creative imagination. Psychologist or not ? With cancer patients. Does this mean that hypnotists who manage cancer patients need not be competent in psychology? Two situations can be distinguished: if the intervention is limited (for example. etc). Usually. all of which induce specific kinds of trance and quite often use suggestions (positive thinking. side-effects. Many different techniques may be appropriate to address a narrowly defined goal: for example. the use of “classical” hypnosis consisted of mastering a subject’s will through vigorous induction using direct suggestions of sleep and surrender. Since the goal is to increase the suggestibility of patients without no large alteration of the state of consciousness. Moreover. the results obtained were not lasting. For more complex goals addressing the past or the personality of patients. Because of the effort made to meet patients’ goals and adapt to their cognitive patterns. What Kind of Hypnosis Should be Proposed? Ericksonian hypnosis: what else ? Setting aside mesmerism. We suggest here different directions to facilitate researches on hypnosis with cancer patients. or even sought. Freud presented this as the reason why he searched for a new approach and created psychoanalysis. induction and suggestions can probably be made by a nurse or physician with limited training in hypnosis. the expectations are usually simple to formulate. as long as no unconscious resistance inteferes with explicit goals. One of the problems they faced was the low proportion of people able or accepting to enter a trance (less than 50%). biofeedback. 2008]. Inductions thus do not need to be very technical. two main historical periods apply to hypnotism: before Erickson and after. other practices also probably meet this condition. Freud’s initial interest in hypnotism under Charcot’s teaching is an example of such an approach. etc. involving more extensive interventions and with . including sophrology [Caycedo. yoga plus meditation was as efficient as hypnosis in ameliorating chronic depression [Butler. and on the type of intervention described in the trial protocol. group sessions to teach self-hypnosis plus individual sessions to address personal needs. then formal training in psychology is necessary. or help patients reduce their distress level. The hypnotist needs to be trained to listen to the patient. however. and the sharing of problems encountered by the participants may help others address similar problems later in personal practice. Psychologists are the best equipped to face these situations. there might not be a single ‘best’ method. depending on the legislation or regulation of the country where the research takes place.3. We recommend that hypnosis in group sessions be limited to the teaching of selfhypnosis. The end of life is also a time when essential questions are addressed. Nancy Uhrhammer. obtained significant results in spite of the pulmonologists having undergone a single 20-hour training workshop. But we have found no trial testing individual versus group approaches specifically using hypnosis. Group training sessions. When taking care of chronic or terminally ill patients. using a standardized technique and a predetermined set of suggestions. Although personal topics may appear unrelated to the pathology. . As discussed in section 2. Individual session are thus more suitable when the suggestions are made to fit patients’ personal difficulties or wishes. as well as to propose suitable directions that the patient will be able to follow and develop. But if investigation is not so limited and may concern various aspects of the patient’s psyche or behavior. Medical research may require hypnotists that are psychologists. or when allegories need to be personalized. although a combination of both types may be the best solution for some trials: for example. seem less well adapted to studies were personal needs and demands are to be taken into account. the requirements of the local ethics committee. Group sessions favor the expression of practical difficulties. some components left to the physicians’ discretion. Here again. and even psychologists may need special training to be able to help patients with these issues. This is only possible when the patient’s current context. as summed up by Smedlungs [2004] in his meta-analysis on psychosocial interventions and survival of cancer patients. This simple consideration may itself determine what type of session to use. Individual or group sessions ? Several trials observed better results with individual rather than with group sessions. Yves-Jean Bignon et al. The number of practitioners available may also be a limiting factor that favors group sessions. In particular. gains or improvements in these areas may indirectly help patients improve their quality of life and reinforce the progress made on pain or anxiety. Physicians and nurses trained in other specialties often do not appropriately manage the emotional crises that frequently occur in depressed cancer patients. the situation is not the same. cancer can temporarily mask deep psychosocial problems. pain may reflect psychosocial difficulties that the patient is unable or unwilling to express: the skills of a psychologist are necessary here to seek for the underlying cause of the pain. In practical terms. No special skill may be required if the intervention concerns a limited aspect of patient management. More training is useful when the interventions are more extended and varied. group sessions may be more difficult to organize. but methods more or less appropriate to the type of investigation. especially if groups are large and patients come from outside of the hospital.224 Fabrice Kwiatkowski. Psychologists and psychiatrists are also the only persons with the expertise to care for depression. culture and background can be taken into account. There are several points of view to consider: . There are several different strategies that can be used to prevent symptoms. the therapist should be prepared to explore areas not immediately identified by the patient.Hypnosis and Cancer: A Dead-End Story? 225 Tailored hypnosis or self-hypnosis ? Self-hypnosis can be taught to patients quite easily. The therapist may even share some of these opinions with his patients. but the therapist should first make sure that his patient does not believe that the efficacy of his chemotherapy is not proportional to the severity of his symptoms [Roscoe. How Theories of Cancer May Modulate the Suggestions Made During Hypnotherapy It is common sense to state that the ideas people have of cancer. its causes and probable development. the quality of trance and the power of suggestions may also diminish greatly with self-hypnosis. highlighting the difficulty of ensuring compliance of patients. or the perceived outcome. The therapist who can enhance these affective patterns. once their chemotherapy has started. but the benefit was lost when patients were switched to self-hypnosis [Liossi. in either individual or group sessions. Fawzy [1990] confirmed that affective changes had more impact on the immune system than coping management. the therapeutic alliance. will influence the way hypnotists manage their sessions. Finally. what domain should hypnotic investigations and/or suggestions cover? One could legitimately argue that such an enquiry is nonsense since what should be covered is only what patients ask for. The absence of the therapeutic alliance makes self-hypnosis more limited and less effective. Although the hypnotist should give post-hypnotic suggestions to favor effective self-practice. In a randomized prospective trial (i. has proven to be one of the most important factors in the success of psychotherapy [Crits-Christoph. in the following cycles it is not rare to discover that these symptoms begin as soon as patients arrive at the hospital. is able to solve more painful problems: his propose alternatives will appear more secure. Roscoe. and thus modify the outcome. of the intervention [Montgomery. i. the quality of the affective relationship established between the patient and his therapist. 2003]. This is relevant.e. with a control group) where the endpoint is survival and the impact of a short series of personal hypnosis sessions is being tested. One study of children. but in the practice of hypnotherapyas in any other kind of psychotherapy. where patients can develop skills to manage their symptoms ad libitum. as expected. Many of these beliefs may shape the expectations of both patient and therapist. This is very important if patient faces irrational fears [Burish. or is blocked by severe defenses that prevent access to past distress or trauma.e. 2006]. and not. it is difficult to obtain regular practice from subjects. Surprisingly. as long as these ideas do not drive patients to dangerous experimentation or acts. 2006]. In spite of audiotapes that could facilitate the exercises. Whether these ideas correspond to scientific truths or not is not relevant to the therapy. Symptoms may appear as early as the first cycle. For example. reported an advantage of personal sessions. some chemotherapeutic drugs produce nausea and vomiting in many patients. Chronic pain is a good indication for self-hypnosis training. 1983]. 2001. 2006]. however. In an example of this strategy. Moser. This attitude appear rather safe. in particular through the coordinate lowering of cardiovascular mortality [McNeely et al. transition/rebellion. Perhaps. Nancy Uhrhammer. this is a very delicate point: when the prognosis is very pejorative. Changing beliefs and/or expectations. this being more effective if the patient is temporarily relaxed and disconnected from his surrounding [Strosberg. not to . since this often prevent him from maintaining projects. 2002 .226 Fabrice Kwiatkowski. In oncology. Yves-Jean Bignon et al. This risks placing him in a very distressing situation when he realizes he was misled. 4. 3. why not use suggestions to ameliorate their behavior? Group educational sessions are partly efficient here. The human “ultradian” cycle (of about 90 minutes) is of particular interest. and if we do not try to work through to the next cycle. a 4-stage hypnotic intervention that fits Kubler-Ross’ analysis of terminally ill patients (initial crisis. is controlling the symptoms of disease and improving patients’ wellbeing. following the requests of patients. reduced physical activity. in terminally ill patients. Alternative projects may be suggested as for example. where the objective can be limited to the quality of end of life. Generating a placebo effect is equivalent to changing beliefs and/or expectations. which will bring satisfaction and in turn reinforce the patient’s will to manage other domains of his life. acceptance and preparation for death). this may reinforce the circadian activity/rest cycle as well as numerous metabolic functions. we have a small period of inattention. especially when they are multifactorial. A same strategy could be used to reinforce circadian rhythm [Rossi. Although examples of remission have been attributed to this approach. the least that can be done is to weaken the patient’s certainty of not having time to live. this is questionnable. including immunity. With many cancer patients.If we pay attention. 1989]. but accept to stop our activity and empty our mind. disturbed circadian rhythms. the surprise to obtain new insights on his personality or reducing anxiety for death. Why not use that moment for a few minutes of selfhypnosis or relaxation? This strategy may be the last that remains. 1. 2006].. The positive imagery approach stems from psycho-neuro-immunology theory. ethically. For example. it has not proven efficient in well-designed randomized trials measuring survival. but to our mind. eating disorders. one cannot let the patient believe he will get cured. The strategy requires good familiarity with the patient in order to choose appropriate allegories. there are many domains that could benefit from sessions targeting behavioral changes. Most practitioners favor a neutral attitude. The primary goal. Hypnosis may also be directed toward behavior modification : if a patient’s habits include behaviors that increase the risk of relapse or aggravation (smoking. 2003]. 2. physical activity after breast cancer was found to improve survival. etc). even very short term ones. when patients are too ill to leave their bed. Every cycle. It might be effective to focus on positive behaviors. the placebo effect is usually considered ineffective against the disease. Between 20% and 50% of therapeutic efficacy is often attributed to the placebo effect itself. 2007]. the aim was to facilitate patients’ coping in their last moments [Marcus. Complementary work under hypnosis may be useful in facilitating such changes. On the other hand. 2006]. that is the beliefs and expectations of patients concerning their treatment. Breast cancer survival improved more significantly when activity was coupled to dietary modifications (higher vegetable-fruit consumption) [Pierce. mainly the idea that immune cells may be boosted by suitable imagery. Behavioral changes in activity and diet may yield significant gains in survival. There is evidence that the immune system can suppress cancer cells in the absence of treatment : once cancer appears.17 0. the biological environment of the tumor plays an important role. separation Financial changes Environmental changes 1. 2003]. Lillberg. and leukocyte infiltration of tumors is common.88 0.92 0. but create opportunities for new strategies based on enhancing immunity. parent. 2005].77 Traumatic events Death of the spouse Death of child.. friend. It has been suggested that traumatic events in the patient’s history may be psychological risk factors for cancer (Fig. favorable unfavorable 1. 2003]. and the state of the disease. Spontaneous recoveries from usually aggressive tumors have been documented: melanoma may be eliminated by the immune system [Wagner.37 1. 3) [Duijts. Curiel-Lewandrowski.. in particular the ability of the organism to fight disease. The known link between immunity and the psyche suggests that the resolution of past psychic trauma with hypnosis could be useful.02 0 1 Odds-ratios 2 Figure 3. The hypotheses behind this proposal are a bit audacious. These discoveries do not indicate that cancer is curable. its development does not follow the exponential growth predicted from in-vitro cell culture models [Horii. and should be tested in cancer patients . Breast cancer risk in relation to life events in the six months before diagnosis [Duijts. In many cases. Personal health difficulties Health difficulties of relatives Divorce. suggesting that psychological patterns can durably depress the immune system. 2003. and here with the help of hypnosis. 2002]. It is possible too that persistent psychological trauma can lower the overall health of an individual. whether the tumor is hormonedependent.35 1. both favorable (neo-vascularization of the tumor bed) and unfavorable (activation of immune defenses). biological or genetic factors. 1998.90 1. Metaphors can be used to replace an unethical message of excessive hope by a story presenting positive unexpected change. 5. The success of these new strategies will naturally depend on numerous clinical. and that resolving past trauma can relieve this depression.Hypnosis and Cancer: A Dead-End Story? 227 use the powerfully therapeutic lever of new beliefs/expectations would be regrettable. Hence. Nancy Uhrhammer. Several tools have been developed to measure hypnotisability: o o o o the Stanford Hypnotic Susceptibility Scale (SHSS) developed in 1965 has been widely used and often treated as a gold standard (but arguably. such as the TAS (Tellegen Absorption Scale). there are only bad hypnotists”. a self-questionnaire of 34 items. even during each session. six randomized study reported numerical values for the correlation between hypnotisability scores and treatment outcomes. 1. Hawkins. Bio-feedback techniques can play a role in this direction. 1978] uses a short hypnotic session including 10 experiences. the more hypnotically susceptible the person is supposed to be. 2. it provides indicators that researchers can use. Also known as the eye roll test.. 1979] and this scale is no longer used. the person is asked to roll his eyes upward. Hypnotisability. In contrast to psychoanalysis. Trance depth may be a useful factor to measure. The Hypnotic Induction Profile [Speigel. Physiological characteristics will eventually become the best means to evaluate the quality of trance. or susceptibility to hypnosis [Smith. The smaller this part of the eye is. the power of suggestions may vary with the subject’s sensitivity to hypnotic induction. What to Measure When Hypnosis is Used in a Trial ? Hypnosis differs largely from other types of psychotherapy. with a correlation coefficient r = 0.19. Unlike other cognitivebehavioral therapies. individuals are tested for certain hypnotic behaviors. after which the subject answers questions about his feelings in each experience. Although Erickson claimed that “non-hypnotisable persons do not exist. Heart-rate 6 In this study. Other scales can reflect hypnotic susceptibility. 1996. According to a large meta-analysis of 57 trials comparing hypnosis to a control group. 228 Beyond Clinical and Biological Parameters. This means that 80% of hypnosis efficacy depend on other parameters.44. In a multidimensional analysis.Fabrice Kwiatkowski. Several studies indicate that the results may depend on the level of hypnotisability of the patients. 1976]. r² = 0. according to Benham [2002]). 1998]. In this last chapter. in order to assess a posteriori if the outcomes are correlated to the strategy employed. . This scale was tested against the SHSS and shown to have a weak predictive power [Kurtz et al. which means that 19% of the outcomes variation is due to the variation of hypnotic suggestibility. The TAS may be a good alternative to the SHSS for prospective trials where patients need to be tested at inclusion but not be hypnotized. the hypnotic suggestibility was responsible for 19% of the treatment outcomes6 [Flammer. 2003]. Crawford [1982] showed a good correlation between SHSS and TAS. and the size of the visible iris and cornea is measured. The Creative Imagination Scale [Barber. we present some of the possible indicators. 1996]. The results correlate poorly with other hypnotic scales [Orne. The test can be administered and graded by a hypnotist in about a quarter of an hour. Yves-Jean Bignon et al. After a very short induction. hypnotherapy does not require years of treatment. immunology or chronobiology has not been rigorously tested in cancer patients. We believe that biological endpoints such as immunity and response to treatment should not be neglected. Small portable devices may soon be available to measure different physiological parameters in realtime. Trance depth may also be evaluated by the subject and/or by the hypnotist. SHSS relies on the same kind of evaluations through its referenced hypnotic behaviors which can be observed by the hypnotist during a session. Such measures may not be as accurate and reliable as physiologic measures.. with a very well-known symptom known in psychoanalysis as “counter-transferance”. Other major advantages are that hypnosis is harmless and non toxic. as new experimental designs have emerged showing that hypnosis may improve the efficacy of standard treatments. quality of life. the therapeutic alliance. but the “patient-therapist” couple also influences the therapist. Simple biological hypotheses can then be addressed in trials that are far less expensive than those testing new molecules or monoclonal antibodies. since no medical solution can be . biology and neurosciences. will help understand what works and what does not. Various qualitative and quantitative elements could facilitate the evaluation of hypnotic sessions. The success of hypnosis in enhancing well-being confirms its place in the management of cancer patients. These are of little interest in common practice. 3. later. in contrast to products from the pharmaceutical industry. CONCLUSION Most studies of the use of hypnosis with cancer patients indicate that this approach is very helpful when facing “psychosomatic” or “psychological” symptoms (pain. Moreover.Hypnosis and Cancer: A Dead-End Story? 229 variability (HRV) may be one such parameter. but when a research protocol tries to evaluate the impact of hypnosis on clinical outcomes. 2007. Some authors are pessimistic about supportive-expressive group therapy and self-hypnosis training having any effect on survival [Speigel.. Why not use this particular feeling as a measure? The statistical analysis of such an indicator should be stratified by therapist if more than one therapist is employed. 2007]. 2008]. as is done for pain with visual analogue scales. but the impact of clinical hypnosis on survival. Other variables can probably also be scored: for example. One could thus decide to abandon research in this domain. Trials with small sample sizes offer good perspectives if targets are precise enough and longitudinal statistics are used to measure the impact of the interventions. possibly through the parasympathetic branch of the autonomic nervous system [Diamond et al. This may appear surprising. Kissane.. it could be evaluated by the therapist with a visual analogue scale . as it has been linked to self-rated hypnotic depth evaluation.) but the effect on the prognosis itself is still controversial. side effects of treatments. anxiety. depression. Despite the subjectivity of such an evaluation. regardless of the stage of the disease or the age of the patient. and enable better control of the sessions of hypnosis. it might be a useful to have some standardized indicators that. We stand once again at the crossroad of hypnosis. This methodology is no longer the privilege of selected research teams. 85(5): 365-76 Anbar RD (2002) Hypnosis in pediatrics: application at a pediatric pulmonary center. Cull A. (1993) The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instument for use in international clinical trial in oncology. The limiting factor today is not means. Duez NJ. Evidence is lacking for any improvement in survival. and supportiveexpressive group therapy has not been found to increase the survival chances of patients. We have no doubt that the gains in quality of life will eventually translate to a significant impact on the disease itself. and the progress of neuroscience. Our purpose was to show that clinical hypnosis is still promising. expectations change. Yves-Jean Bignon et al. de Haes JC et al. but well-being is not without value. J Natl Cancer Inst. hypnosis sessions should not be too strictly predetermined.230 Fabrice Kwiatkowski. Filiberti A. If we consider the constant development of new classes of ever more efficient psychotropic drugs. hypnotic susceptibility scores were increasing? REFERENCES Aaronson NK. perhaps new research into hypnosis is our last chance to promote a more human paradigm of medicine. It helps patients to handle the major side-effects of cancer and its treatments. but ideas and priorities. As beliefs about hypnosis progress. Bergman B. Flechtner H. And if in some sub-group. A large amount of data on psychosocial intervention has accumulated. it is possible to perform clinical studies in most hospitals. leading to new data that may change beliefs. proposed to cancer patients in palliative care. BMC pediatrics. And so on. Nancy Uhrhammer. To paraphrase Goodwin [2005]. flexibility and spontaneity. the decline of the psychiatric use of psychotherapy [Mojtabai. Bullinger M. where areas of expertise are already shared by groups of physicians. this population seems very appropriate to test new hypotheses. if not longer ! Although there is a need for standardized procedures. and so forth ! Didn’t Benham [2002] show that in western countries. Fleishman SB. Patients differ: sessions must differ. Our intent was not to replace a disappointed hope by another labeled “hypnosis”. Clinical hypnosis and the teaching of self-hypnosis to patients constitute an attempt to give him back power over his sickness and over his own life. 2008] in favor of pharmacotherapy. This is particularly true for specialized cancer centers. 2: 11 . the least we can offer them is to live better. Cancer deprives of life: let’s reintroduce life. rather than a short-sighted mechanical symptom-pill attitude that gives full latitude to industry and leaves patient with more dependencies. but the global management of patient in which hypnosis is a better way to facilitate personal adjustment and learning. always delivered in a same manner. Ahmedzai S. It spares place for living. notably pain. it will be time to focus on the matter and develop new directions for new studies using randomized prospective trials. What should be practiced is not some special set of suggestions. an effect can be established. With the dissemination and sharing of knowledge and expertise in clinical research and statistics now so largely spread by accessible major medical reviews. while most of other types of psychological approach have failed to meet the great expectations of the last three decades. Stonisch-Riggs G. Chen XH. Kraemer HC. Altman DG (1995) Multiple significance tests : the Bonferroni method. 22(6): 979-89 Classen C. J Pain Sympt Manag. daydreaming styles. Neijt JP (1990) Measuring psychological and physical distress in cancer patients: structure and application of the Rotterdam Symptom Checklist.108(4): 227-230 Crwaford HJ (1982) Hypnotizability. 48(1): 18-26 Byock I. Psychotherapy Research. Redd WH (1983) Behavioral approaches to reducing conditional responses to chemotherapy in adult cancer patients. JAMA. Kaufman A. Crits-Christoph K. Narducci J (2006) Can therapists be trained to improve their alliances? A preleminary study of alliance-fostering psychotherapy. Hastings TA. Behavioral Medicine Update. Nagy TF. Symons BK. Alibhai A (2007) Cognitive hypnotherapy for depression : an empirical investigation. 21: 84-108 Benham G.Hypnosis and Cancer: A Dead-End Story? 231 Alladin A. Fetting J. Chiche J. CA Cancer J Clin. Br J Cancer. Psycho-oncology. Nash MR (2002) Hypnotic susceptibility scales: are the mean scores increasing? Int J Clin Exp Hypn. Investig. Schapiro IR. BMJ. Pediatrics. Atkins MB (2001) Immunotherapeutic approaches for the treatment of malignant melanoma. 50(1): 5-16 Biegler KA. 7: 103-6 Cook DJ. 85(12): 1301-7 Burish TG. Smith N. cognitive impairment and meditation. Boesen EH. Spiegel D (2005) Hypnosis reduces distress and duration of an invasive medical procedure for children. Waelde LC. Johansen C (2002) Mind and Cancer: do psychological factors cause cancer ? European journal of cancer 38 : 1313-1323 De Haes JC. Int J Clin Exp Hypn. Blasey CM. 17: 438-47 Caycedo A (1964) Sophrology and psychosomatic medicine. Acta Oncol. Chest. Van Knippenberg FC. Gallop R. Opin. Curr. Guyatt G. Marshall J. Bland JM. 2(11): 1553-63 Dalton SO. Schmale AM. 16(3): 268-81 Curiel-Lewandrowski C. Spiegel D (2008) Meditation with yoga. anxiety and mood disturbance. and absorption: a multidimential study. Henderson SL. Westerndorp J. Seibert EO. J Mol Med. 5: 12-6 Butler LD. 115: 7785 Butler LD. Am J Clin Hypn. Morrow G. 12:231-244. 249(6): 751-7 . Blasey C. J Clin Psychol. 310 : 170 Brahimi-Hord MC. Carnicke CL Jr (1983) The prevalence of psychiatric disorder among cancer patients. Chaoul MA. Shortliffe LD. group therapy with hypnosis and psychoeducation for long-term depressed mood: a randomized pilot study.64(7): 806-820 Carpenter JS (2001) The hot flash related daily interference scale: a tool for assessing the impact of hot flashes on quality of life following breast cancer. Gronskaya Palesh O. Wilson SC (1978) The Barber Suggestibility scale and the Creative Imagination Scale: experimental and clinical applications. Connolly Gibbons MB. J Pers Soc Psychol. 55(2): 147-66 Barber TX. Pouysségur J (2007) Hypoxia and cancer. Lampucis A Sackett D. 55: 109-16 Derogatis LR. Morrow GR. Koopman C. Merriman M (1998) Measuring quality of life for patients with terminal ilness: The Missoula-VITAS Quality Of Life Index. Cohen L (2009) Cancer. J Pal Med. Pennam D. Goldberg J (1995) Clinical recommandations using levels of evidence for antithrombic agents. Schamberger M. Drug. 62: 1034-8 Deng G. Atkinson A. Ross L. DiMiceli S. 42(5) : 915-26 Crits-Christoph P. imagery vividness. Piasetsky S. Henrichs M. Giese-Davis J. Cassileth BR (2005) Integrative oncology: complementary therapies for pain. Symons B. Am J Clin Hypn. Spiegel D (2008) Supportive-expressive group therapy for primary breast cancer patients: a randomized prospective multicenter trial. Am J Clin Hypn. Rajab MH. 15(4): 199-207 Hjerl K. Tan AW. Tschann JM. Int J Clin Exp Hypn. Basgall J. Fahey JL (1990) A structured psychiatric intervention for cancer patients. 56(2): 67-71 Erickson MH. Mortensen PB. Schretzmann B. 268(17): 2420-5 Harter M. Yves-Jean Bignon et al. Psychosomatics. Morton D.France Fawzy FI. J. 12(2): 140-4 Hutchings DF. Kosmidis VH (1995) Hypnotherapy for control of anticipatory nausea and vomiting in children with cancer : preliminary findings. USA Extremet J. Institut J Paoli-Calmettes. II. Contemporary Hypnosis. Marcus J. Borne V (2003) The association between stressful life events and breast cancer risk: a meta-analysis. 107 : 1023-9 Elkins G. 55(3): 275-87 Elkins G. Akiyama F. Keiding N. J Dev Behav Pediatr. Patterson DR (2007) Hypnotherapy for the management of chronic pain. Weis J (2001) Psychiatric disorders and associated factors in cancer results of an interview study with patients in inpatient. Jorgensen T (2003) Depression as a prognostic factor for breast cancer mortality. Living better if not longer. Palamara L. Reuter K. J Ark Med Soc. Cancer. Perfect M. Hypnosis in the prevention of chemotherapy-related nausea and vomiting in children: a prospective study. Aschenbrenner A. 37: 316-25 Goodwin P (2005) Support groups in advanced breast cancer. 44(1): 2430 Horii R. Kosmidis VH (1998) Hypnosis in the alleviation of procedure related pain and distress in paediatric oncology patients. 4: 101-6 Hawkins P. J Clin Oncol. 56(1): 1-18 Duijts S. A cross-sectional survey. Behav Res Ther. Cousins N. Stearns V. Liossi C. Ewart BW. Cancer. Int J Clin Exp Hypn. Hasenburg A. Kasumi F. Pronk NP. Sakamoto G (2005) Spontaneous "healing" of breast cancer. Davis OC. Levittown. Am J Clin Hypn. 20(4): 179-97 Genuis ML (1995) The use of hypnosis in helping cancer patients control anxiety. Arch Gen Psychiatry 47(8) : 729-35 Flammer E. 37(11): 1385-93 Hawkins P. 47(1): 29-42 Elkins G. Marcus J. Brunner/Mazel publishers. Palamara L. Diamond SG. JAMA. Kemeny ME. Ruud C. Houston BK (1980) Anxiety management and applied relaxation in reducing general anxiety. 104(11): 2596-601 Gray CM. Int. Hatira P. Zeegers M. Fawzy NW. Changes over time in immunological measures. Breast Cancer. Liossi C. Eff Clin Pract. 18:181-90 Jacknow DS. Marschner N. Eur J Cancer. Bongartz W (2003) On the efficacy of hypnosis: a meta-analytic study. Boyce WT. Mouridsen HT. Compte rendu des journées médicales sur les problèmes psychologiques en rapport avec le cancer. Nancy Uhrhammer. Andersen EW. Keith T (2008) Randomized trial if a hypnosis intervention against hot flashes among breast cancer survivors. 15(4): 258-64 . Hatira P. Rossi EE (1989) The February man: evolving consciousness and identity in hypnotherapy. Koike M. Contemporary Hypnosis. 5(1): 17-22 Guyatt G for the Evidence based medicine working group (1992) Evidence-based medicine: a new approach to teaching the practice of medicine. Stearns V (2004) Can hypnosis reduce hot flashes in breast cancer survivors? A literature review. Howe RD (2008) Heart-rate variability as a quantitative measure of hypnotic depth. ahead of print Erickson MH (1959) Hypnosis in painfull terminal illness. O’Connor PJ (2002) Complementary and alternative medicine use among health plan members. Ewart BW. Jensen MP. PsychoOncology. rehabilitation and outpatient treatment. pain and emesis: a review of recent empirical studies. Link MP. Chertok L (1975) Tentative d’introduction de l’hypnose dans un centre anticancéreux. Marseille .232 Fabrice Kwiatkowski. Elashoff R. Denney DR. 19(2): 24-7 McNeely ML. Cox CE. Klassen TP. Love AW. Snyder RD. Campbel KL. Bignon YJ (2007a) To test the impact of hypnotherapy upon immunity and circadian rhythms among palliative cancer patients : a promising goal ? Path biol . NY Ladas EJ. J Pediatr Hematol Oncol. Rowe BH. Ellenberg L (1987) Hypnosis in the reduction of acute pain management with pediatric cancer patients undergoing bone marrow aspirations. Hatira P (1999) Clinical hypnosis versis cognitive behavioral training for pain management with pediatric cancer patients undergoing bone marrow aspirations. Brain Behav Immun. 10(7): 519-22 Kupers R. Krozely MG. Post-White J. 15(1): 34-8 Liossi C. 9(3): 205-14 Liossi C.50: 509-24 Marcus J.11) : 42-5 Koeller JM. Anderson B.Hypnosis and Cancer: A Dead-End Story? 233 Jacobson E (1938) Progressive relaxation. Glaser R (1999) Psychoneuroimmunology and Cancers : fact or fiction ? Eur J Cancer 35(11) : 1603-7 Kissane DW. Laureys S (2005) The cognitive modulation of pain: hypnosisand placebo-induced analgesia. Faymonville ME. Dao M. Chicago: University of Chicago Press Katz ER. Gonzalez L. McGinn S. Int J Clin Exp Hypn. 150: 251-69 Kurtz RM. Blanchet A (2007b) Reinforcing biological rhythms with hypnosis: a new paradigm of immunotherapy in oncology ? in: Progress in circadian rhythms research. 38(3): 172-84 Kwiatkowski F. Strube MJ (1996) Multiple susceptibility testing: is it helpful? Am J Clin Hypn. 61(suppl. Taromina K (2006) Evidence for symptom management in the child with cancer. Grabsch B. Zimmerman B. Hawks R. Adv Mind Body Med. J Pediatr Psychol. Prog Brain Res. Glvary D. Chapter 1. Clark-Snow RA (2002) Antiemetic guidelines: creating a more practical treatment approach. Lubaroff DM (2008) Depressed and anxious mood and T-cell cytokine expressing populations in ovarian cancer patients. Yang C. 12(3): 379-94 Kiecolt-Glaser JK. Lambin DM. 16: 277-286 Kocsis JH (2000) New strategies for treating chronic depression. 55 : 186-93 Kwiatkowski F. Grunberg SM. Oldham RK (1982) Efficacu of relaxation training and guided imagery in reducing the aversiveness of cancer chemotherapy. DeGeest K. Elkins G. 175: 34-41 . Cantor A. 51(1): 4-28 Liossi C (2006) Hypnosis in cancer care. Contemporary hypnosis. Kellerman J. Bennett MP. Clarke DM. J Clin Psychiatry. Djeu J (2008) Immune responses to guided imagery during breast cancer treatment. Mott F (2003) A model of hypnotic intervention for palliative care. ISBN:978-1-60021-876-7. Hatira P (2003) Clinical hypnosis in the alleviation of procedure-related pain in pediatric oncology patients. 28(9): 601-15 Lengacher CA. Sood AK. Uhrhammer N. Maiseri H. Li Y (2007) Supportive-expressive group therapy for women with metastatic breast cancer : survival ans psychosocial outcome from a randomize controlled trial. 23(1): 47-57 Lutgendorf SK. Kris MG. Aapro MS. Jacobsen PB. Psycho-Oncology. Gralla RJ. J Clin Consult Psychol. Contemporary hypnosis. Smith GC. 22(6): 890-900 Lyles JN. Hesketh PJ. Burish TG. 47(2): 104-16 Liossi C (2001) Efficacy of clinical hypnosis in the enhancement of quality of life of terminally ill cancer patients. Support Care Cancer. Biol Res Nurs. CMAJ. Nova Sciences Publisher. Int J Clin Exp Hypn. Bloch S. Courneya KS (2006) Effects of exercice on breast cancer patients and survivor: a systematic review and meta-analysis. Support Care Cancer. Levi F (2000) Marked 24-h rest/activity rhythms are associated with better quality of life. 19(5): 418-26 Reich M. Lesur A. Havlik RJ (1998) Chronically depressed mood and cancer in older persons. Jami A. Madlensky L. Int J Clin Exp Hypn. Kealey S. J Consult Clin Psychol. Morrow GR (2006) The role of . tome 1. Viterbori P. Editions Institut Synthélabo. Kangas M. 50(1): 17-32 Montgomery GH. Musso M. Higgingson IL (2005) Systematic review of hypnotherapy for treating symptoms in terminally ill adult cancer patients. Can Fam Physician. Coll. Hallquist MN. Hajek R. Shelke AR. Spiegel D. 13: 834-41 Newton BW(1983) The use of hypnosis in the treatment of cancer patients. le défit du magnétisme naturel. Am J Clin Hypn. Cohen MM. Ferrucci L. Giachetti S. Venturini M (2001) Predicting mood disorders in breast cancer patients. better response and longer survival in patients with metastatic colorectal cancer and good performance status. Bonci F. Al-Delaimy WK. Orne EC. Health Psychol. JCO. Caan B. Flatt SW. Bogdan A. Bovbjerq DH. 17: 483-7 Mystakidou K. (2005) Adjustment disorders in oncology: a conceptual framework to be refined . Lellouch J. Weltz CR. Spiegel H. Cancer Causes Control. Schaumberger K. Evans FJ. Thomson CA. Hilgard ER. Bovbjerq DH (2001) Specific response expectancies predict anticipatory nausea during chemotherapy for breast cancer. 6(8): 3038-45 Moser M. 28(3): 317-22 Morasso G. Sakkas P. 2345-51 Pirotta MV. Garrone O. Tsilika E. Yves-Jean Bignon et al. Parpa E. 172(3): 102-3 Quinn SO (2007) How southern New England became magnetic north: the acceptance of animal magnetism. Le PlessisRobinson.234 Fabrice Kwiatkowski. 110(1): 9-17 Rogovik AL. 27(2): 85-102 Penninx BW. 31(2) : 118-26 Roscoe JA. Bleuzen P. 25(17). David D. forms A and C. Crawford HJ. 65(8): 962-70 Montgomery GH. Int J Clin Exp Hypn. Bole C. Cerhan JR. Kotsirilos V. L'Encéphale. Arch Gen Psychiatry. 90(24): 1888-93 Pierce JP. Hist Psychol. Del Mastro L. France Mojtabai R. Stevens RG (2006) Cancer and rhythm. J Natl Cancer Inst. Touitou Y. Bovbjerg DH (2002) Brief presurgery hypnosis reduces distress and pain in excisional breast biopsy patients. Sternfeld B. Jean-Pierre P. Clin Cancer Res. Nancy Uhrhammer. Seltz M. Breast Cancer Res Treat. Soldatos C (2005) Life before death : identifying preparatory grief through the development of a new measurement in advanced cancer patients. Frischolz EJ (1979) The relation between the Hypnotic Induction Profile and the Standford Hypnotic Susceptibility Scales. Rock CL (2007) Greater survival after breast cancer in physically active women with high vegetable-fruit intake regardless of obesity. Green S. Natarajan L. Costantini M. 69(5): 831-5 Montgomery GH. Newman VA. Perdrizet-Chevallier C (2007) Depression. Pahor M.10(3): 231-48 Rajasekaran M. Schnur JB (2009) Fatigue during breast cancer radiotherapy: an initial randomized study of cognitive-behavioral therapy plus hypnosis. Palliat Med. 37(2): 216-23 Mormont MC. Farish SJ (2000) Complementary therapies: have they become accepted in general practice? Med J Aust. Méheust B (1999) Somnambulisme et médiumnité. Olfson M (2008) National trends in psychotherapy by office-based psychiatrists. Parker BA. Goldman RD (2007) Hypnosis for treatment of pain in children. Edmonds PM. Wallace RB. Les empêcheurs de penser en rond. 53: 823-5 Ronson A. Waterhouse J. Stefanick ML. Schernhammer E. Eur J Cancer. 25: 104-13 Orne MT. quality of life and breast cancer: a review of the literature. Katsouda E. Misset JL. Guralnik JM. Kaufman ME. 25(17): 2397-404 Steinhauser KE. Clipp EC. 36(1-4): 90-2 Syrjala KL. Butler L. France. DiMiceli S. Bosworth HB. Int J Clin Exp Hypn. Giese-Davis J (2003) Depression and cancer: mechanisms and disease progression. Haber J (1976) Psychometric analysis if the Hypnotic Induction Profile. 21(3): 226-7. Cancer. Barret-sur-Méouge. Kippes ME. 30(2): 40-98 Ross L. Siegrist HP. Cart JE (1995) Relaxation and imagery and cognitive-behavioral training reduce pain during cancer treatment: a controlled clinical trial. Perey L. Int J Psychosom. Carr B (2007) Depression. Classen D (2000) Group therapy for cancer patients: a research-based handbook of psychosocial care. Goldhirsch A. Fleiss JL. Bloom JR. 11(5) : 1130-8 Spiegel H. Barabasz A. Gottheil E (1989) Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Giese-Davis J. Bloom JR. 48: 137-46 Syrjala KL. immunity and survival in patients with hepatobiliary carcinoma. Johansen C (2002) Mind and Cancer: do psychosocial intervention improve survival and psychological well-being ? European journal of cancer 38 : 1447-1457 Rossi EL (2002) Psychobiologie de la guérison. Maguire P (1999) The effect of psychosocial interventions on anxiety and depression in cancer patients : results of two meta-analyses. Bonnefoi H. Clipp EC. Bacchi M. Carlson R. Boesen EH. 45: 333-39 Spiegel D. Psychosom Med. Cummings C. Curr Probl Cancer. Kraemer H (2007) Effects of supportive-expressive group therapy on survival of patients with metastatic breast cancer. Bernhard J. J Psychosom Res. Palliative and supportive care. Aronson M. 24(3): 300-15 Steel J. 63: 189-98 Temoshok LR. Sparks TF (1980) Psychological intervention in the treatment of cancer. Herrmann R. Breast Cancer Res Treat. Psychosomatics. New-York: Basic Books Spiegel D. Geller D. 43:187-95 Spiegel D. 1(2): 135-45 Tsao JC. Wald RL (2002) Change is complex: rethinking research on psychosocial intervention in cancer. Miller E. 2: 3-14 Strosberg IM (1989) Hypnosis techniques. McNeilly M. J Palliative Medicine. J Couns Psychol. Edition "Le souffle d'or". Fobair P. New-york Sabbioni M. Br J Cancer 80 : 1770-80 Simonton OC. Parker J. 231-3 Smedslund G. 5(6): 829-41 Steinhauser KE. Bosworth HB. (1983) Group therapy and hypnosis reduce metastatic breast carcinoma pain. Zelter LK (2005) Complementary and alternative medicine approaches for pediatric . Thurlimann B. Integr Cancer Ther. 59: 279-287 Sheart T. Dalton SO. Davis MW. Gamblin TC. Olek MC. Tulsky JA (2004) Measuring quality of life at the end of life: Validation of the QUAL-E. Parker J.57: 123-31 Smith JT. Koopman C. Ringdal GI (2004) Meta-analysis of the effect of psychosocial interventions on survival time in cancer patients. Castiglione M. Donaldson GW. Lancet 2 : 211-22 Spiegel D. Tulsky JA (2002) Initial assessment of a new instrument to measure quality of life at the end of life. 54: 269-282 Spiegel D. Hurny C (2000) Association between immunity and prognostic factors in early breast cancer patients before adjuvant treatment. Christakis NA. Original edition (1993) WW Norton & Company Inc.Hypnosis and Cancer: A Dead-End Story? 235 patients’ response expectancies in side effect development and control. Donaldson GW (1992) Hypnosis or cognitive behavioral training for the reduction of pain and nausea during cancer treatment: a controlled clinical trial. Kraemer HC. Biol Psychiatry. McNeilly M. Pain. Matthews-Simonton S. J Clin Oncol. Pain. Christakis NA. Classen C. Barabasz M (1996) omparison of hypnosis and distraction in severely ill children undergoing painful medical procedures. Eur J Cancer. 2: 683-90 . 30: 473-83 Wagner SN. 354: 1331-6 Wild MR. pain: a review of the state-of-the-science. Zelter M (1984) The effectiveness of behavioural intervention for reduction of nausea and vomiting in children and adolescents receiving chemotherapy. van Achterberg T (2004) Psychosocial inteventions for patients with advanced cancer – a systematic review of the literature. Heys SD. De Mulder P. Ah-See AK. Yves-Jean Bignon et al. Sarkar TK. Greer S. Potting K. Nancy Uhrhammer. Ogston K. 25: 207-13 Zaza C. Goos M (1998) Immune response against human primary malignant melanoma: a distinct cytokine mRNA profile associated with spontaneous regression. Vermooy M. Lancet. Psycho-oncolgy. 91: 1050-62 Wade JE. Espie CA (2004) The efficacy of hypnosis in the reduction of procedural pain and distress in pediatric oncology: a systematic review. Baine N (2002) Cancer pain and psychological factors: a critical review of the literature. Eremin O (1998) Psychological. 1032-5 Zelter LK. Ratcliffe M. 24 : 526-542 Zelter LK. Sherbourne CD (1992) The MOS 36-item short-form health survey (SF-36). Haviland JS. J Dev Behav Pediatr.236 Fabrice Kwiatkowski. LeBaron S. Miller ID. Ah-See AK. Schultewolter T. Eremin O (1999) Psychological factors can predict the response to primary chemotherapy in patients with locally advanced breast cancer. Lab. Evid Based Complement Alternat Med. Miller ID. Invest. Bensing J. 9: 39-45 Walker LG. Ogston K. 78(5): 541-50 Walker L. 80 (1/2): 262-8 Walker LG. Walker MB. Hutcheon AW. Walker MB. Wagner C. 35(13): 1783-1788 Watson M. Sarkar TK. Medical Care. Journal of Pains and Symptoms Management . Hutcheon AW. Briedigkeit L. 2(2): 149-59 Uitterhoeve RJ. Dawson A (2000) Relaxation and hypnotherapy: long term effects on the survival of patients with lymhoma. LeBaron S (1982) Hypnosis and nonhypnotic techniques for reduction of pain and anxiety during painful procedures in children and adolescents with cancer. Heys SD. Bliss JM (1999) Influence of psychological response on survival in breast cancer. J Pediatr: 101(6). A population based cohort study. Davidson J. J Clin Oncol. Litjens M. Kwasnicka HM. British Journal of Cancer. clinical and pathological effects of relaxation training and guided imagery during primary chemotherapy. British Journal of Cancer. Becker JC. In: Hypnosis: Theories. namely. the ultimate aim is to enable patients to activate therapeutic suggestions in those everyday situations in which they need them. The sequence is structured while flexible to be adapted to the intervention. and a metaphor for hypnosis. attitudes. motivation. R. Some of the advantages of waking hypnosis are the following: clients show less fear of losing control. Elena Mendozaa. Delisle ISBN 978-1-60456© 2009 Nova Science Publishers. hypnosis is used in combination with motivational questions to help clients understand the relevance of their thoughts in the maintenance of their problems and the usefulness of hypnosis in changing them. Chapter 10 THE VALENCIA MODEL OF WAKING HYPNOSIS AND ITS CLINICAL APPLICATIONS Antonio Capafonsa and M. originally introduced by Wells in 1924. and several standardized methods were generated shaping this Model. The procedures implemented as part of the model in order to achieve good rapport with clients are the following: a cognitive-behavioral introduction to hypnosis. Research and Applications Editors: G. beliefs. b a b University of Valencia. D. During the intervention. authors describe in detail the Valencia Model of Waking Hypnosis. was developed in Spain. and is focused on variables such as expectations. clients can remain selfhypnotized with eyes open while engaged in other activities. it usually takes less time to obtain results. Private Practice. The concept of waking hypnosis. Koester and P. The model consists of a number of efficient methods intending to be straightforward and pleasant for the patient as well as quick to learn and to apply. which enables them to give themselves therapeutic self-suggestions that can go unnoticed when the problem occurs . Thus. Spain. Sta. Inc. Cruz de Tenerife (Spain) ABSTRACT In this chapter. and represents the first approach to waking hypnosis that disregards the concept of trance. It is based on the socio-cognitive or cognitive-behavioral paradigm of hypnosis. Rather it advocates the continuity between hypnotic and everyday life behaviors. Furthermore. two induction methods of waking hypnosis are added to these procedures. the latter also known as Alert-Hand Hypnosis. Rapid Self-Hypnosis and Waking-Alert Hypnosis. etc. a clinical assessment of hypnotic suggestibility. in which relaxation. The hypnotized person can speak fluently. People are asked to keep their eyes open. Elena Mendoza 238 in public situations. waking hypnosis. Additionally. This way of using hypnosis is more parsimonious and the person is not as afraid of losing control over him/herself as in traditional hypnosis. such as. and it is easily convertible into a general coping and self-control set of skills. WHAT IS WAKING HYPNOSIS? The term of waking hypnosis was used by Wells (1924) to designate a form of hypnosis in which the person does not receive a formal method of hypnotic induction including suggestions for drowsiness or relaxation. essentially. Waking hypnosis cannot be considered as merely waking suggestion. trance. until the 1960s. direct and permissive. etc. catalepsies. expectancies.Antonio Capafons and M. due to its characteristics. the Valencia Model of Waking Hypnosis presents many clinical applications. such as beliefs. it is versatile and efficient. An illustrative case of the clinical application of this model is described in this chapter. hypnosis was associated with the methods based on Braid (1843) or Charcot (1882) views. whereas waking hypnosis counts with a set of hypnotic induction rituals. drowsiness. Hypnotic suggestions are. to expand their attention. and is considered as a therapeutic model embracing a variety of methods combined to change attitudes and use suggestions maximizing their effects. . imagination. due to its versatility. EXPERIMENTAL AND THEORETICAL BASES OF THE VALENCIA MODEL OF WAKING HYPNOSIS Suggestion and other related variables. since the latter can be used without any induction ritual. The Valencia Model of Waking Hypnosis (VMWH) was developed on the basis of the socio-cognitive or cognitive-behavioral paradigm of hypnosis (Capafons. it is easy to generalize to everyday life. restriction of the attention. authors like Bernheim (1884). 2001). The main characteristics of the VMWH are as follows: • • • • • There are not suggestions of drowsiness. and eye closure were suggested. Likewise. to be mentally and physically activated. have been considered for many years components of the hypnotic experience. presents a great deal of practical possibilities and is accessible for more people than traditional hypnosis. walk. Nevertheless. or relaxation. and Hull (1933) advocated for these ideas on the base of their experimental studies of hypnosis. regression. and so on. hallucinations. For instance. and perform almost any of his/her everyday tasks. Hypnosis is introduced as a coping skill avoiding allusions to trance or altered states of consciousness. while experiencing the hypnotic suggestions. with increased sensation of self-control. Wundt (1882). Therefore. the terms used to designate hypnotic reactions were taken from psychopathology and some of them still remain. Gorassini & Spanos. The clients should be able to use the procedures with their eyes open and to generalize them to their everyday life.X. There were even procedures proposed from a behavioral perspective resorting to basic principles of Functional Behavior Analysis (Pascal & Salzberg. Thus. etc. Moreover. & Starr. attitudes. T. Finally. Matthews. and Chaves. 1976). besides the objective response to the hypnotic suggestions. Barber proved that the subjective experience of “involuntarity”. as well as the methods utilized to achieve it in promoting exceptional responses (Spanos & Barber.) (Hawkins. like Kratochvil (1970). or started to use hypnosis without a formal induction (Kuhner. 1993). They should be straightforward for clients to apply and learn (self-hypnosis). to produce the hypnotic responses (Capafons. 1967). Barber and his colleagues (Calverley. could be achieved by using task motivating or think-with instructions (Barber & Calverley. metaphors. To this end. 1986. 1992). alternative methods were developed to bring about responses to the suggestions. thus increasing hypnosis efficiency. Sachs & Anderson. recently. Spanos. In this way. 1976). Conti. Spanos & Coe. and Coe and Sarbin (1991) proposed. They should emphasize self-control and be versatile enough to be used as methods of either relaxation or activation depending on the client’s needs. resorting to variables such as expectations. etc. and Wark (1998). 1974. and experimental research proved the possibility of increasing hypnotic suggestibility (Diamond.The Valencia Model of Waking Hypnosis and Its Clinical Applications 239 Subsequently. On the basis of this theoretical background. Later in the 1970s. Ericksonian authors quit traditional hypnosis and focused on communication and social influence. Lynn & Kirsch. the model advocates the continuity between hypnotic and non-hypnotic behavior. studies conducted by T. 1959). 1962). beliefs. 1998). emphasizing permissive and indirect suggestions in a hypnotic setting away from the usual one (use of analogies. Several methods were developed to increase it.X. the Valencia Model of Waking Hypnosis was developed in an attempt to meet the following criteria: • • • • • The procedures should be pleasant and acceptable for clients. among others) in the 1960s questioned the necessity of the concept of hypnotic trance itself. On the other hand. In this way. in which differential reinforcement of successive approximations or the use of instigators helped more people use hypnosis. Another questioned concept was the trait-like quality of hypnotic suggestibility. Iglesias and Iglesias (2005) used waking/alert hypnosis from a dynamic perspective to treat panic attacks and other disorders. Wilson. 1991. motivation. proposing methods of alert hypnosis [such as hyperempiria (Gibbons. in Hilgard’s laboratory. . active-alert hypnosis was created by making up different methods of inducing hypnosis formally opposed to the traditional ones (Bányai & Hilgard. 1999. the procedures of VMWH derive from the methods for increasing hypnotic suggestibility by Sachs and Anderson (1967). The procedures should not create iatrogenic reactions. and recover Well’s basic ideas of waking hypnosis and Gibbons’ concept of hyperempiria. Wilson & Barber. Other authors. 1965. 1998. and disregards the concept of trance as Barber (1969). the essential theoretical rationale of VMWH lies on the Response Expectancy Theory by Kirsch (1990. 1979)]. ruled out the concepts of drowsiness and focus on a narrow range of stimuli. 1978). 2005. some of them had already been pointed out by Wells in 1924. the Model puts forth a sequence that serves as a guide in the intervention with waking hypnosis (Fig. at the same time. a cognitive-behavioral introduction to hypnosis. PROCEDURES OF THE VALENCIA MODEL OF WAKING HYPNOSIS As mentioned before. Capafons. walking.240 Antonio Capafons and M. c) requires less effort on the part of the therapist and it is easier for the beginner to learn. 1998b. 2001) disregarding the concept of an altered state of consciousness. and engaged in any other activities of their everyday life allows them to experience therapeutic suggestions where the problem they need them for arises (Alarcón & Capafons. flexible enough to be adapted to the cases and patients’ preferences and necessities. In contrast. . In order to establish a good rapport with patients. the methods of the VMWH are intended to be efficient and at the same time pleasant. In the next paragraphs these procedures are explained in detail. they are easier to carry out since the clients count with a coping strategy to go through them successfully. Thus. two hypnotic induction methods (Rapid Self-Hypnosis (RSH) and Waking-Alert Hypnosis (WAH). easy and quick to learn and apply for both therapists and patients. d) it can be used with more people successfully since the start. Chaves. Additionally. namely: a) it has a less mysterious appearance and its impression is more desirable. the methods can be adapted with a greater chance of success if the suggestions given in waking hypnosis were successful (Wells. many of the post-hypnotic therapeutic suggestions can be supported by the client in situ. Secondly. In this sense. in this way. than traditional hypnosis. 1924). that the fact that clients can remain self-hypnotized while keeping their eyes open. 1) and that can be adapted to each specific case. the latter also known as Alert-Hand Hypnosis (Cardeña. 1998b. namely. Elena Mendoza ADVANTAGES OF WAKING HYPNOSIS OVER TRADITIONAL HYPNOSIS Waking hypnosis has several advantages. 12-1-2005). a clinical assessment of hypnotic suggestibility. when homework assignments are included in the therapy. in press). e) when it is needed or preferred to employ hypnosis by relaxation. and was framed in a trance setting (Wells. Alarcón. Additionally. personal communication to the first author. 2004a. obtains benefits faster. usually two or three minutes if not earlier. waking hypnosis strengthens clients’ expectancies for success. talking. Capafons. 1998)) complement the VMWH. The core of the Model is RSH. b). b) it takes less time in obtaining results. reinforces their motivation for subsequent sessions and therapy more generally. and a metaphor for hypnosis. 2006. who. and magnifies their sense of general efficacy and self-control (Capafons & Mendoza. Accordingly. First. it is worth pointing out that the VMWH fosters an active participation on the part of the client. & Bayot. the VMWH introduces waking hypnosis as a strategy for coping and selfcontrol (Capafons. three procedures have been implemented as part of the Model. Finally. 1924). but. the Wells’ model was authoritarian promoting passivity in clients (John F. Our experience with the VMWH allows us to add further advantages. and it is very structured. COGNITIVE-BEHAVIORAL INTRODUCTION TO HYPNOSIS After the therapist has a diagnosis and a functional analysis of the problem.The Valencia Model of Waking Hypnosis and Its Clinical Applications 241 Figure 1. Then. 2006). Clinical intervention sequence of the VMWH (Taken from Alarcón & Capafons. it is convenient to assess the misconceptions about hypnosis that the . the intervention plan is established without mentioning hypnosis and a good rapport is established. Those who use it are showmen. Hypnosis generates exceptional. 1998a): 1. 3. Hypnosis produces a sleep-like “state”. The hypnotist simply facilitates the experience of suggested responses. 2006. in which the following ideas are important to be conveyed: a) responses to suggestions are acts committed by the clients. stop. Hypnosis is beyond the scope of scientific research. Elena Mendoza patient holds as well as his/her attitudes toward it (Capafons et al. and the patient can be scared if the pendulum is used. The most popular myths are as follows (Capafons. answering all doubts the clients may have. Accordingly. d) Accordingly. Coe. 7. 2. If such characteristics are not achieved. . Capafons & Mendoza. quack doctors. but at the same time.242 Antonio Capafons and M. 2004a. but rather involves preparing the mind to access resources that facilitate perceiving responses in daily life as automatic (Alarcón & Capafons. 4. Hypnosis is an efficacious and quick therapy (hypnotherapy) that does not require any effort on the part of the client to change his/her behavior. Hypnosis makes people lose their voluntary control. the person is not hypnotized. However. and therefore not dependent on any “power” of the therapist. Subsequently. Hypnosis can worsen people’s “latent” psychopathologies. these myths about hypnosis are dispelled and explained in detail. which are activated in a manner similar to how they are activated on an everyday basis. as in some countries such type of exercise is used “to get in touch with spirits”. Hypnosis can make people get “stuck” in a trance. or immoral or socially ridiculous acts. Capafons & Mendoza. 5. e) From this perspective. 2005). hypnosis is a form of self-control. People who improve through hypnosis are gullible. or resist suggested responses. 6. Thus. the therapist initiates the introduction to hypnosis from a cognitivebehavioral standpoint (Capafons. Capafons. 1993. including cultural ones. Capafons & Amigó. the therapist performs an exercise with the Chevreul pendulum illusion (see the script of this exercise in Appendix I) (Capafons. 2001. in press). and can commit crimes. in press). even if less conscious effort is required on behalf of people to regulate certain behaviors. Kirsch. 1994).. 2001. f) To be hypnotized does not require entering into a trance or altered state of consciousness. 1980. the person becomes an automaton in the hypnotist’s hands. unusual. and charlatans. b) Actions during waking hypnosis are automatic. To this end. they would lose their will and become insane. being unable to “come out” of such state. ignorant and “dependent”. People with psychopathological problems may get even worse by using hypnosis. hypnosis involves reactions in everyday life that can be activated or deactivated at will at any given moment. they are voluntary in the sense that individuals have the ability to initiate. That special situation can only be achieved by means of a hypnotic induction method. only very suggestible people can benefit from it. in which people show special characteristics. the examples provided in this exercise can be adapted to the patient’s preferences. and quasi-magic reactions in people. It even can make healthy people to develop psychological alterations. Obviously. in a way that. c) What happens during hypnosis depends mainly on person’s ability to utilize their resources. For the first exercise. firm. & Chaves. Schoenberger. 2006). since they are in an unbalanced position that. Actually. However.. In this way. Shindler. it is convenient to determine the reasons why they are resisting. with no intervention of suggestions produces swaying. in itself. patients are asked to stand with their feet together and their eyes closed. Clients are then asked to let themselves fall before the exercise starts so that they can confirm that the therapist has the strength to hold . Patient’s expectancies and attitudes towards hypnosis are assessed as well. Gearan. & Pastyrnak. Kirsch. although they used a different trance explanation suggesting that an altered state of consciousness was instrumental to responding during hypnosis. the VMWH puts forth these exercises that help reduce the fear many people have of being hypnotized and familiarize patients with “waking” suggestions. Even though there are many forms of assessing hypnotic suggestibility. and reinforces the explanations given before when dispelling the above-mentioned myths. unless they block the effects of the suggestions. there is a high likelihood that they are resisting the natural effects of suggestions. These results are in accordance with the findings of a study by Lynn. but nice voice to sway back and forth. postural sway. and confidence in the therapist and the hypnosis itself. CLINICAL ASSESSMENT OF HYPNOTIC SUGGESTIBILITY According to the VMWH. Montgomery. falling back (Hilgard. Afterwards. Vanderhoff. 1997). 2004a) is aimed to assess the clients’ confidence in the therapist with greater certainty than the previous one. it has been found that when reluctant people are offered to received a self-hypnosis method. everyone sways slightly. It may be due to their fears. 1999. clients are informed that. The exercise starts asking clients to close their eyes and try to guess the location and distance of the therapist from them. 1974. that means they are collaborating and experiencing the effect of suggestions. and Stafford (2002). skepticism. since the therapist will catch the clients when they fall backwards. 1965. or other interfering beliefs that should be further explained and dispelled. If clients markedly sway. Additionally. In this case. because of the posture. they can be sure that the therapist is in the right place to hold them when they fall backwards. Capafons. no such differences in dropout rates are observed (Capafons et al. if clients do not sway at all. the initial assessment of hypnotic suggestibility is performed outside the hypnotic context and as a form of assessing patients’ collaboration with. 2005). the therapist suggests with a monotonous. The next exercise. we can assume that they are not interfering or blocking reactions. according to a recent study (Capafons et al. since it has been found that they are related to positive outcomes of psychological treatments that include hypnosis as an adjunctive (Barber. Additionally. 2001.The Valencia Model of Waking Hypnosis and Its Clinical Applications 243 The information conveyed through the presentation increases the probability that clients will feel comfortable with the hypnotic procedures. Chaves. reluctances.. Spanos. If clients begin to gently sway. Nevertheless. the angle of fall should be small. this presentation reduces dropouts more than other presentation that emphasizes achieving a trance state when people who expressed reluctance to experience hypnosis are selected and given the opportunity of being (hetero) hypnotized. just enough to allow therapists to test whether clients try to avoid falling in any way. In case the clients open their eyes because they were afraid. if the clients let themselves fall backwards. Then the therapist indicates that the magnet is moving to the left and drawing the client’s body with it. it can be assumed that clients experienced the subjective reaction suggested. it is assumed that their lack of confidence is not toward the therapist but toward hypnosis. It is introduced as an exercise involving mental self-control. it can be concluded that this client benefits more from imaginative suggestions. the therapist clarifies to the clients that the tricks will be always explained to them. and assesses whether they understood the instructions. and that certain tricks are employed as a part of the treatment in order to improve their responsivity to suggestions. Given that they let themselves fall before the exercise. This is a variant of the standard exercise in which the therapist asks clients to imagine that s/he is holding a powerful magnet his/her right arm.244 Antonio Capafons and M. If clients avoid falling. clients are asked to roll up their eyes and then close their eyelids without lowering their eyes. Often times. If the clients do not open their eyes. which feels the attraction toward the magnet.. or felt as if their hands were stuck together. the therapist can ask clients to look at a given spot on the ceiling. Barber.e. clients find it difficult to roll up their eyes and hold them in that position with their eyelids closed. the therapist ask them how they feel and explain the trick behind this exercise (i. If they also report that they felt unbalanced. After this. then backwards (which are the postural sway movements). In view of the fact that certain clients prefer to use their imagination to completely experience suggested reactions (T.X. clients adopt the same position than in the postural sway exercise and the therapist gives them suggestions for feeling unbalanced and falling backwards. without moving their eyes from this position. If clients fail the challenge by separating their hands. When these difficulties are overcome. it is virtually impossible to raise one’s eyelids while maintaining your eyes in this position). it can be assumed that they trust hipnosis and are collaborative. the . and addresses the possible causes of lack of confidence. In case there are better responses after the application of the magnet metaphor. Elena Mendoza them. If. hand clasping. If this is the case. they open their eyes. the therapist leaves aside the hypnotic suggestibility assessment. thus converting them into prompts for suggested responses. the therapist asks for determining the reasons of their lack of confidence. on the contrary. The last exercise is a motor challenge suggestion. and that the magnet is being passed around clients’ head. 1999). and the therapist inform that they will not be able to do so (challenge exercise). they are asked if at least they felt tension in their fingers. the exercise is repeated. they are instructed to attempt to raise their eyelids. If this is the case. In the next exercise. then forwards. When clients do not interfere with the reaction. Finally. after that to the right. At this point. the therapist can complement this exercise by using a metaphor to facilitate a “postural sway and fall backwards” response. and the therapist explains that it consists in getting the sense that the hands get stuck following suggestions that the hands are so tightly stuck together that they cannot be separated. they will feel they cannot separate their hands until they “break” the response and stop experiencing that their hands are stuck. the therapist asks them about any reluctance they experienced. the magnet attracts the client so strongly backwards that s/he becomes unbalanced and falls into the supporting hands of the therapist. Conversely. and the “trick” is explained. After this. Obliging them to lift their gaze and then to lower their eyelids without moving their eyes from the target spot. they are reminded about the difference between automatic response and involuntary response explained in the cognitive-behavioral introduction to hypnosis. the therapists can obtain useful information about the willingness of patients to collaborate and get involved in the therapy. Finally. clients are invited to initiate their experience with self-hypnosis. and (3) a challenge suggestion (“confirmation” exercise). feeling of heaviness. modeling and the chaining of the . In case the clients respond appropriately and do not become frightened by their failure to separate their hands. heaviness and immobility. Before inducing hypnosis it is convenient to warn clients about the expected effects they can experience during the hypnotic induction.The Valencia Model of Waking Hypnosis and Its Clinical Applications 245 therapist asks them why they separated their hands. dizziness. The clients are informed that these exercises are designed to produce sensations of relaxation. The steps are very structured and the way the training is done is based on Applied Functional Behavior Analysis. Rapid Self-Hypnosis consists of the three following steps: (1) hand clasping. namely. these reactions are similar to the ones experienced when relaxing by any other method.. By including the assessment of attitudes and expectancies in a qualitative way. since they have activated the tension response in their hands and have not interfered with it. Additionally. and that with some practice they will probably be able to perform the exercise while in hypnosis. then the mechanism behind the exercise is explained. (2) falling backwards. it consists of the shaping of the behavior through successive approximations to the goal. If clients report that they did so because they feared losing voluntary control. If the clients have performed correctly most of these exercises and have a positive attitude toward hypnosis. it is worth pointing out that the way of using and interpreting these classic exercises is different to the usual one. Rapid Self-Hypnosis (RSH) is an induction method of waking hypnosis that also can be employed as a traditional method suggesting relaxation and restriction of peripheral attention. the therapist gives the clients strategies for them to cope with interfering thoughts and images that prevent them from concentrating. and to decrease tension and concerns about testing. If the clients fail to experience any reaction. and they are told that there is a very high probability that they will respond well to the therapeutic suggestions that follow. In case of suggesting relaxation. Also. the exercise is repeated using counting and imagination techniques (i. as well as to activate the brain so that it works in a rapid and effective way. On the other hand. drowsiness. RAPID SELF-HYPNOSIS AND ARM DISSOCIATION At this point. it should be explained what is expected from the clients so that they do not confuse the activation instructions with anxiogenic instructions. If none of these endeavors succeeds clients are told that they are not in hypnosis. using jokes to help establish rapport. tingling. when RSH is used as an activation method. lightheadedness. That is.e. a strong glue that sticks the hands together). the therapist may proceed to teach them a self-hypnosis method. Additionally. all these exercises are carried out in a relaxed atmosphere. it is convenient to remind them of the trick. verbal explanations. Finally. namely. etc. the importance of experiencing the tension without interference. it is appropriate the establishment of a sign indicating the therapist that the client wants to come out of hypnosis. such as cognitivebehavioral interventions. all individuals need to do in everyday life is to activate the dissociation of the arm in order to set the stage for self-administering therapeutic suggestions. these self-hypnosis procedures becomes more abbreviated and better disguised. Bayot. Additionally. The exercise consists in asking the clients to self-hypnotize and then imagine themselves being the main characters in an adventure story in a jungle facing a number of fictitious problems. Likewise. 1999). nor the adoption of a relaxed posture. as well as to activate self-efficacy expectations to facilitate therapeutic outcomes (Callow & Benson. & Bustillo. (b) successful responding does not imply a lack of effort or perseverance to achieve a change in behavior. With practice. therefore. afternoon. nor the closing of the eyes. Moreover. This brief variation of RSH is called Arm Dissociation (AD) (Capafons. and the sensations of heaviness are faded. clients are told that it is important to practice the method three times in a row in the morning. and it has been found that the AD method makes RSH a more efficient and effective hypnotic method. the therapist provides them with a metaphor aimed to convey the following ideas: (a) hypnosis is not dangerous. relaxed. which will help the therapist to adapt exercises in future sessions to the clients’ characteristics. Capafons. clients are interviewed to know their reactions and preferences. Once this procedure is over. as if “it were not theirs. The therapist’s instructions.246 Antonio Capafons and M. They overcome them successfully with their own effort. clients capable of reproducing extreme heaviness in their arm. and they are also advised to perform it in various places according to the principle of stimulus generalization. or when relaxation is needed. the patients learn the steps separately and then they are put together. 2001). A detailed description of the steps of these procedures is in Appendix II. and (5) it results in an increase of the client’s suggestibility (Reig. AD surpasses the initial method in a number of relevant characteristics: (1) it is more pleasant. and (c) hypnosis is an important tool that can act as a catalyst of other treatments. RSH can be reduced in this way to a single instruction of reproducing a sensation. 1990). In this way. and use of a . Therefore. which. although the last two can be used to maintain the habit and optimize overlearning. the metaphor is intended to be a didactic aid that allows clients to consolidate and remember the information about hypnosis explained to them before (Porush. A METAPHOR FOR ATTITUDINAL CONSOLIDATION Once clients have experienced self-hypnosis. (3) it is shorter. Simply put. the instigating exercises. the whole procedure is similar to a process of stimulus fading and generalization. Clients thus gain access to self-hypnosis by fading the relaxation exercises and relinquishing the traditional hypnotic appearance (eyes closed. (4) it is less noticeable in public. Elena Mendoza behaviors. goes unnoticed by others. The ability to respond is then generalized to new therapeutic suggestions with no need of further shaping exercises. At that moment they are “in self-hypnosis” and. with very little practice. are ready to implement the therapeutic suggestions they need in a given situation. without interrupting their activities) and give themselves suggestions for feeling their arm heavy and immobile. sleepy). creativity. and night. (2) it can be applied easier to the client’s everyday life.” and experiencing a dissociation of the arm from the body. can concentrate on the arm (with the eyes open. 1987). since it requires neither overt exercises. Accordingly. or any object even imaginary ones) can provoke reactions that in a natural way. 1999). it is possible to conduct several practice exercises in which clients start realizing that a series of stimuli (pencils. Capafons. According to research. HETERO-HYPNOSIS: WAKING-ALERT HYPNOSIS (WAH) This procedure (also known as Alert Hand Method. Alarcón. A description of the introduction. but with the understanding that clients will eventually use hypnosis on themselves. (b) it includes some exercises to be performed previously to avoid that clients confuse the concepts of being activated with being anxious. 1998). Bányai. since clients always keep their eyes open. & Hemmins. whereas in Banyái’s method it is not this way all the time. Among the methods of alert hypnosis developed. is to increase clients’ selfefficacy and outcome expectancies (Kirsch. & Cardeña. Insofar as in the VMWH the suggestions are given while clients keep their eyes open. & Bayot. 1998a. encourages clients to keep their eyes open. they would never provoke. and WAH method can be found in Appendix IV. PRACTICE AND TRAINING SUGGESTIONS One of the purposes of hypnosis. especially waking hypnosis. and (f) it can be performed by clients who are in poor physical condition but still can benefit from suggestions of alertness (Cardeña. like RSH. 1998). 2001) as a part of the VMWH and to complement the RSH. Capafons. 1976. Waking-Alert Hypnosis. and even maintain a pleasant conversation with the therapist. pre-induction exercises. 1998a. Cardeña. 1964). adopt a normal everyday appearance. & Bayot. Zseni.The Valencia Model of Waking Hypnosis and Its Clinical Applications 247 multipurpose tool. Capafons. since the latter requires an ergonomic bicycle. Alarcón. and promotes a greater level of suggestion (Alarcón. Capafons. and the most similar to WAH in the sense that both promotes to keep the eyes open and general activation while remaining hypnotized. the one created by Bányai (Bányai & Hilgard. current findings from research have shown that WAH counts with a number of advantages over Bányai’s method as follows: (a) WAH is more pleasant (Cardeña. (c) it is easier to conduct that Banyái’s approach. Nevertheless. 1986) fostering their motivation to get involved in the intervention. or a spacious room in which the clients can walk around and activate themselves. watches. It is especially helpful for those clients who prefer to be hypnotized by the therapist (Capafons. 2001). 1998) was designed by the first author (Capafons. (d) WAH is easier to generalize to everyday life. & Turi. In these cases. b. Alarcón. & Bayot. 1999). after listening to this metaphor. (e) WAH produces fewer dropouts than Banyái’s method. Alarcón. most participants change their opinion about hypnosis and consider it as an adjunct technique to the intervention that helps gain self-control (Capafons. . a machete that represents hypnosis (see the full text of this metaphor in Appendix III). something that could happen (Ludwig & Lyle. 1993) is probably the most researched of them. 1985. Bayot. the therapist can hypnotize clients with the aim of reinforcing the efficacy of the self-administered suggestions. and your attitude towards the problem can help you solve it? Answer: Yes. An array of types of suggestions that the therapist can use is as follows: ¾ Suggestions for the efficacy of suggestions and techniques. and on your attitude towards it? In other words. to reverse the suggestion means that the ball pen will evoke lightness later. On the other hand. relaxation. on the contrary. Now those symptoms are no longer out of their control. or imagine. energy. self-hypnosis reveals to be an adjunctive method that helps increase self-control and self-regulation. what lead them to change the meaning of their symptoms. strength. the therapist proceed to chose the kind of therapeutic suggestions more suitable for the case and the patient’s characteristics. Next. ¾ Do you think that the objects evoke the reactions that you have experienced due to the meaning that you have associated to those objects? Answer: Yes. Elena Mendoza These exercises start asking the clients to self-hypnotize. . By using Hull’s (1933). ¾ Ego-strengthening suggestions: confidence. they are modulated. ¾ Do you think that hypnosis can help you manage better your thoughts and your imagination. clients tend to respond adequately to the questions. reactions of heaviness and lightness are suggested to be evoked and associated to seeing or touching different objects. ¾ Do you think that changing your way of thinking. Then. Clients also learn that they are developing their own ability to respond to hypnotic suggestions that is based on a sort of mental discipline. and keep a better attitude towards your problem? Answer: Yes. and/or maintained by their attitude and understanding of the problem. In this way.e. as well as your attitude has favored those reactions? Answer: Yes. that is. if it has been suggested that seeing a ball pen will generate heaviness. THERAPEUTIC SUGGESTIONS Once a patient has learned the procedures described so far. satisfaction. ¾ Well-being: joy. terminology the therapist explains the client that these exercises are useful to facilitate homoaction (i. these exercises allow asking the following motivational questions to the clients: ¾ Do you think that there is any objective reason by which seeing or touching those objects would generate heaviness or lightness? Answer: No ¾ Do you think that the way you think. of imagining. the improvement of the responses through practice) and heteroaction (i. do you think that your problem depends on the meaning that you have associated to it? Answer: Yes. In this way. Usually. ¾ Do you think that the magnitude and implications of your problem partially depend on your way of thinking.e. these suggestions are reversed. of imagining. ability. determined. the improvement of the performance in difficult suggestions by practicing others less complicated).248 Antonio Capafons and M. clients understand that responding to suggestions is also a matter of practice and learning that facilitates the use of self-hypnosis as a technique to promote coping skills. ¾ To express suggestions forcefully and with confidence. Paradoxical intention (as a variant of challenge suggestions). Anxiety.The Valencia Model of Waking Hypnosis and Its Clinical Applications ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ 249 Distancing: indifference. hallucinations of solutions. Motor suggestions: immobility. It is better to say: “As I face the situations I am afraid of. ¾ To involve as many sensory stimuli in the visualization as possible. when you come out of hypnosis. you will feel refreshed and active…” ¾ The suggestions have to be credible for the client. even showing an intense emotional involvement. Age regression to the time the person did not have the problem (without looking for precision of the recall). Amnesia. from surroundings. etc. To modulate the tone of voice all the time. sadness. RECOMMENDATIONS TO INCREASE THE EFFICACY OF SUGGESTIONS It is important to take into account the following aspects when using direct suggestions: ¾ To use the appropriate tone of voice for each message: emphasizing key words and talk with the rhythm. Analgesia / Anesthesia. showing confidence and fluency. Alteration of the physiologic experience of anxiety or similar. Dissociation of parts of oneself. in case of failure in responding to the suggestions the following strategies may be helpful: . ¾ To use a positive wording. calmness. It is better to say “tobacco is indifferent to you”. repulsion. Satiety – appetite. Desire / Control. serenity. than “you do not feel like smoking”. Repugnance. you will feel refreshed and active… during the next half an hour. slowing down or acceleration of movements. than saying: “From now on. rejection. ¾ To have available a variety of suggestions to prevent boredom or habituation. To avoid repeating the suggestions dully and mechanically. they will quit bothering me”. confusion. objectivity. Automatic writing. pauses. Finally. ¾ To use short suggestions or break them in short sentences. and pace adequate to the client. Time progression to a date in which the problem has already solved. excessive worry. Time distortion: acceleration (while in pain) and slowing down (while enjoying a meal). I will always enjoy riding my bicycle” (in case of an agoraphobic patient). and during the next half an hour. Reinterpretation of psychophysiologic reactions and thoughts. panic. ¾ Post-hypnotic suggestions will have a short and specific limit of time: “In a moment. The patient asked for help through hypnosis to manage pain and cope with peri-surgery anxiety. was familiar with cognitive restructuring of irrational thoughts. CLINICAL APPLICATION OF THE VMWH CASE J. and was prescribed pain medication. and so on. At first. unrealistic expectancies. It has to be stressed that the idea is to evoke responses already in the repertoire of the patient. J. or to promt those not still in it. the only option left was surgery. o Association of that response to a verbal.Antonio Capafons and M. ¾ To perform exercises to correct the response as outlined below: o Instigation and observation of the response aimed to suggest. Given that he was receiving cognitive-behavioral treatment for his GAD. Elena Mendoza 250 ¾ To turn to the learning of sensory/emotional recall control or the reproduction of responses in general. . After seven days. Explanation of the ways one can interfere with hypnotic procedures. Explanation of how hypnosis works. and progressive muscle relaxation. to learn self-hypnosis and its applications to the problems he was facing at that time related to the injury of his wrist. distractions. ¾ To emphasize individual differences in speed and style of learning. including exercises using a pendulum. o Encouraging the response reproduction by activating the cue. since J. Session 1 First. such as different ways of not following the suggestions. ¾ To distinguish between involuntary and automatic behaviors (the later can be controlled). (SURGERY ANXIETY AND PAIN MANAGEMENT) The patient is a 47 years old male who was in psychological therapy for Generalized Anxiety Disorder (GAD). removing distrust and/or impatience. the physician decided to check for a hidden scaphoid fracture through an MRI. In the course of this treatment he suffered an accident that resulted in an injury in his right wrist. visual. the cognitive-behavioral explanation of hypnosis was introduced to the patient. ¾ To emphasize the concept of interference. had not improved at all. and pain. By the means of several practical examples. distress. diaphragmatic breathing. This diagnosis was confirmed and due to failure to diagnose and treat the fracture earlier and acutely. The goal of this part of the treatment was for J. or both cue (optional). it was supposed to be a severe sprain and the patient was given a Velcro wrist splint that he took on and off. the presentation consisted of the following concepts: • • • Correction of the misconceptions about hypnosis offering precise information supported by scientific research. J. and that hypnosis is a helpful agent in the treatment but not the entire intervention in itself. the therapist used a small rubber ball that the patient squeezed with his healthy hand to exert the pressure. Finally. it was assumed that J. Since the patient had pain in his wrist. the patient allowed himself to fall backwards and reported to have felt unbalanced as soon as the exercise started. All the exercises were done outside the hypnotic context. was collaborating and experiencing the effect of the given suggestions. who responded appropriately and found this exercise very amazing. and confidence in the therapist and the hypnosis procedure itself. in this session another exercise was proposed to the patient. and then they were chained together to complete the method. “roll up the eyes”. found the exercises easy to perform since they are closely related to the hypnotic suggestibility exercises practiced in the previous session. It is worth pointing out that the rapport with this patient was already established since he was in an ongoing treatment with the same therapist for GAD. a variant of the first step of the method (hand clasping) had to be made up. the therapist proceeded to teach J. The third exercise. Therefore. pleasant. was able to understand all these concepts and showed a good attitude to continue with the next exercises. the “hand clasping” exercise was not carried out. Therefore. Rapid Self-Hypnosis (RSH). the initial assessment of hypnotic suggestibility was performed in order to assess J. Also. therefore. 1999)). & Hemmings. he reported that he liked the exercises and found the session very fun. While he was selfhypnotized and kept his eyes open. due to the patient’s injury in his wrist. while focusing on the feelings of heaviness in this hand. Session 2 The patient came back a week later for this session. The first one was the “postural sway” as explained before in this chapter.’s collaboration with. J. was explained to the patient. Alarcón. the metaphor helped consolidate the information about hypnosis already given in the presentation.The Valencia Model of Waking Hypnosis and Its Clinical Applications 251 J. the patient was asked to hypnotize himself using the method he just learned and the therapist proceeded with the following exercise. The goal of this exercise was to convey the ideas that hypnosis is safe. and at the moment of dropping the hand on his leg. Second. After asking him general questions about how he was doing and if there was something new about his wrist treatment. he let the ball go and relaxed his hand. The patient’s sway was pronounced in response to the suggestions to do so. In the next exercise. had confidence in her and it was easy for him to do the exercises without fears. The other steps were taught to the patient separately without any other variants. In this case. “falling back”. It consisted in reading a fictitious story in which the patient had to imagine himself coping with a series of difficulties to survive in a jungle that he solved successfully thanks to his effort and the correct use of a machete that represents hypnosis (see Appendix III for a detailed script of the metaphor (Capafons. that it is required an effort on his part to change behaviors. Finally. the therapist suggested the patient to evoke reactions of . Subsequently. and interesting. since it might cause him pain.252 Antonio Capafons and M. for instance. afternoon. . Other thoughts were the following: “what if the surgeon makes a mistake”. and dissociation of his right hand. “what if the delayed surgery results in non-union of the scaphoid bone and the subsequent osteoarthritis and deformity”. Capafons. so he needed a full recovery before being able to come back). was taught to him. He was able to respond to the suggestion for arm dissociation quickly and found this method more straightforward and pleasant than the long version. muscle tension/muscle relaxation. It was easy for the patient to feel the suggested reactions and to associate them to cues. & Bustillo. he was afraid that his sick absence was too long leading him to be dismissed from his work (he worked in an office using computers. The patient needed some time to do the associations and. this ability of changing his sensations would improve and become more automatic. Elena Mendoza heaviness and lightness. The assignments for the next session were to practice RSH three times in a row in the morning. All of them were suggested in his right hand except for the muscle tension/relaxation. that he answered as expected. 2001). also. he associated the mental image of an ice cube to the sensation of cold in his hand. had made the list of worries about his problem. “I will be unable to learn to write with the left hand if the right one never heals”. in this case. In addition. “I will be unable to sleep at all in the hospital”. Once again these sensations were associated to several stimuli chosen by the patient. many patients prefer to choose cues reminding them the pursued sensation. After finishing the exercise the patient was told that with practice. however. he would be able to use that method everywhere he needed to use self-hypnosis and to give himself therapeutic suggestions. heaviness was associated to the touch of a red pen and lightness to the sight of a small notebook. and that selfhypnosis would be a good tool to accomplish these changes. and the pain and difficulties this injury was causing him. and night. J. J. “I will suffer intense pain after surgery”. He included catastrophic thoughts about not being able to bear the pain of his wrist after surgery and during the physical therapy. It is worth mentioning that it is not necessary that the suggested reaction is similar to the object. Then. numbness. word. the brief variation of this technique. and so on. each reaction was associated to the sight or touch of different objects. Then. or image that will be associated to it. was told that from now on. A review of the assignments indicated that the patient had understood well the RSH procedure and had been practicing it easily. called Arm Dissociation (AD) (Reig. when he had achieved them. The following sensations were suggested: cold/hot. “I will be very anxious all the time”. and his attitudes toward them. Given that the patient had practiced RSH and was comfortable with it. his staying in the hospital. understood well the rationale of this exercise and became aware that he had control over his problems and symptoms by changing his way of thinking about them. Session 3 This session took place one week after the last one. the therapist asked him the questions mentioned in the “practice and training suggestions” section. Bayot. the patient was told to use AD and self-hypnotize for an exercise similar to the one carried out in the last session. and to make a list of the main worries he had about his surgery. heaviness/lightness. During this exercise he started to realize that he had much more control over his feelings and sensations than he thought which motivated him and made him feel more relaxed and positive about his situation. J. for instance: “I can manage successfully any uncomfortable sensation in my wrist”. had a good response to the “sensory substitution” practice. etc. Shaw. anxiety. contrasting with the original script. some emotions he had found particularly helpful were used in this exercise. He had done a strong association with a cue and was well able to reproduce it quickly.) with other sensations (either pleasant or neutral). 2003) was conducted. The patient received the suggestions of substituting any uncomfortable sensation in his wrist (i. Finally. by concentrating on them. cope with his catastrophic thoughts. and AD was used as the self-hypnosis method. it was used the “direct diminution” exercise (Patterson & Jensen. and that it is easier to generalize to everyday life situations. another exercise with waking hypnosis was performed. the “sensory substitution” exercise for pain management (Patterson & Jensen. The associations practiced in the previous exercise were very helpful. he was asked to restructure the irrational thoughts he had recorded in the way he had learned in his therapy for GAD (Beck. Then. I feel calmer and more relaxed”. 2003). This time J. J. In this case. such as cold. 1979).The Valencia Model of Waking Hypnosis and Its Clinical Applications 253 Subsequently. he reported that he had reproduced the alternative sensations easily and that. etc. Also. “I have the ability of controlling my sensations and emotions”. Likewise.e. and dissociation of his hand. in this case the patient kept his eyes open all the time like in any other waking hypnosis exercise. One of them was the idea of feeling proud of himself for having been able to control his anxiety and overcome all the problems related to the injury in his wrist. which made him feel in control and with self-efficacy expectancies. Also some imaginative metaphors were used for the uncomfortable sensations decrease (the therapist gave the patient the option of closing his . However. could use in selfhypnosis. J. The idea of this exercise is to train the patient to substitute uncomfortable sensations (such as pain. he had been able to increase their intensity in a way that the pain intensity decreased considerably. in which suggestions for the uncomfortable feelings become less clear. numbness. He reported to feel much better and having used successfully the exercises he had learned every time he felt pain or anxiety. “As I breathe deeply. The advantages of adapting this exercise to waking hypnosis are that the patient is active in the process all the time and explains to the therapist how he feels and the difficulties he goes through during the exercise. the patient preferred to close his eyes to concentrate better in visualizing himself healthy in a near future. a time projection exercise was performed in this session. going back to his job. & Emery. after a pause in which the patient talked to the therapist about his medical treatment for his wrist. The therapist reviewed the patient’s list of rational thoughts resulting from the cognitive restructuring and the more suitable were adapted in suggestions that J. kept his eyes open and the therapist suggested the same sensations than in the previous session to reinforce and consolidate the associations. As assignments for the next session. etc. In order to help J. Some of the emotions mentioned were also used in this exercise. less strong. further away or smaller were provided. pain) with other sensations. was asked to practice the exercises of this session every day and anytime he would feel pain in his wrist or any other distress. Session 4 The patient came back for this session one week later. Rush. relaxed during his stay in the hospital. whereas in other cases reproducing sensations of cold or numbness was enough to make the movements bearable and almost without being aware of any discomfort. the cast of the patient’s wrist had been recently removed and the X-rays performed indicated that the bones had healed properly. relaxation. the sleepier I will feel”. anxiety or any other discomfort he could suffer during this period. so that he could use them whenever he needed them. Finally. sessions were pleasant. such as pain killers or anxiolitics. he expressed a great satisfaction with the treatment and its results. the therapist taught him how to use paradoxical intention as a variant of challenge suggestions. His level of anxiety had decreased dramatically since the last session. Additionally. Elena Mendoza eyes for this last part or the exercise. as well as suggestions for analgesia and anesthesia were explained in detail separately. it is worth mentioning that. The reasons he mentioned were: it was a short treatment. according to his physician. fun. The therapy outcomes reported by the patient were positive in all the areas for which the treatment was implemented. he needed less medication. different suggestions for restorative restful sleep. self-confidence. holding positive expectations about his fast recovery and his ability to manage pain. Furthermore. To sum up. and for a refreshed awakening in the morning were taught so that he could use them before going to sleep. little efforts yielded good results. Moreover. were also given to J. Follow-Up 1 The patient came back after surgery. J. he reported that he was sleeping well at nights. He reported that by using self-hypnosis he was able to stay relaxed and to manage pain during the ongoing sessions. He reported that at that point he felt much better. etc. Particular suggestions. and procedures were practical in the sense that he was able to use them anytime he needed them. The swelling had significantly diminished and the pain was bearable and less intense than he had thought. the patient reported to . Moreover. Also. he was told to restructure any negative thoughts he could have relative to his problems to sleep. reported problems to sleep. even before surgery. due to the fact that J. He still needed to wear a cast for several weeks. Finally. but he was used to waking hypnosis and felt so comfortable with it that he preferred to keep them open). compared with other people suffering from the same problem.254 Antonio Capafons and M. and interesting. such as the suggestion for time distortion to accelerate difficult moments like the peri-surgical period. in a telephone follow-up one year after the treatment. The patient was referred to begin a rehabilitation program. three weeks later than the last session. reported that self-hypnosis allowed him to remain calm and relaxed during all the hospitalization process. Follow-Up 2 After two months of the surgery. for instance: “the more I try to be awake. for relaxation. some general suggestions for well-being. He found especially helpful the dissociation of the hand in cases in which the exercises were too painful. in four sessions the patient was able to learn a self-hypnosis method and a variety of self-control strategies as well as suggestions management for reducing pain and anxiety related to a peri-surgical situation. in a way that the Physical Therapist worked easier with him. Moreover. easy to learn and to apply. they are flexible and easy to adapt to the preferences. some interviewed therapist reported about VMWH (Capafons & Mendoza. The fact that the model is based on waking hypnosis entails some characteristics that distinguish them from other methods using traditional hypnosis. CONCLUSIONS The procedures of the Valencia Model of Waking Hypnosis described in this chapter count with empirical validation and come into view as potentially useful in clinical practice. Clients soon incorporate Waking Hypnosis ways of using suggestions as coping and self-control skills and abilities. Likewise they are easily convertible into a general coping and self-control set of skills. whereas they keep the efficacy attributed to other forms of hypnotic suggestion management. Waking Hypnosis increases their interest and motivation for the treatment. keep their eyes open. needs. Findings in research on the VMWH validate and confirm some well-worn concepts: a) waking hypnosis is as effective and efficient as hypnosis by relaxation. and useful. the procedures comprising the VMWH do not mention trance or altered states of consciousness that may frighten or discourage clients. . and for increasing motivation and performance in sports.The Valencia Model of Waking Hypnosis and Its Clinical Applications 255 have reached full recovery of his wrist injury and to keep on using self-hypnosis and the other therapeutic procedures to any difficulty he has to deal with in his everyday life. Therefore. concepts like selfcontrol and perseverance are emphasized. All these methods of suggestion management have been described by both patients and therapists as pleasant. It can be used easily for urgent and/or very difficult cases (Pires. and characteristics of the different cases. efficient techniques. The Valencia Waking Hypnosis methods are easy to learn for patients. as an adjunctive. The Valencia Model of Waking Hypnosis reduces the duration of the interventions and makes them more pleasant. they are as efficacious as other forms of hypnotic suggestion management and even surpass a number of other methods in research support. maintain a fluent conversation with the therapist. On the contrary. Additionally. and. enjoyable. ultimately. the clients are able to respond to the suggestions while they remain active. this model puts forth waking hypnosis as a compelling alternative and complement to the traditional use of hypnosis by using pleasant. namely. Finally. Moreover. b) almost everyone can experience hypnosis to some extent or be trained to be hypnotized. to treat different problems. and its ways of managing suggestions as very pleasant. the procedures have a great versatility. helpful. and c) hypnotic responses imply that clients can access certain resources that are also available in nonhypnotic circumstances. Patients perceive the Waking Hypnosis ways of hypnotic induction. 2007). in press) the following: • • • • • • They have successfully used the Valencia Model of Waking Hypnosis. In fact. and experience a strong sense of control. Alarcón. 33.. Bányai. Barber. A. Barber. Anales de Psicología. (2006).J. Active-alert hypnosis in psychotherapy.F. Princenton.. Barber.. Rush A. Elena Mendoza Additionally. (2001). (1976).J. (1965). E.) and diverse health professionals share similar opinions to those mentioned previously. (1843). Journal of Abnormal Psychology. The Valencia Model of Waking Hypnosis. Clinical hypnosis and self-regulation: Cognitive-behavioral perspectives (pp. D. Bayot. T. A.X. B. A. G. Capafons. 41. Capafons. Washington. Shaw. American Journal of Clinical Hypnosis. D. A. In J.. Handbook of clinical hypnosis (pp. & Benson.. D.. USA.C. Hypnosis: A scientific approach. J. S.256 Antonio Capafons and M. 71-88..: American Psychological Association. 218-224. A. (1999). E.X. 54-60. Bernheim. E. (1979). & Cardeña. etc. (1999). A. Cuba. A.T. Neurypnology: Or the rationale of nervous sleep considered in relation to animal magnetism. (1974).. A comparison of active-alert hypnotic induction with traditional relaxation induction. (1993). therapists of different countries (Brazil. A. E. Psicothema. La hipnosis despierta setenta y cuatro años después (Waking hypnosis seventy-four years later). 21-48). Journal of Personality. T. Rhue.W. .I.R. New or innovative techniques?) Papeles del Psicólogo. Spain. Capafons. 85. REFERENCES Alarcón. (1998a). Empirical evidence for a theory of “hypnotic” behavior: The suggestibility-enhancing effects of motivational suggestions. Metaphor technique (story telling) as a treatment option. E. Lynn & I.. relaxationsleep suggestions. Portugal. Hipnosis. Cardeña & S. Papeles del Psicólogo.. (Hypnosis). 15. (1999).. Callow. Beck. (1990). 269-276. N. & Emery. A comprehensive three dimensional theory of hypnosis. 69. (1969).S. & Hilgard. 70-78.: American Psychological Association. & Capafons. Kirsch. Washington... & Túry. Capafons. Braid. De la suggestion dans L’etat hypnotique et dans l’etat de veille. Barber. Hypnotism: Imagination and human potentialities.. H. 77-88. A. G. In I. and suggestions that the S will be effectively hypnotized. Paris: Doin. Preference between two methods of active-alert hypnosis: Not all techniques are created equal. Capafons. Cognitive Therapy of Depression. A.P. A. Bányai.F. Zseni. 27. Hipnosis clínica: una visión cognitivo-comportamental (Clinical hypnosis: A cognitive-behavioral perspective). Madrid (Spain): Síntesis. & Chaves. NJ: Van Nostrand Reinhold. New York: Pergamon. & Calverley. London: Churchill. 7.I. 256-270. Amigó (Eds. 571-581. Educational and Child Psychology.X. Kirsch (Eds. T. G.. T. 271-290).X.C.). Spanos. F.M. (1998b). Capafons. A. (1884). J.). Rapid self-hypnosis: A suggestion method for self-control. New York: Guilford. . 27. CR Academy of Science. & Bayot. (2004a). In F. Clinical applications of “waking” hypnosis from a cognitivebehavioural perspective: From efficacy to efficiency. Australian Journal of Clinical and Experimental Hypnosis. Espejo. Cabañas.. A social-cognitive skills approach to the successful modification of hypnotic susceptibility.R.. Coe. (1999). Espejo.. New York: Pergamon. 94. D. 303-323). 1004-1012. Alarcón. & I.J.. Introducción práctica.). P. (1999). W. (1986). Washington. (1998). (In press).J. A. E. S.). Chaves..J. Capafons. Modification of hypnotizability: A review. Kanfer & A.L. (2006). Kirsch (Eds.. Handbook of clinical hypnosis (pp. Rhue. New York: Harcourt. A.E. Capafons. (2004b).R. Y. A. hypnosis. Contemporary Hypnosis. Amigó (Eds. M. A.C. Diamond. M.. Waking hypnosis for waking people: Why from Valencia? Contemporary Hypnosis. B. Cabañas.M. & Amigó. & Mendoza. (1991).. Gorassini... Capafons. Madrid (Spain): Eudema. Alarcón. New York: Appleton-Century Crofts.P. A metaphor for hypnosis. 136-145. (1980). (Hypnosis and self-regulation therapy. E. Capafons. 119-134. C. 280-294.. Introducción a la hipnosis clínica: una perspectiva humanista (Introduction to clinical hipnosis: A humanist perspective). Applying hypnosis in pain management: Implications of alternative theoretical perspectives. 227-247). E. Charcot. 158-172.W.. (1974). Helping people change (2nd ed.. Selma. 21.H. J..: American Psychological Association. 180-198. Cardeña. A. 187201. A. In I. . & Sarbin.L. Washington DC: American Psychological Association. Role theory: Hypnosis from a dramaturgical and narrational perspective. Mendoza. B. Contemporary Hypnosis. Hawkins. M. Alarcón.F. Alarcón. A. Kirsch. 21. Physiologie pathologique: Sur les divers états nervaux determinés pour l’hypnotization chez les hystériques. Coe. A. Change of attitudes toward hypnosis: effects of cognitive-behavioral and trance explanations in a setting of heterohypnosis. S. Brace & World. Australian Journal of Clinical and Experimental Hypnosis.F. M.P. 403-405. Capafons. A practical introduction). S. J.. Lynn. & Monje. 22. Capafons.). 34. & Spanos. A. (1993). (1933). & S. (2005). & J.E. J. International Journal of Clinical and Experimental Hypnosis. S. A. Hypnosis and suggestibility: An experimental approach.R.The Valencia Model of Waking Hypnosis and Its Clinical Applications 257 Capafons. Effects of different types of preparatory information on attitudes toward hypnosis. (1998).. M. A.W.). & NatkinKaner.C. Hypnotic Susceptibility. (1882). Lynn. Effects on suggestibility of a new method of active-alert hypnosis. Kirsch. Mendoza. Chaves. In J. Rhue (Eds. W. M. 45. Hipnosis y terapia de auto-regulación. N. A. Valencia (Spain): Promolibro. A. Hilgard. A. (1965). DC: American Psychological Association. 81. 67-76. In I. Capafons. Psychological Bulletin. A. 50. Cardeña. & Hemmings. Journal of Personality and Social Psychology. Hull. T.).J. Handbook of clinical hypnosis (2nd edition).. Washington D.E. Goldstein (Eds. Expectations. S. Capafons.C.. and suggestions in change. Clinical hypnosis and self-regulation (pp. “Waking” hypnosis in clinical practice.. Pires.. Kirsch. Self-efficacy and expectancy: Old wine with new labels. Teorías de hipnosis (Theories of hypnosis). I.. Changing expectations. terapia de auto-regulación e intervención comportamental. 49. Matthews. Porush. 17. Chicago.R. (1962). Lynn. (1990). (2005). Kirsch. 231-240. 70–76. 7. J. S. Journal of Social and Clinical Psychology.P. Unpublished pre doctoral degree thesis.. narratives.). and performance standards.R.. Theories of hypnosis. S. International Journal of Clinical and Experimental Hypnosis. A systematic approach to inducing hypnotic behavior. Valencia (Spain): Promolibro. 4. In S.H. Kirsch. D. I. 18. California: Brooks Cole Publishing Co. Kratochvil. Hipnoterapia cognitivo-comportamental: Expectativas y cambio de comportamiento (Cognitive-Behavioral Hypnotherapy: Expectancies and change of behavior). Current thinking and research in brief therapy. Kirsch. Vol. The social learning theory of hypnosis. (2002). Early research on self-efficacy: What we already know without knowing we knew. Prague. Kirsch. I. A. C. (1986). Capafons & S. (1964) Tension induction and the hyper-alert trance.J. & Starr. Journal of Personality and Social Psychology. 25. (Hypnosis. L. Matthews & J. 37. 69. (1991).. suggestibility. & Kirsch. Investigación sobre la preferencia entre dos métodos de autohipnosis (A research about the preferente between two self-hypnosis methods). (1987). 9-15. A. & Salzberg. (2007. July). M. Philadelphia: Taylor & Francis Pub.M.J. (1985). D. What Homer can teach technical writers: The mnemonic value of poetic devices. strategies. Patterson. Hypnosis without hypnosis. 25-40. (1993). H. A. A. Defining hypnosis as a trance: vs. Martínez-Tendero. 824-830. (1998). Czech Republic.. solutions. Current models and perspectives (pp. (1970). Awake-alert hypnosis in the treatment of panic disorder: A case report. Journal of Technical Writing and Communication. Clinical Hypnosis as a nondeceptive placebo: Empirically derived techniques. Lynn. G. American Journal of Clinical Hypnosis. 249-258. S. (2005).J. American Journal of Clinical Hypnosis.J. International Journal of Clinical and Experimental Hypnosis. (2003.). 467-483).J. Vanderhoff. Amigó (Eds. American Journal of Clinical Hypnosis. I. Pain management. Illinois. W.L.). cooperation: Hypnotic inductions. Using clinical hypnosis to improve the effects of psychological therapies in some complicated clinical cases. H. & Jensen. W. 339-358. & Lyle.. 93-99. Edgette (Eds. self-regulation therapy and behavioral intervention) (pp. Papeles del Psicólogo. 45-61). 47. Oral presentation at European Congress of Psychology. November). I. 239-263). Ericksonian hypnosis: A review of the empirical data. Shindler K. II (pp. Jynn & J. (1959). 129-143. .258 Antonio Capafons and M. New York: The Gildford Press. 10. 95-106. Journal of Abnormal and Social Psychology. A key to effective psychotherapy. (1994). J. 44. (1995). I. Hipnosis. In W. Ludwig. Rhue (Eds. 161-167. & Stafford J. Workshop at 54th Annual Scientific Program of Society for Clinical & Experimental Hypnosis. Sleep hypnosis and waking hypnosis. University of Valencia (Spain)... Kirsch.. In A. & Iglesias.W. I. Pacific Grove.C. Kuhner. Conti. International Journal of Clinical and Experimental Hypnosis. Pascal. Elena Mendoza Iglesias. New York: Academic Press Inc. (1992). APPENDICES Appendix I Cognitive-Behavioral Introduction to Hypnosis (Capafons.. That particular one never works when I try it. N. & Coe. New York: Guilford Press. 102-130). In W. 18.).. or anything that can be used as a pendulum.. Gearan. in press) This introductory presentation begins with the therapist providing the client with a pocket watch with a chain. Behavior modification and hypnosis.. Nash (Eds. 20. Journal of Abnormal and Social Psychology.J. Hypnotismus und suggestion (Hypnotism and suggestion). T. Leipzig: Engelmann. Behavior Therapy. Contemporary hypnosis research (pp.). In E. (1924). So what have you asked the watch? [The . the therapist holds the pendulum between his/her thumb and forefinger. he or she asks the clients to do it in more or less the following way: Therapist: “Now stretch out your arm and allow the pendulum to come to rest completely still.. P.R. Wark. & Bustillo.. N. G. Suggestion and degree of pleasantness of rapid self-hypnosis and its abbreviated variant. W. W. Current Thinking and Research in Brief Therapy: Solutions. Capafons. Ask it whatever you wish but do not ask it to defy gravity and move up towards the ceiling. Philadelphia: Taylor & Francis Pub. Kirsch.M..L. Wells. Schoenberger. 172-180. Capafons & Mendoza. I. Spanos. & Barber. Strategies. A. Very good! Now ask the watch to move in some direction or other. Sachs.E. Wilson. D. 2001. (1976). (1998). 235-249. 2004a. A. Eisler. 389-404. The creative imagination scale as a measure of hypnotic responsiveness: Applications to experimental and clinical hypnosis. the therapist asks the watch to perform circular movements or oscillations.The Valencia Model of Waking Hypnosis and Its Clinical Applications 259 Reig. Edgette (Eds. International Journal of Clinical and Experimental Hypnosis. American Journal of Clinical and Experimental hypnosis. When the therapist has finished the exercise. Alert hypnosis: History and applications. (1997).P.. Spanos. (1892). (pp. 287-304). (1967).L. 28. Hersen. I. Matthews & J. & Anderson. (1978). N. 152-164. W.C.. T. A social-psychological approach to hypnosis. to trace circles or move from left to right or backwards and forwards.B. (2001).). S. Narratives. A. In M. S. Modification of Hypnotic Susceptibility. W. & P. 29. L. 127-140. Progress in behavior modification (pp. R. & Pastyrnak. Montgomery. The therapist explains and serves as a model for the following exercise: With the dominant arm stretched out in front of his/her. 1-43)..M. Hypnotic enhancement of a cognitive behavioral treatment for public speaking anxiety. and if it did work I would probably die of shock. 4.X. Experiments in waking hypnosis for instructional purposes.P.X. Australian Journal of Clinical and Experimental Hypnosis. At this moment.M. Bayot. Wundt. Fromm & M.C. Miller (Eds. & Barber. When a person is hypnotized s/he does not lose control. interference is something positive: You have shown me that you are an active person and that you control what occurs in hypnosis at any given moment. The reactions which that person experiences are automatic (you asked the watch to move. Can you notice anything? C: I think I notice very minute movements in my hand. It’s incredible. Ask it now! [The client does so but the watch does not move]. in a way. just a stupid game. they just jump out without having to think of them. It just moved by itself. its fun isn’t it? OK. it’s a pendulum. lets try it again but this time I want you to watch your hand very closely (the watch moves). you did not ask your hand to move the watch. it would hardly move at all regardless of what we ask it to do [the therapist demonstrates the idea]. I can stop when I wish [the therapist stops talking for a few moments]. and that you are in fact being ridiculous. However. Generally. right? T: Precisely! But let us try another exercise. or once it stopped interesting you. but I do not have to search for the words in order to talk. but voluntary. In this way talking is automatic. Whenever you hear my voice (or indeed your own voice) suggesting things to you your brain will send “orders” to the organs involved in the response which you experience. I guess that’s obvious. this is another form . This is what we call interference. hypnosis.260 Antonio Capafons and M. given that you yourself initiated and detained the response once you thought that it was ridiculous. Maybe I moved it without realizing it. which amplifies the almost unnoticeable movements of your hand at the end of the pendulum and for that reason you can see the movements. Elena Mendoza client answers and the watch moves] Ah! Fantastic! I can see you are quite good at this. is like that. T: Yes. OK? But remember. then they obstruct us in our attempts to achieve some goal or other. Well. I would have to think about many of my words. however. But I’m not doing it on purpose! T: Exactly! Do you know what this pendulum is. If there is anything that you do not like or if you think that anything is inappropriate. The word interference usually has negative connotations: interference impedes us from watching the television. Why do you think the watch moved? Client: I don’t know. You see. and you will do things in order to experience these responses. of course I do. ask it forcefully and demandingly. or just think of something urgent that you have to do at home or at work (the watch usually comes to a stand still).. which happen. you will experience voluntary but automatic responses. or from using our mobile phone. Talking itself is a voluntary act. Do you understand? C: Yes I think so: It’s just like walking.. It is also you who puts an end to them.? C: Well. T: OK. I want you to think that what you are doing is really nonsense. Hypnosis is like that. Now. as if they just happen. If I had to speak to you in a different language which was not so familiar to me. it is always you who triggers the things.. Can you see what happens? If you don’t move your hand the watch will stop moving. Let’s do another exercise. If we were to shorten the chain which suspends the watch [the therapist holds the pendulum near the watch end of the chain]. you can interfere with it and stop it..e. in my case. they will be so subtle that you will not even notice them and you will experience them as if they happened by themselves. it would be something voluntary but not automatic. i. If someone interferes. your brain understood the instruction and activated the hand movements by itself). Stretch out your arm and ask the watch to move in a specific direction [the watch moves]. voluntary but automatic at the same time. Stretch out your arm and ask the watch to move but this time ask it as if your life depended on it. But in this case it works as an amplifier. Have you ever had anything like that happen to you? C: Yes.. forcefully demanding that it occur. for me. as it would imply a break in our communication. which I would like to ask you: If you wished to interfere with the suggestions or the therapy how do you think you might do it? C: Well. T: I see. It is just like when you try to remember something that is on the tip of your tongue.. Otherwise our communication will be broken. I don’t think I will interfere. Do you think that I could believe it possible that you should be frightened by something that you know is not real but is actually a fantasy. etc. then I guess so. C: I suppose I would think of something else. I look away from the most terrifying scenes. and you do not communicate this to me but instead keep silent. If you wish to experience something and you are waiting on it. please tell me right away. actors. T: Good. now I would like to explain something else. T: Do they frighten you? Do you notice anything about yourself? C: Yes I get scared. The cinema is an art form. even though I like the movie. and that I am observing you while you watch the movie. I don’t know. you will lose confidence in me and I will not be able to help you. Do you understand? C: Yes. a scriptwriter. and you know that everything is just a story. this would be an inappropriate interference. T: Excellent! Just a moment ago I mentioned that. there are interferences that would be inappropriate. perhaps not follow the instructions or not offer any ideas about looking for solutions. You know that there is a director. Tell me. yes I believe so. then it most probably will not happen.. Nevertheless. T: Perfect. Do you know what they are? C: No. fear.The Valencia Model of Waking Hypnosis and Its Clinical Applications 261 of interference. your hands sweat and you feel a sense of danger? C: Yes. the more you try to remember it the more blank your mind goes. T: There is still one more thing. cameras. have you ever seen a horror movie? C: Yes. T: Probably not. but try now to imagine what you would do in such a case. T: But really it’s not like that. I think I am getting the hang of what it means to be hypnotized. If this were to happen. This would not be positive. I don’t know what you mean. then both you and I would be wasting our time here. if we can overcome all possible misunderstandings. T: I mean that if at any moment you feel unhappy or do not agree with any of the suggestions or with any of the things we do to help overcome the problem which has brought you here. I know that you have understood what to expect from hypnosis but I would still like to us to agree on one more thing. a lie? Don’t you think that I should believe that you were not very intelligent? C: Well if you look at it like that (laughter). sometimes. many times. OK? C: All right. T: Your heart beats faster perhaps. I assure you that all the time that we spend here talking about this will be time saved in the future. Right? . I’ll give it a try. I am going to ask a favor of you: If you discover that you are doing one of the things which you have just described. As I said before in this case we would both be wasting our time. Now try to imagine that I am an extra-terrestrial. I notice tension. interference is something positive. . I am looking forward to experiencing what it is like to be hypnotized. OK. C: OK. I will propose that you experience certain things. C: Exactly. All you have to do is avoid going to the movies or stop paying attention to the director’s proposals. happiness or pity generated by the images. but it doesn’t take much effort unless of course the movie is really badly made. crying etc. So what happens when you watch an interesting movie is that you experience enriching intense automatic reactions? In spite of the fact that you know everything is false. I think that now I know why I sometimes get a sense that I do things almost without wanting to but without losing control. If you decide that the story does not interest you. what do you or indeed other people do when they don’t want to see certain sequences of a horror movie? C: I look away. Don’t you think that these behaviors are like interferences? C: Well. Sometimes I think that it is all a lie and I distance myself from the plot. You may even experience certain behaviors a sudden start for example. or you may wish to interfere in it. . T: Well. just don’t listen to it. hypnosis works in a similar way: Sometimes I will be the director of the movie (directing the hypnotic suggestions) and at other times you will be the director (selfhypnosis). just like the fear. I guess they are. Sometimes these reactions can be very intense but they will always be under your control. OK? C: Yes. All things considered. All of these reactions however are under your control. sometimes I cover my face with my hands and I look out from between my fingers. generally. What happens in hypnosis is voluntary and automatic at the same time. you can experience enriching intense sensations and reactions which will help you to overcome the problem which you have told me about. well hypnosis is just like a story or a film..262 Antonio Capafons and M. T: Perfect.. It depends on you. OK. now that you mention it. which deep down you will know are not true (for example that you cannot lift your arm or that you forget something. and you become involved in the story that is being told.) because if you allow things to happen (just as in the cinema) then they will happen. I never thought that hypnosis worked that way. you let yourself go along with the director’s proposals and thus you experience intense emotions. covering your eyes. given that you must “forget” something that is obvious. T: Precisely. but do not forget to tell me. You may wish not to initiate the processes to experience certain reactions. Some people actually leave the cinema. just like “forgetting” that all is fantasy and paying attention to what happens on screen. T: In other words. You unconsciously “forget” that behind the scenes there is a whole team of people who have recorded the movie and that all you see are the effects of a few lights reflecting consecutive stills on the screen. The reactions that you experience are automatic. You can even get up and leave the theatre. you voluntarily choose not to think of the fact that it is all a fantasy. it is actually a great effort. is that right? C: Yes. Elena Mendoza C: Yes of course (laughter). T: That’s right. If you like the proposed script. In fact. T: Going to the cinema is a voluntary act. If you wish we can begin with a few exercises that will give us information about your current level of responding to hypnotic suggestions. or I leave my seat. the flame must move but not go out. Remember that we will use anything that will help us experience those sensations. It is not a matter of using a lot of pressure. so that by the third exhalation there is a level of pressure that is mild but strong enough to notice heaviness in the arms and hands when they are suddenly dropped on the legs. the therapist takes a deep breath and during the exhalation lightly presses each hand against the other. without relaxing the hands as I inhale (the therapist demonstrates). I am going to repeat the exercise twice. the therapist can ask him/her to imagine a candle 25 cm. Now. or cannot exhale slowly. we did an exercise in which I suggested that you would fall backwards. As the client exhales. after verbally reinforcing the patient: «Very good. On the other hand. in a matter of seconds. the patient is told «Pay attention. That is how softly the exhalation must be.)» It may be useful to be very clear with the patients that with each exhalation they must very lightly press each hand against the other. etc. it is time to continue to go to the next exercise. Do you remember them? Well. If the client finds it difficult to exhale slowly. the exercises we will practice are designed so that you won’t fall to the floor and get hurt. It is also helpful with individuals who suffer from rheumatism. This is a good . away from his/her mouth. but only enough to notice later on the sensation of heaviness in the arms. but as a form of self-hypnosis. We are going to use two of them. and another one in which I suggested that your hands were so tightly stuck together that they could not be separated because of the sense that your hands got stuck together. it will be easier later on to notice their heaviness as we do an exercise of arm immobility. Don’t worry.» Hand-Clasping After explaining the steps. The client is told that «This way is useful so that I won’t get hurt if I wear rings or jewelry.» Next. you are learning very fast. We will use hand-clasping and falling backwards (assuming that the client’s susceptibility to hypnosis has been assessed through the exercises of falling backwards and hand-clasping). When I assessed your hypnotic susceptibility. And that is what we will do next. as the therapist helps and corrects as necessary. It is very important to just exert a light pressure as you very slowly exhale.The Valencia Model of Waking Hypnosis and Its Clinical Applications 263 Appendix II Steps of Rapid Self-Hypnosis (RSH) (Capafons. I have chosen them because they are very powerful and can be used in such a way that they will go unnoticed in everyday life. Once this has been achieved. 1998b) Before learning the steps. the therapist explains the rationale of the method more or less as follows: «There are many ways to induce hypnosis very rapidly. You must now do the exercise. arthritis. If the patient cannot imagine that. (The client does the exercise. the therapist clasps his or her hands without interlacing the fingers and without pressing them against each other. the therapist can use a real candle so that the patient will learn to move the flame without turning the candle out. Making them feel tired in this exercise. It is not appropriate to exhale abruptly or to use much pressure. these two exercises can be modified into fast methods to induce hypnosis. some people exhale too rapidly or abruptly. Slow breathing will help us notice general sensations of heaviness and relaxation. At that moment. falling backwards. «As you may have seen. if the patients state that they do not feel heaviness (or lightness. the therapist should show surprise and indicate that this is a good signal of what is to come). When I do this. Hence. the therapist asks the client to do the same. separating my back from the back of the sofa some 10 cm. we should suspect that they are interfering.. I will give you some suggestions so that you can focus on sensations of heaviness and paralysis. Next he or she does it again twice. as it is experienced by some patients). you can interrupt them any time and without difficulty. while explaining what reactions should be occurring. When the therapist has finished shaking the hands with the last exhalation. now we are going to link both steps. This is not a «hypnotic» reaction but a biological response that will help us evoke a later response. All right. This is the position that I will be in when I let myself fall backwards.e. as we mentioned above. (The client repeats the exercise a number of times).» If clients indicate that they do not experience anything of what we have described. Now you should repeat this exercise. and then I will let myself fall backwards. assisting and correcting the client in a kind and encouraging way. At the moment of exhalation. You will see that it is not difficult or uncomfortable. of which only 43% also had to use imagery to achieve heaviness. the therapist lightly will press the hands against each other and will exhale slowly. actually all of your body is heavier and you notice that you are lightly relaxed. without relieving the pressure on the hands with each inhalation. Next I will lean forward. but you must practice so that you can end up in a comfortable position and in such a subtle way that no one will notice anything. Now we are proceeding to the next step. Martínez-Tendero (1995) has shown experimentally that 90% of the people that used rapid self-hypnosis felt great heaviness. so I will ask you to collaborate as much as possible. which is very important to activate our mind and enter self-hypnosis. I notice a sense of muscle relaxation (by being more comfortable) and of momentary paralysis. This light paralysis is a natural reaction.» Falling Back Here the therapist models the exercise and says the following: « I am now reclining into the sofa so that I will be comfortable. It could be fear of hypnosis. separating from the back of chair. Afterwards. while explaining to the client what is happening. Elena Mendoza sign that you can use this method successfully.264 Antonio Capafons and M. (The therapist lets him/herself fall backwards twice of thrice). shaking the hands and inhaling. the therapist models this exercise. the hands are very heavy. disbelief about what the . the therapist must interrupt the session and find out what the problem is.» Chaining of the Two Steps As with the other two. (Some people get very relaxed at this stage. This allow us to stimulate the reactions of the following step (i. You will also know that if you do not like them. since the exercises are designed to let anybody experience heaviness and relaxation. if this occurs.. You know that if you do not interfere you will notice the reactions that I will propose to you. he or she abruptly lets the hands fall on the legs and the back on the back of the chair. Next. the sensation of relaxation instigates a sensation of immobility). in a similar way as what I would do if I were sitting upright and I wanted to be more comfortable. 1999) Now imagine that you are driving a jeep through the South American jungle. if you wish. 2001. heavier and glued. To help you achieve that. You are travelling through a forest road. glued to the legs . 1. Now. All of a sudden your car . as if they were fused to the legs.. Capafons. but walking would take you about five. the therapist should not proceed to the following step.The Valencia Model of Waking Hypnosis and Its Clinical Applications 265 person is experiencing.. (in a slow and rhythmic voice). you will open the eyes (if the patient closed them) and your mind will be active.. or you feel so heavy and relaxed that you feel too lazy to try to separate them.. Remember that at any point you can interrupt those reactions. glued. Once the client dominates the previous sequence. Very well. you could separate them now. I will give you suggestions to feel your hands more and more glued to your legs. or disappointment that the method is not powerful or «esoteric» enough. Try it and you will notice how difficult it is to detach the hands from the legs (the client tries to do it and »cannot«). One or both of them will feel heavier and heavier.. & Hemmings. or of a very heavy object that does not allow you to lift the hands. All right. you will notice that in a moment it will be very difficult to lift the hands. you can use images of a soft rope that binds your hands to your legs. 2. They are lighter and lighter.. and if you so wish. I notice that you are able to control your mind so that it can follow your instructions. You are going to a town where your expedition companions are waiting for you. Is that all right?» Once the client has practiced once again shaking the hands and falling backwards. but if you put your mind in action. if you wish. you will have activated your mind and your brain.. the therapist begins the suggestions: «Now. and will recover their usual sensation. among giant trees. Until those fears and doubts are eliminated. That’s it. excellent. focus on your hands. you can lift your hands at any point..says the therapist. Body Immobility «Now . and when you have “fallen backwards”. the therapist goes to the following stage: body immobility. and wherever and whenever you want.. the more difficult it will be to lift them and the more they will feel glued to the legs. close the eyes. heavier and heavier. clear. You know that. When it becomes very difficult to separate the hands from the legs.you will repeat the sequence you just learnt. They will feel lighter and lighter.. Going by car it does not take more than an hour. calm and relaxed. close to an equatorial river. and focus on your hands. or of a very powerful glue that glues your hands to your legs. fear of being hurt. if you let your brain be sufficiently activated. and you will be able to produce some enriching and useful responses to your problem. with a desire to work on the problem. the more you try to separate them. you will notice that you cannot separate your hands from the legs. that’s right. I will now count to three and you will «come out» of self-hypnosis. What matters here is that you may be able to use them so that you can self-administer the therapeutic suggestions in a very efficient way. If you notice these reactions. Alarcón. Furthermore.. and they feel even more glued to the legs. and 3 How are you feeling?» Appendix III Metaphor for Attitudinal Consolidation (Capafons.. You also remember that it is full of piranhas that would devour you in a few minutes. and reasoning. and you have nothing to defend yourself against them. You are surprised to find that you are out of gas. You feel nauseous when you see the head separated from the body.266 Antonio Capafons and M. And. You know that it can be very dangerous to try to walk to the village. but you have no option. There are very strong currents and raft is unstable. sure of your strength and ability. You rapidly start to cut some small trees and lianas. which have allowed you to overcome hopelessness. But you suddenly realise that the river is close to the road you are on. It is coming to you so fast that you can even smell its fetid breath. and desperately took for something that will get you out of this mess. confusion. above all. You try to think what to do. you decide to go for it. You are very tired and it is getting darker. You continue marching towards the river with self-assuredness. You imagine how you will be received when you reach the port. You feel satisfied. you grab the machete. It frightens you but it is the only thing you have to save your life. but you continue clearing the path without pause. you do not give up because you know that you have the machete to help you to continue struggling to reach your objective. You become more and more worried. You try to start the jeep. You start walking towards the river. But you remember that you still have the machete. despite the pain in your hands and the overwhelming fatigue. Once again you are scared. In it you will be able to cross the river safely and reach the town's port where they are waiting for you and you will be safe. strongly cutting the vines. bewildered. and confusion. You are increasingly tired. Just then. You have got rid of . It seems that the machete is a sharp and dangerous weapon. despite the river's rapids and the protruding rocks that could destroy the raft. A number of people are waiting for you. armed with an oar which you have built. which is still moving and from which blood is spurting. you behead it. You are tense and confused. If you could cross it. from within the trees a giant serpent with dangerous fangs attacks you. You are no longer afraid. and despair. You will feel satisfied. clearing a path through the jungle. but you know that you are close to your goal. but it is also empty. Elena Mendoza stops. You can see the lights of the town and even hear some distant voices. Once the raft is finished you enter the river. you should shortly be in a safe place. Finally you reach the river's edge but notice with surprise and despair that the river is enormous and turbulent. You have reached your objective. You are becoming more and more tired. Reluctantly. You have been able to ward off the attacks of your enemies. You look at the additional gas tank. self-confident. You use the oar strongly. Your associates. through your effort. Fear and uncertainty cloud your thoughts. bushes and shrubs that hinder your way with the machete. You are again overwhelmed by anxiety. With them. Finally you reach the port. You are afraid because you do not have supplies or water. You are very scared and can barely avoid it. You notice your anxiety [the therapist describes the patient's anxiety reactions]. The jungle is full of dangerous insects and deadly creatures. you are hungry and thirsty. amazed and admiring. The sun is setting and it will be dark soon. Your feet seem exhausted and your legs seem to bend. fear. You remember that the town is on the other side of the river. Suddenly you find a very big machete. Then. but there is no sound. The hand and arm with which you are holding the machete are increasingly fatigued and they are starting to hurt. fear. you will have solved your problem with your own effort and courage. Suddenly. You know that the serpent wants to devour you. will greet you with admiration. perseverance. and a death sentence to stay by the jeep. You cannot even start a fire. This scares you. happy. You know that with the machete you have been able to untangle and eliminate the obstacles in your path. you build a raft. Nonetheless. with a precise stroke of the machete. You have had to run risks. you will be able to control your anxiety and give yourself therapeutic suggestions so that.) To enter hypnosis. but also to create new ways of life and relationships. It seems dangerous and it scares us. It is not a matter of feeling unusual or anxious but active and alert. You know that it is not necessary to be relaxed or to close your eyes. Imagine that it is 30 minutes before that . It is a frightening instrument. for instance when you were going to meet someone you had not seen in a while and wanted very much to see. Appendix IV Introduction. etc. But remember. we will do some exercises so that you can understand better what I am saying. confused or in despair.). At that moment. design and build something new to reach your goal. you can look for the best solutions to the problems you may be facing. Without your industry. You can use it whenever you wish. effort. your objective. in such a way. But before doing hypnosis. so that they can retain a greater sense of control and feel more comfortable. your mind must be receptive so that if you so wish. & Bayot. 1998) Introduction (After establishing rapport. intelligence. 1998a . The hypnotic induction follows if the participant understands the exercises. it can become a peerless instrument to go forward in the path we have traced. it is a help to overcome your problems. But you also know that this is not enough. it is of no use whatsoever. improve our habits. to eliminate hindrances and obstacles. Capafons. the following instructions are given. Exercises 2 and 4 can also be carried out. Do remember that every time that you are afraid. You will see that it is an enriching experience that will help your mind be active and work efficiently. You have built the raft. The machete is like hypnosis. to open new options by taking the risk of changing our life or the way we see it.The Valencia Model of Waking Hypnosis and Its Clinical Applications 267 what prevented you from reaching your goal. You can enjoy hypnosis without having to be relaxed. Pre-Induction Exercises. Try to remember that time. a new way of transportation. courage. as when you expect something pleasant to occur. you must have felt impatient when waiting for something you wished for very much. struggle and persevere to attain what we aim for (decrease our fears. It is not enough to firmly and decisively get rid of the obstacles. you can say the word "machete" to yourself and focus on the arm dissociation. and Waking-Alert Hypnosis Method (Capafons. courage and creativity. But if we use it with cunning. And you have achieved all this with the help of the machete. This is like life. In fact. but when you understand it and use it with decision.) Exercise 1 At some point. perseverance. you can follow my suggestions and enjoy them. many people prefer to keep their eyes open and not to relax. I can help you feel alert and active. and dexterity it becomes an instrument that can be of great benefit to reach our goals and objectives. We have to fight. Cardeña. Pre-Induction Exercises (Note: Exercises 1 and 3 will be done with every participant. The machete is the self-hypnosis. Alarcón. Otherwise. Elena Mendoza encounter and that you are starting to feel anxious. that is. and you want it to happen..268 Antonio Capafons and M.. To continue walking becomes easier. It is possible that your breathing will be faster. Let us do another example. you start to feel clear minded and refreshed. instead. (Go to Exercise 3. when you decide to start strolling.) Focus on me word ("congratulations") above the drawing. we'll do another exercise. As time goes by. That's it. You feel restless. As you continue walking. Now. a very pleasant breathing because you feel increasingly more energy as you continue strolling. (Go to Exercise 3) Did you imagine the situationidescribed? Comments: Did you experience the sensations (heartbeats. how about if we start with the hypnosis session? Did you experience how your mind expanded? Comments: . surely you start feeling better. Let's do another example. It is possible that at the beginning. Do you understand what I mean? (If not) Don't worry. But after a while. and that emotion over-whelms your body. It is only a few minutes before you will see that person. concentrate on the scene under the houses. and there is a pleasant sensation throughout your body.) (If yes) Perfect! Because I can see that you understand what I am talking about. (Go to Exercise 3. now try to see the bird underneath it. anxiety) I described? Comments: Exercise 2 Remember a time when you were taking a long walk. fine. (Go to Exercise 2) Comments: (If yes) Very well! Now we'll go to another example. The time will come when you have the whole scene in your mind. look at the little animals and continue expanding your field of vision so that you will now see that some animals are eating ice cream and some others are playing with a ball. considering that many muscles in your body are working. Let us continue. you will see that there are some houses and. and you enjoy walking more and more.) Did you imagine the situation I described? Did you experience the sensations (breathing. (The experimenter will need a drawing. you feel more refreshed and active. and you will understand it then. you start to notice that your heart is beating faster. not an unpleasant restlessness but a very pleasant one.) (If yes) Very well! Now we will go to another example. it is a bit difficult and you feel a bit lazy. energy) I described? Comments: Exercise 3 Let us do a little exercise. so that your mind will also expand— If you do this. Remember that as time goes by and you continue walking. because your mind is expanded and active. and the phrasing of the exercise will change accordingly. in the periphery of your vision. Have you followed the exercise? (If not) Don't worry. but it is not a worrisome breathing. a few trees. (Go to Exercise 4. Do you understand what I mean? (If not) Don't worry. Ready? Good. It is. each minute beating faster. The goal is to gradually increase your field of vision.. pleasantly anxious. any cars. We will continue imagining… Continue flying over the city as you get higher and higher... so that you will be able to see not only the city but the whole country. which feels so expansive and activated that you can see the Earth within the Milky Way. Try to imagine it. you have a complete view. but now imagine that the roof and everything else over that room has disappeared.. Start moving it up and down from the wrist. pedestrians… Try to imagine it all from above. and oceans… Your mind expands more and more. while you rest your arm on the arm of the chair. you start to go higher and higher. Did you imagine the situationidescribed? Comments: Did you experience how your mind expanded? Comments: (Note: Once this exercise is done – for those who need it induction follows. your mind is totally focused on the TV set. at the distance.. You are controlling your mind. You can see the whole room. lamps. any buildings or parks. the closest things and those that are farthest away.The Valencia Model of Waking Hypnosis and Its Clinical Applications 269 Exercise 4 "I am going to ask you to close your eyes and imagine what I am saying: Imagine that you are watching a TV show... You can see your city and the whole country at a distance. the rest of the buildings… And. automatically… Your muscles will not get tired but the opposite.) Now.. Your heartbeat is speeding up. so that from above. you can see it from the air. very good… Now. oceans. Keep moving the hand up and down without stopping… You will notice soon that the movement becomes more and more automatic and that the hand will start moving on its own. you can continue seeing the TV set. the planets.) Waking-Alert Hypnosis Method (WAH) (Once we are ready to proceed with the induction and the client is comfortably seated in an armchair. as you notice that the arm feels also pleasantly tense and activated. You like this program very much and are absorbed in it. the street where your house or apartment is. lamps. From that perspective. Your mind is expanding more and more.. and you can see the people and the cars becoming smaller. for instance. they will become more and more activated … Notice how the movement becomes more and more automatic. Your heart is pumping more and more blood to move the muscles… and you can notice how your heart rate is increasing slightly. as if you were flying over the city. concentrate on your right hand. You continue to be in the room with the TV set.. you can see your house or apartment over there. that room and the rest of your house or apartment— Imagine the whole building. furniture. You can see the whole globe and can differentiate high mountains. Now place your street in your city. look at all of the streets. and so on.... and your breathing starts to speed up more and more. the rest of the Universe— you can see the Earth from the vast space. That's it. so far that you can see its rivers. stores.. and what I am describing to you is easier and easier because your mind is becoming more active. as if the hand had a mind of its own… The hand is becoming more and more active.. any chairs. imagine the room with the TV set and try to see everything that is around the set. imagine any piece of furniture the TV set is on. in a similar way as when you are impatient or somewhat excited. more and more. we proceed. the stars. It is becoming easier to control your mind. if you have an apartment. That's it. the whole area.. You are breathing more and more rapidly but with a nice rhythm…It is a . You can see the country as if it were drawn on a map. very far away. you can see the whole space. to such an extent that you can see the Earth itself. mountains. may be carried out to "show" participants that their mind can do these exercises when it is activated. you will regain this level of mental activation (touch the shoulder or do another cue). Your muscles are less activated." and as long as you wish it. to happen. and you will have an active mind..) To save time before the next sessions. your heartbeat starts to gradually slow down. each time I touch your shoulder (or another appropriate cue) and tell you that you will "go into this active and alert mental state. alert.. with an urge to do things. very well. The participant can be told. and your breathing is slowing down 2. your chest and head are also more active and feel like moving… You now feel the need to get up from the armchair and walk. and as long as you wish it. increasingly clear and expanded. You will sense the urge to be active.) As you walk. 1.. In a moment. All your body is becoming more and more active— The blood coming from your hand is irradiating throughout all the veins and arteries of your body. less activated physically and less expanded mentally. very hypnotized. with an activated and receptive consciousness… Your mind is prepared.. waiting for an event. As your heartbeat and breathing slow down. expanding… You can now stop the movements in your hand. 3. .. When I reach 3. but your breathing remains rapid and agitated and you are becoming more and more hypnotized. the following. both to a comfortable level. very expanded... and as you do so. to the door of the room. Now listen carefully. activated and very. This will be very helpful to you and me because we will be able to spend more time solving a problem. you will have come out of hypnosis. How are you feeling? (In a clinical setting.. activated and hypnotized… Your mind is working more and more rapidly. and activation. Elena Mendoza fast but pleasant rhythm. or any other that may be of particular interest. That's it. your muscles will be relaxed. your mind is active but less expanded. and you are feeling even more hypnotized. you will feel calm. it may be profitable to do a quick reinduction and leave a cue for future sessions. expansion. (Note: After this induction. taking along a sensation of energy.270 Antonio Capafons and M. you start coming out of hypnosis. a pleasant event. I will count to 3. I am going to give you a cue so that you will be able to re-hypnotize in a few seconds. your breathing also becomes slower. but in a serene and peaceful way. exercises such as arm levitation.. Remember that every time I touch your shoulder this way (touch the shoulder or do the other cue again).) (After the exercises. (The person gets up and walks. similar to when you are alert... You are out of hypnosis but remain active and relaxed. And you start noticing that you are more and more hypnotized. Your mind is hypnotized and ready to work quickly and effectively. You are coming out of hypnosis. before the last count. Your legs are more active and they have a tendency to move. you will achieve this same efficient and active mental state.) Now concentrate on my voice.. the person is dehypnotized in the following way. calmly and at your pace. you feel yourself more hypnotized. and Kilham. Cavalletto. This chapter describes and evaluates the ways in which one such alternative. The emphasis is placed on finding reported since recent critical reviews by Spanos (1989.In: Hypnosis: Theories. Inc. It also considers the spectrum of application of hypnosis in chronic pain management and reviews systematically collected data as well as case studies pertaining to several chronic pain problems. Delisle ISBN 978-1-60456© 2009 Nova Science Publishers. 1987. help them appreciate * A version of this book was also published as a chapter in The Handbook of Chronic Pain. Even though we now have a wide array of medical therapies that are relatively safe and largely effective in managing many forms of chronic and acute pain. AND THE ACUTE PAIN ACCOMPANYING THEIR TREATMENT * John F. Dalla Pozza. has been used in the management of chronic pain. especially in the management of chronic pain. Carmanico. Inc. 1997). Research and Applications Editors: G. Chaves The effective management of chronic pain continues to present a serious challenge to the health professions. . 1994). Spanos. Kreitler. Diego Beltrutti. Koester and P. It describes the nature of hypnotic interventions and the manner in which they have been used in chronic pain management. published by Nova Science Publishers. these therapies have significant limitations. D. clinical hypnosis. 1977. It was submitted for appropriate modifications in an effort to encourage wider dissemination of research. The pain relief achieved with traditional biomedical and surgical therapies is often incomplete and sometimes ineffective (Stevens. 1994) and Chaves (1989. including the management of acute pain associated with the treatment of underlying medical conditions producing chronic pain. Aldo Lamberto and David Niv. relief too often comes at a high cost in terms of the patient’s quality of life (Douglas. 1993. 1999). Adding to these considerations has been our growing awareness of the limitations of a narrow biomedical perspective on health and well-being and a recognition of the need to embrace a broader biopsychosocial perspective that encourages our examination of alternative approaches to pain management (Engel. edited by S. Chapter 11 HYPNOSIS IN THE MANAGEMENT OF CHRONIC PAIN CONDITIONS. Cooper. R. and Ellis. Moreover. My goal is to provide a framework for clinicians who may be unfamiliar with this modality to understand better the nature of hypnotic treatment. 1994). 1983). there has been substantial growth in the amount of research. or Mesmerism. mastectomies. 1976. however. systematic efforts were underway to refine older therapeutic strategies and to develop new strategies for exploiting psychological resources that were already available to patients as well as assisting them in developing new skills that could be beneficially applied to reducing their symptoms (Fordyce. 1997). and dental extractions apparently completed with substantially less than the expected levels of pain (Deane. these accounts predate the discovery of inhalation anesthetics. By the time inhalation anesthetics had been discovered in the middle of the 19th Century. Ellenberger. in part. and treatment of many painful medical conditions. Although substantial gains in the clinical practice of pain management have been made since the Gate Control Theory was promulgated. 1997. Soon. Ward and Topham. Chaves the empirical evidence supporting its use. 1983). 1965) that offered new ways of understanding the neurophysiological mechanisms by which psychosocial factors could amplify or attenuate the pain experience. Of course. Delatour. so it is not surprising that evidence . even as more sophisticated psychological interventions for pain management were developed (Turk et al. Turk. West. 1996. being conducted on psychological interventions for chronic pain management. In recent years. To put this topic in context. to the reconceptualization of pain perception provided by the gate control theory of pain (Melzack and Wall. 1986. or reduce reliance on them. A BRIEF HISTORICAL OVERVIEW OF CLINICAL HYPNOSIS Hypnosis is arguably one of the oldest forms of psychological therapy (Crabtree. that can augment more traditional medical or pharmacological approaches. and introduce some of the practical issues involved in its effective use in chronic pain management. 1844. 1826. have the potential to play an important role in contemporary pain management (Chaves and Dworkin. the biomedical perspective has continued to dominate contemporary medical practice. the articulation of a formal theory that provided explicit mechanisms by which this modulation of pain could be produced had an enormous impact on research and clinical practice and helped to encourage the development of multidisciplinary approaches to pain management (Kotarba. 1983). as it was then called. diagnosis. Favorable results have contributed to a growing acceptance of the notion that interventions like hypnosis. the topic came to the serious attention of the health professions in the late 1700’s and early 1800’s. These reports described limb amputations. hypnosis had already attracted a substantial following in the medical community. led by John Elliotson. National Institutes of Health. and Genest. Although the basic observation that pain could be profoundly modulated by various psychological interventions was already well known. Although hypnotic-like phenomena have been observed throughout recorded history (Edmonston.272 John F. including randomized clinical trials. a wellknown physician at the University of London (Chaves and Dworkin. 1836).. it is important to note that contemporary approaches to chronic pain management have increasingly coming to reflect an awareness of the significant contribution of psychosocial factors in the etiology. Meichenbaum. 1842. 1983). It was then that anecdotal reports began to appear in the medical literature suggesting that hypnosis. Hilgard and Hilgard. 1970). could be used to control the pain associated with various medical procedures. Holroyd. That fact is due. 1995). 1993. especially since its use was initially associated with high mortality rates. Crawford. Some saw the induction of an unconscious state. while hypnosis was initially relegated to the margins of medical practice (Parssinen. and skill of the surgeon (Rey. It is also noteworthy that the initial clinical reports focused almost entirely on the mitigation of pain associated with medical and dental procedures. 1993)! Even in colonial America. In the 1950s and 60s interest in hypnosis grew rapidly and important research programs developed that investigated. Hilgard. among other topics. 1969. 1997). pain was thought to play an important facilitative role in the healing process (Rey. Chaves and Barber. During the Middle Ages. as creating an ethical dilemma. The superiority of inhalation anesthetics was not obvious at first. who were often members of the clergy. 1985). 1989. 2001.Hypnosis in the Management of Chronic Pain Conditions… 273 that surgical pain could be controlled received considerable attention. . by any means. Winter (1991. within a few years. By bringing this phenomenon into the laboratory. Interest in hypnosis waxed and waned over the next several decades. inhalation anesthesia became a part of medical orthodoxy. Periods of heightened interest were most commonly associated with the appearance of clinical reports describing the successful use of hypnosis to control pain. 1998) has provided us with a fascinating analysis of the brief but intense struggle between professionals who advocated the use of inhalation anesthetics and those who advocated the use of hypnosis in managing surgical pain. other reports of the successful use of hypnosis in alleviating surgical pain appeared describing the fragile medical condition of patients that placed them at significant risk if pharmacological agents were employed (Chaves. 1976). For a variety of reasons. at times. as is probably true even today. Interestingly. However. this was not always the case. when pharmacological agents were unavailable. That line of research has continued to the present and in recent years has been augmented by psychophysiological and electrophysiological studies intended to assess the physiological dimensions of the response to hypnotic procedure. Gur. Accordingly attitudes towards pain and its relief by techniques like hypnosis. Hilgard. talent. Skolnick. because the unconscious patient would be unable to assess the speed. 1975. Barber. Later. 1959. the barriers to adopting new measures for pain relief seemed greater for professionals than for laymen. pain was seen both as a means of punishment and a means of redemption (Caton. Hilgard and Hilgard. The development of newer neuroimaging strategies have also added tools that have been applied in an effort to understand how hypnotic interventions reduce clinical and experimental pain (Chen. 1993). 1993). Gur. and the redemptive view that pain was a means of moral growth and salvation (Rey. 1967. expressed deep ambivalence about pain and its mitigation. the health professions have. it was hoped that a better understand might be achieved concerning which aspects of the hypnotic intervention were effective in reducing pain. Although we now accept the mitigation of chronic and acute pain as important and legitimate therapeutic goals. Indeed. and Benson. Quen. and later by inhalation anesthesia. or in limited supply. Weitzenhoffer and Hilgard. must be understood within the cultural context of the era (Caton. such as that associated with battlefield injuries incurred during WW I and WW II. That context probably served initially as a barrier to the adoption of inhalation anesthetics as well as the adoption of hypnosis (Chaves and Dworkin. during the 17th and 18th Centuries. and to better understand how hypnotic interventions might be devised that optimized the clinical application of these techniques. rather than with chronic pain. Occasionally. 1962). displayed complex attitudes toward pain that were influenced by both the Augustinian tradition that interpreted pain as the just punishment of the wicked. the use of hypnosis to control pain (Barber. physicians. 1963. 1979. 1973). 1985). 1996).g. and for entering a hypnotic state. they typically include instructions to focus attention. encourage positive expectations about its impact on patient comfort and motivation.g. the belief that good hypnotic subjects are intelligent and imaginative individuals) (Cronin. The hallmark of the hypnotic intervention is often thought to be the induction process. and Barber. 2001. Although three randomized prospective studies have shown a survival differences favoring cancer patients who have been exposed to psychosocial interventions. and Stites. although evidence indicates that suggestion. easily led individuals who lose control during the process (Barber and de Moor. Special ethical and psychological complexities arise when hypnosis is employed for patients with cancer and patients or their family members express the belief that the disease might be cured by the use of hypnotic suggestion (Syrjala and Roth-Roemer. and to illustrate the involuntary character of hypnotic responding for the patient. Although the possible influence of such psychosocial interventions on neuroimmune pathways is under active investigation. each with its own specific issues: (a) Patient Selection and Preparation. duration. 1971). (e) Post-hypnotic suggestion and (f) Termination. . and character of hypnotic inductions is highly variable. Other beliefs and expectations can inhibit responding (e. 1999). Johnson and Hauck.g.274 John F. Sephton. They may also involve suggestions for overt responses that are often described by good hypnotic subjects as occurring effortlessly (e. On the other hand. Spanos. and Bushnell. and improved quality of life is much more compelling. 1999.. Rainville. two others have not (Spiegel. and Duncan. 1993. with emphasis on some of the special issues that arise in its application in pain management. Some of these beliefs can facilitate responding (e. Sometimes these include elaborate notions about who can or cannot be hypnotized and how the process of becoming hypnotized occurs. 1999. Although the nature. the present state of the evidence makes it inappropriate to offer hope of cure or even hope of prolonged survival to patients at this time. decreased reliance on pharmacological agents. Chaves 1993. it may be helpful to look at how hypnotic interventions are designed and implemented. 1999). Rainville. Bushnell. per se. Rainville et al. automatic eye-closure in response to suggested drowsiness or movement of the arms in response to suggestions of lightness or heaviness). All patients come to hypnosis with expectations about the nature of hypnosis (Chaves. Duncan. Terr. Carrier. Kirsch. Under these conditions it is important to be clear about the lack of evidence that hypnosis can directly alter the course of the disease and. Before considering some of the chronic pain syndromes to which clinical hypnosis has been applied. as we shall see. (b) Induction. Such suggestions serve both as observable markers of the patient’s subjective response to the procedure for the therapist. suggestions for relaxation. THE CLINICAL APPLICATION OF HYPNOSIS IN PAIN MANAGEMENT The typical treatment protocol for chronic pain management with hypnosis can be divided into six phases. 1998). (d) Therapeutic Suggestions. the case for success in enhanced comfort. Hofbauer. good hypnotic subjects are gullible. 1972). 1989). Hofbauer. (c) Deepening. can exert powerful effects in a wide variety of contexts (Spanos and Chaves. at the same time. decreased reliance on medication. The dilemma facing the clinician is the decision about the extent to which to capitalize on initially positive expectations that may be unrealistic. even for chronic pain patients. Council. significant issues arise with respect to the preparation. . Patients sometimes approach hypnosis with almost magical expectations regarding its efficacy. the failure to achieve unrealistically high initial expectations can make it difficult to pursue more modest. 1990. and so forth (Chaves. Shutty. suggested alteration of breathing patterns. Let is briefly consider some of these issues SPECIAL ISSUES IN USING HYPNOSIS IN CHRONIC PAIN MANAGEMENT One of the most important challenges clinicians face in using hypnosis in chronic pain management concerns the management of patient’s expectations. or disorders whose pathophysiological basis has not been clearly established. such treatment sub-goals as increased uptime.Hypnosis in the Management of Chronic Pain Conditions… 275 Deepening suggestions follow the induction and are intended to help the patient have a more profound experience through various images. 1986). As Dworkin and I have noted (Chaves and Dworkin. suggestions of bodily heaviness. and increased participation in family activities become legitimate treatment objectives. Kirsch. neurophysiological evidence suggests that expectation of pain activates sites within the medial frontal lobes. This strategy is often augmented with further training in the use of self-hypnosis or by audiotaping the hypnotic intervention and asking the patient to listen to the tape on a regular basis at home. Kirsch. This application requires an approach that encourages positive expectations. This is particularly true for patients with chronic benign pain syndromes. Patient expectations are known to play an important role in shaping treatment outcomes (e. In working with chronic pain patients. The nature of these suggestions is highly variable. Shutty and DeGood. this “rehabilitation model” is not consonant with the way hypnosis has traditionally been used. 1979). While we often strive to assist patients in developing positive expectations about treatment outcomes. the gains achieved with respect to these specific. Indeed. Eventually a point is reached where therapeutically relevant suggestions are administered. 1999. DeGood. 1999). Accordingly. and Hafner. and Tuttle. In addition. 1990).g. The process of engaging a chronic pain patient in treatment typically entails a complex and often difficult negotiation in which the patient comes to relinquish the goal of seeking a “cure” and accept the legitimacy of the of the goal of pain management. evidence suggests that expectations can play an important role in shaping the hypnotic experience itself (Kirsch.. Some of the considerations involved in developing these suggestions are discussed below. 1990. and post-hypnotic suggestion phases. measurable outcomes can serve as important markers of patient progress and help document success for these patients. 1997). but attainable treatment goals. therapeutic suggestion. while minimizing magical expectations of immediate cure. post-hypnotic suggestions are generally administered to facilitate the continuation of treatment gains outside of the hypnotic context. With chronic pain patients. insular cortex and cerebellum distinct from but close to sites activated during the pain experience (Ploghaus et al. Indeed. 1999. 1996. cutting the rubber bands. especially the chronic benign pain syndromes. this model can provide a rationale for the hypnotic interventions to follow. The obvious dilemma for the patient is that successful treatment will confirm the dismissive diagnosis that the pain only existed “in their head. 1980. Chaves A second barrier encountered in preparing patient for the use of hypnosis for chronic pain. 1985b. An added feature of this patient’s discomfort involved the vivid visual images she reported of her phantom limb when her pain was intense.g. Of course. and visualize her phantom being immersed in a dense fog that prevented her from seeing it.g. Brown and Chaves. is that these patients have often been told. The careful and empathic listening that is required to elicit this information also helps establish rapport and confers an important therapeutic benefit for those patients who too often are surrounded by those who have become tired of listening. This approach can be particularly important when patients are experiencing such subjectively puzzling phenomena as phantom limb pain. She said that when she thought of her pain. This exploration provides a rich resource for the development of personally-relevant suggestions that may be therapeutically useful. But their use can be enhanced when integrated with suggestive elements derived specifically from the patient’s own experience of pain. 1993). The therapeutic suggestions derived to assist this patient included spraying her phantom limb with a powerful ant killer. including suggestions that a painful part of the body is numb and insensitive. as well as their understanding of the views of the clinicians who have previously treated them. trigeminal neuralgia) or peripheral manifestations of central pain syndromes related to stroke or space-occupying lesions in the central nervous system). 1997. 1993. causalgia. Chaves. to psychological interventions like hypnosis. Patients’ views regarding the etiology and pathophysiology of their conditions. these statements have the unintended consequence of creating ambivalence. The period of patient preparation for hypnosis also provides an important opportunity to explore the patient’s phenomenology of the pain experience. can be very helpful in developing a “heuristic model” for the patient that can help them understand the complex interplay between their cognitive and emotional life and their experience of pain. a patient of mine with phantom-limb pain was asked to describe her experience of pain. For example. 1989. 1999). “the pain is in your head.” The successful use of hypnosis in chronic pain management requires that both of these issues be successfully managed before beginning treatment.” This diagnosis is frequently offered in a context in which psychological causes for pain are implied if not explicitly stated (Chaves. or that it is disconnected from the rest of the body. reflex sympathetic dystrophies. Although often offered to assuage patient concerns about more serious medical conditions. In turn. These brief examples illustrate how the clinician can assist the patient in developing cognitive strategies that may be idiosyncratically beneficial in . My own clinical experiences. complex regional pain syndromes (e. may be therapeutically valuable in chronic pain management.276 John F. The other involved rubber bands that she could imagine being tied tightly around the end of her stump. indicate the importance of rejecting generic pain-relieving suggestions in favor of those that are shaped by the patient’s own phenomenology of the pain experience. 1985a. One included little red ants that were nibbling at her stump. described elsewhere (e. 1981. commonly used suggestions for hypnotic analgesia. no matter how hard she tried. if not aversion. two images came to mind. That requires that patient attitudes and expectations regarding treatment be carefully elicited prior to treatment. Hypnosis has been used in a multifaceted fashion for patients suffering from cancer. there is substantial evidence from the experimental pain literature supporting the value of this kind of approach (Chaves and Brown. The intent is not to provide a comprehensive critical review of that literature. at times. In addition they seemed to indicate . I view this phase of the hypnotic intervention as the most important in devising effective interventions. Certainly. and anxiety associated with many aspects of cancer treatment (Chaves. 1960). Steggles. in my experience. other descriptive reviews have appeared (Genuis. Indeed. It has used as a tool for chronic pain management as well as to reduce the pain. Liossi and Mystakidou. 1999). Lightfoot. Fehr. Nevertheless. 1997. Stam. 1974. 1962. Maxwell. Although the focus is on the use of hypnosis in chronic pain management. 2000). these explorations can be quite fruitful and. Radtke-Bodorik. 1986. Damore-Petingola. Steggles. THE SPECTRUM OF CLINICAL APPLICATION Hypnotic techniques have been applied to a wide variety of medical conditions. 1996. the goal is to provide some samples of the ways in which hypnotic interventions for chronic pain are being implemented and evaluated. discomfort. and Rivers. 1997. I have included a description of ways in which hypnosis has been used in reducing pain associated with these treatments. poorly specified treatment interventions and outcome measures limit the usefulness of these early reports. In recent years. Chaves and Barber. Where relevant. and Lightfoot. although their positive findings were encouraging. 1987).Hypnosis in the Management of Chronic Pain Conditions… 277 reducing pain. can greatly enhance the efficacy of interventions for pain management. Here I review some of the more important areas of application that have been explored. it sets the stage for all other aspects of the hypnotic intervention and can play a vital role in its ultimate success. Spanos. Lea. or other aspects of their phenomenology that limits their ability to cope can also be very helpful (Chaves. Lynch. 2000). By the same token. they may have difficulty grasping what you are driving at when you ask about their pain phenomenology. Steggles. Maxwell. 1975) Patients do not readily admit us to their phenomenal world. and Mayer. A number of early reports described the application of hypnosis with cancer pain (Cangello. and Chaves. Instead. Preexisting cognitive coping strategies and metaphors that have guided efforts at pain-self management pain can also be very helpful. Ware. Horton. knowledge of the patient’s catastrophizing ideation. Stam (1989) has provided a detailed critical review of much of the early literature. 1995. Steggles and his colleagues have provided useful annotated bibliographies of the relatively recent literature on the use of hypnosis in cancer in adults and in children and adolescents (Spanos. Methodological limitations. 1979. Fehr. many chronic pain conditions are accompanied by significant acute pain associated with medical treatments. 1961. and Aucoin. 1987. and Monroe. CANCER Cancer is often accompanied by pain associated with disease progression as well as with the implementation of uncomfortable diagnostic and treatment protocols. Properly conducted. Steggles. Steggles. Damore-Petingola. and Aucoin. including lumbar punctures and bone marrow aspiration (LP/BMA) (Katz. The hypnotic intervention included eye fixation. although rapport seemed to predict pain reduction in the Katz et al study. since the procedure was not defined as a hypnotic intervention to either the patients or their families. and coping suggestions. The intervention included weekly group therapy and . talking).g. Girls showed more distress than boys on 3 of 4 measures. Although both procedures were effective in reducing the pain of BMA and anxiety associated with LP. Chaves that the benefits of hypnotic intervention could be seen across the entire spectrum of hypnotizability. 1983). Zeltzer and LaBaron (1982) compared a hypnotic treatment that entailed therapistassisted deep breathing and pleasant imagery with alternative behavioral intervention. In more recent years. and hyperthermia (Reeves and Shapiro. 1987. Kuttner. including deep breathing exercises and non-imaginal distractions (e. The hypnotic technique employed in this study might be more accurately described as a guided imagery intervention. The use of hypnosis for pain management usually involves the administration of suggestions for relaxation as well as suggestions that are specifically intended to attenuate pain and discomfort. to three treatment groups: hypnotic “imaginative involvement. all groups showed reduced distress. Bowman. (1988) randomized two groups of children receiving BMA. Kuttner at al. Kellerman. while another 61 were assigned to a control condition. the hypnotic procedure was more effective in reducing pain and anxiety. (1987) studied 12 female and 24 males aged 6-11 years with acute lymphoblastic leukemia who were undergoing repeated BMA. Two intervention sessions were investigated. while both treatments reduced distress for the older patients. Katz et al. more detailed and complete reports have become available describing the use of hypnosis with cancer pain and the pain associated with medical procedures frequently used with children suffering from cancer.278 John F. ages 3-6 and 7-10. Spiegel and his colleagues have explored the benefits of a complex psychosocial intervention for patients with metastatic breast cancer that includes teaching them to use self-hypnosis. The patients were randomized to either a hypnosis or an unstructured play comparison group. 1982. 1989). During the second intervention. The authors concluded that hypnosis had an “all-or-none effect” while the response to distraction only developed with experience.” distraction. and there was some suggestion of an interaction between gender and treatment. The intent of the intervention was to encourage patients to express and deal with strong emotions and also focuses on clarifying doctor-patient communication.. Spiegel and his associates (Classen et al. Hilgard and LeBaron (1982) examined the role of hypnotizability and relief of BMA pain in children. and Teasdale. and Ellenberg. Both procedures were found to be effective in reducing pain. They found that children identified as highly hypnotizable showed greater reductions in self-reported and observer-rated pain than low hypnotizables. relaxation. 1988. Wall and Womack. During the first session distress was reduced for the younger group using the hypnotic treatment. 2001) studied the impact of this intervention on sixty four-women were randomized to the intervention group. and standard medical practice. Zeltzer and LaBaron. counting. Both groups showed reduced self-reported fear and pain. imagery. Wall and Womack (1989) compared a hypnotic intervention to a distraction procedure in reducing pain associated with BMA and LP for children and adolescents. but not anxiety. However. indicating that its use need not be restricted to very good hypnotic subjects. This finding has not been confirmed in other studies by Wall and Womack (1989) and Katz et al (1987). Some reports used hypnotic imagery techniques (Davidson. Friedman and Taub. 1975. 1980. and Linssen. tension or mixed migraine/tension headaches have appeared (Andreychuk and Skriver. others used rational stage-directed hypnotherapy (Howard. 1984. Reardon. although they do not consistently demonstrate a superiority of hypnotic interventions over other cognitive-behavioral interventions. Van-Dyck. Donaldson. 1987. Donaldson. Hypnosis was effective in reducing treatment-related oral pain for these patients. Zitman. MacDonald. Spinhoven. In related study (Syrjala.Hypnosis in the Management of Chronic Pain Conditions… 279 educational materials in addition to a self-hypnosis exercise. and Carr. 1984. and Levy (1999) reviewed 31 investigations of recurrent pediatric headache that have appeared since 1981 using predetermined criteria to evaluate the adequacy of research methodology. 1995) oral mucositis pain levels were compared in 94 patients receiving BMT. 1977. significantly increasing survival duration and time from recurrence to death. Spiegel and Moore (Spiegel and Moore.. Cummings. and Chapman. However. . 1985. Cummings. Kippes. Spierings. Milne. and Hoogdiun. Zitman. and Uden. Syrjala and associates (Syrjala. Spinhoven. 1992) they compared the benefits of hypnosis. HEADACHE Hypnosis has often been applied to the management of headache. Golden.. 1992). and Donaldson. Olness. and usual treatment in 67 patients with hematological malignancies who were undergoing BMT. these studies suggest that hypnotic interventions seem to be consistently effective in treating these headaches. Rooimans. and Tosi. Van Dyck. Friedman and Taub. Graham. 1987. The treatment groups did not differ with respect to nausea. al. Schlutter. Complete or moderate success has been reported in relieving pain associated with migraine headache. 1975. Milne. therapist contact. emesis and opioid use. Results showed that the intervention reduced traumatic stress symptoms and mood disturbance. Deichmann. In a later study (Syrjala. 1983). and Blume. et. 1967. 1988. Spinhoven. Comparative studies of hypnotic and non-hypnotic treatment of migraine. 1994 Spanos et al. Davis. 1982) and still others employed suggested hand warming (Ansel. They concluded that sufficient evidence exists to support the conclusion that hypnosis/self-hypnosis is a well-established and efficacious treatment for recurrent headache. Mellis. Taken together. Friedman and Taub. Nolan. Holden. and Linssen. 1993. 1991. Harding. cognitive behavioral coping skills training. 1985. 1983). adding behavioral skills training did not improve pain levels beyond the level achieved with the relaxation-imagery intervention alone. 1997) reported a 10-year follow-up of a randomized trial involving 86 women with cancer showing that this kind of intervention also conferred a survival benefit. 1987) reported that hypnotherapy reduced oral pain secondary to chemotherapy and radiation treatment for cancer (caused by oral mucositis). Interestingly. the cognitive-behavioral intervention was not effective in reducing symptoms in this study. Participants were assessed at baseline and every four months during a 12-month period. A cognitive-behavioral skills training and a hypnotic-like relaxation-imagery intervention were equally effective in reducing pain. none of the other pretreatment differences predicted either immediate or long term pain reduction. Rosen and colleagues (Rosen. Hosoi.. Positron emission tomography (PET) was employed to study the central pathways by which the phantom limb . complex regional pain syndrome. Berner.280 John F. Moreover. many other personal and demographic variables do not seem to predict treatment outcomes. Nevertheless. Gainer (1993) employed hypnosis and self-hypnosis to treat a patient with reflex sympathetic dystrophy (RSD). the patient reportedly achieved complete relief from her RSD symptoms. Chaves Gysin (1999) compared the efficacy of five weekly hypnosis/self-hypnosis sessions with behavior therapy and physician counseling for children and adolescents suffering from chronic episodic headaches. Phantom limb pain is a common sequelae of surgical or traumatic amputation and is frequently unresponsive to conventional medical/surgical interventions (Chaves 1985b). Willoch. 2001). ter Kuile. personality. NEUROPATHIC PAIN A variety of neurological conditions are associated with chronic pain. 43 were classified as responders (greater than 50% pain reduction) while 113 were classified as nonresponders. These findings confirmed those of an earlier study that also found a correlation between hypnotizability and response to hypnotic treatment or to autogenic training for recurrent headache (ter Kuile et al. A number of case reports describe the use of hypnosis with phantom limb pain. diabetic neuropathy. 1996) describe the use of hypnosis in the treatment of severe lower limb phantom limb pain and an associated post-traumatic stress disorder. hypnosis was thought to enhance patient control of headaches. early treatment responders had higher hypnotic susceptibility scores than non-responders. Spinhoven and Linssen (1995) employed cognitive self-hypnosis training or autogenic training for 156 patients with chronic recurrent headache. 1994). Although hypnotizability appears to predict treatment response for headache pain. coping strategy use and pain appraisals. post amputation and AIDS-related neuropathy (Haythornthwaite and Benrud-Larson. Although patients who expected more pain reduction at pretreatment achieved greater pain reduction. This included demographic and medical status variables. Bartenstein. hypnosis was combined with other psychotherapeutic interventions. Mine. While clinical reports of the use of hypnosis to manage the pain associated with these conditions have appeared. Pain reduction immediately following treatment and at later follow-up was significantly associated with hypnotizability. hypnosis was employed as one part of a more complex intervention that included antidepressants. Although both treatment interventions reduced headache frequency and intensity. Komiyama. They allocated 169 patients to either a selfhypnosis or an autogenic training treatment. Over a two year period. no clinical trials have been reported. measures of psychological distress. spinal cord injury. Spinhoven and ter Kuile (2000) explored the role of hypnotizability in the treatment of patients with chronic tension-type headaches. In this case. Muraoka and associates (Muraoka. At 6 month follow-up. In this case. These include post herpetic neuralgia. a few examples suggest some of the ways that hypnosis has been employed in these conditions. 2001) used hypnosis to modify the experience of phantom limb pain in two patients. and Rosjo. and Kubo. 2000). They found that phantom limb pain sensations were associated with activation of the anterior and posterior cingulate cortex. Patterson. and Patterson.Hypnosis in the Management of Chronic Pain Conditions… 281 was experienced and hypnotically modified in these patients. 1995. and Gibran. Everett. Martin-Herz. A number of studies. Patterson and his colleagues have made important contributions to this literature (e. Thurber. This finding was subsequently extended in a study with 8 patients where hypnosis was used to alternate between sensations of pain and movement (Willoch et al. and Marvin. In both cases. deriving therapeutically relevant pain-relieving suggestions from the patient’s pain phenomenology seemed important to achieving a successful outcome. Patterson. Self-reported ratings of the sensory and affective dimensions of pain decreased significantly during and after hypnosis. Burns. reduce awareness of the phantom. and Boltwood. Patterson and Ptacek. Hypnosis was employed twice on 15 patients while the remaining 15 patients served as controls. 1996. The authors concluded that hypnosis can be incorporated into treatment protocols for phantom limb pain. Adcock. 1997). have suggested that hypnosis can be an effective intervention for patients who are unresponsive to conventional medical treatments for this condition. mostly conducted in the UK. Wright and Drummond (2000) asked 30 hospitalized burn patients to rate their levels of pain and relaxation for four burn care sessions. 1993. 2000. hypnosis was only one part of a more complex intervention. Patterson. An excellent outcome was achieved with little or no opioids. no anxiolytic medication and a shortened length of wound care. 1992. and Bombardier. 1989. Goldberg. Indeed. Questad. The use of hypnosis in the management of burn pain is supported by numerous clinical reports as well as by controlled studies. Patterson. which generally includes dietary and pharmacological .. and alleviate depressive symptoms. 1987. 1997. Carrougher. in one case. Chaves (1985b. 1993) described the hypnotic treatment of phantom limb pain in two different cases using a combination of suggestions designed to reduce pain sensations. Burns. 1997). and Ehde. IRRITABLE BOWEL SYNDROME Irritable bowel syndrome (IBS) is not always responsive to conventional medical therapies. hypnosis proved effective in managing the pain of a 55-year old man with an extensive burn who had experienced significant respiratory depression due to low dosage of opiods that had been administered during wound care (Ohrbach. Another important element was the use of audiotapes of clinical sessions to reinforce daily practice with the hypnotic intervention. while for the other. Everett. anticipatory anxiety prior to subsequent dressing changes decreased in the hypnosis group. 1992. Patterson. 1985b). BURN PAIN Patients who suffer burns experience pain associated with their injury as well as procedural pain associated with surgery and wound debridement. Patterson. Patterson. Patterson.. Patterson. In addition. although admittedly the former seem stronger than the latter (Patterson et al.g. One patient was successfully treated in three sessions (Chaves. 1998). Montgomery. and Heimbach. 2000) compared gutdirected hypnotherapy with a specially-devised non-hypnotic audiotape in a randomized controlled trial involving 52 patients with established IBS who had not responded to dietary and pharmacological therapy. Treated patients also showed reduced state and trait anxiety scores. Heyman.g. bloating. Nevertheless. The evaluation of these findings is somewhat complicated by the fact that a comorbid psychiatric diagnosis is common in IBS.282 John F. 1997). Post-hypnotic suggestions form only a “modest” part of the therapy and regressive strategies (e. (Forbes. The non-hypnotic tape lasted approximately 30 minutes and consisted of background information about IBS. Galovski and Blanchard (1998) confirmed the findings reported in the UK studies in a study with 6 pairs of matched IBS patients assigned to either a gut-directed hypnotherapy group or to a symptom-monitoring wait list control. An audiotape was made of one of the sessions. there was no correlation between hypnotic susceptibility and treatment gain. and this was provided to the patient for practice at home. backache. and Colgan. abdominal pain. dyspareunia). bowel habits. more than half of the patients in each group clinically improved. Sessions lasted about 30 minutes. It is difficulty to say at this point whether it will be possible to achieve significant economies of scale in using hypnotherapy in treating IBS. but those in the hypnotherapy group showed significantly greater symptom reduction. Houghton. Wald. many symptomatic individuals never seek treatment (Goldberg and Davidson. Prior. 1999. to uncover psychodynamic factors) were not used. it is instructive to review how hypnosis has been employed with this population. and Chiotakakou-Faliakou. On a composite measure of IBS symptoms. Subjects in the control condition were later crossed into the treatment condition. Forbes et al. Moreover. flatulence. but more expensive intervention with hypnosis for treatment failures. For the 45 patients who provided complete data. 1984). 1990. 1999). including suggestions for progressive muscle relaxation and hand levitation. hypnotherapy was significantly better than the control condition. generally the third. in spite of its higher initial cost. Whorwell. and Faragher. Chaves interventions (Camilleri. They concluded that hypnotherapy was a good long-term investment. stress management strategies. the tape might be recommended as a second line of intervention for patients who had not responded to traditional IBS treatment. When patients displayed eye-closure and altered breathing pattern. Patients were encouraged to use the tape on a daily basis. additional deepening suggestions were administered. 1987. Interestingly. Their hypnosis treatment protocol followed that advocated by Whorwell in several important earlier investigations (Whorwell. Some of those . Those assigned to hypnotherapy received 6 treatment sessions scheduled at two-week intervals. with the hypnotic intervention consuming only about 15 minutes of that period. Therapeutic suggestions were then administered that focused on the predominant IBS symptoms. The patient-selection criteria included abdominal pain or discomfort. Whorwell. MacAuley. and structured relaxation. Prior. for economic reasons. The clinical gains achieved in using hypnosis with IBS patients do not seem restricted to disease-specific symptoms (e. saving the more effective.g. The authors concluded that. Hypnotic induction employed eye-fixation with suggestions for closure. and Whorwell (1996) found that IBS patients treated with hypnotherapy also demonstrated improvements on a number of measures of quality of life and had reduced absenteeism from work as compared to control patients with disease of comparable severity. In spite of the methodological limitations that apply to many of the studies cited here. the answers to these questions remain incomplete and ultimately will require more systematic data. 1990).Hypnosis in the Management of Chronic Pain Conditions… 283 who have reported successful use of the procedure are convinced that an individually-tailored approach is necessary to achieve the best treatment outcomes (Vidakovic-Vukic. (Sutcher. Margolis. 1983). multiple sclerosis ((Dane. sickle cell disease (Thomas. Hopefully this may not only permit hypnosis to be considered when conventional interventions have failed. and Brooke. 1997). In the meantime. and Thomas. and Redd. Oakley et al. APPLICATION OF HYPNOSIS WITH OTHER PAINFUL SYNDROMES Hypnosis has occasionally been applied with a variety of other painful disorders including arthritis (Nolan. DuHamel. 1994. 1984). McGrath.. and Leipzig. 1995). recurrent aphthous stomatitis (Andrews and Hall. repetitive strain injuries (Moore and Wiesner. a number of important questions remain. and back pain. Patterson. Simon and Lewis. There is a need for more systematic data to be collected with respect to all of these applications to document more fully the efficacy of hypnotic interventions and specify the indications and contraindications for its use. Domangue. 1996) and interstitial cystitis (Webster and Brennan. 1985). This conclusion is supported not only by clinical case studies. Karjalainen et al. 1997). however. head. Of course. and Edwards. 1996). 1996. ischemic pain associated with Burger’s disease (Klapow. Lieberman. Dorn. CONCLUSIONS Those working with more conventional biomedical therapies for chronic pain need to be aware of the potential contribution of hypnotic interventions. 2000). and Kaji. 1984. 2000).. 1999). facial. hypnosis has demonstrated substantial promise and is sufficiently benign in the hands of properly trained professional health care . 2000). How can we select patients most likely to benefit from hypnosis as an intervention? What is the role of hypnotizability in determining treatment outcome? How can we best prepare patients for clinical hypnosis? What are the best treatment protocols for using hypnosis in pain management? What is the role of practice and training in optimizing clinical outcomes? What comorbid conditions are indications or contraindications for hypnotic intervention? At present. they point strongly to the potential value of hypnosis as an effective intervention for the relief of clinical pain that is not or cannot be managed effectively with conventional medical therapies. 2000). Patterson. Dinges et al. taken together. 1983. We also need additional information about how hypnotic interventions might be beneficially added to the array of service offered to patients during end-of-life care (Pan. Morrison. Support for these applications is generally based on case reports or small clinical studies. Koshy. temporomandibular disorder (Stam. (Toomey and Sanders.. but also meta-analyses of systematic studies that have evaluated the use of hypnosis for both clinical and experimental pain (Montgomery. but also enable more prospective exploration of where hypnosis might be introduced earlier in the painmanagement process to maximize its benefits. Fugh-Berman. Ness. (1975). (1962). Indeed.. Cangello. T. International Journal of Clinical and Experimental Hypnosis. . Hypnosis for the patient with cancer. C. X.. 112-135. J. F. the assessment of hypnotizability is not necessary before conducting a clinical trial with hypnosis. REFERENCES Andrews. (1980). 2 Suppl. 1993). Camilleri. and Chaves. 303-333. F. Barber. Chaves. 15(2). NY: Guilford. F. For most clinical purposes. (1961). V. Psychosomatic Medicine. Dowd. The secularization of pain. D. (1972). Hypnosis in the treatment of sexual dysfunction. (1990). 23(3). Chaves. and Hall. 56. H. Ansel. J. X. American Journal of Clinical Hypnosis. San Francisco. T. V. The effects of "hypnosis" on pain: a critical review of experimental and clinical findings. Barber. E. Audiotape series (6 cassettes). and hypnosis. that it probably should be considered in any case where pain control is incomplete or unsatisfactory with conventional therapies. Psychosomatic Medicine. This makes it possible to address concurrent anxiety and depressive symptoms as well as other disease-related symptoms beside pain. W. and Skriver. Journal of Sex and Marital Therapy. T. Caton. 25. Review article: clinical evidence to support current therapies of irritable bowel syndrome. A theory of hypnotic induction procedures. X. W. placebos. 4. T. 68-71. opiates. M. CA: Proseminar. Andreychuk. 215-226. and probably influenced by a complex array of factors. Another advantage of the use of hypnosis is that its flexibility permits the simultaneous pursuit of a wide range of therapeutic targets. 48-53. (1977). (1985). 6(1). 63-74. H. T. A simple exercise to enhance response to hypnotherapy for migraine headache. Healy (pp. M. 52(5). The use of hypnotic suggestion for pain relief in malignant disease. (1981). and de Moor. The effects of relaxation/imagery training on recurrent aphthous stomatitis: A preliminary study. International Journal of Clinical and Experimental Hypnosis. (1963). L. International Journal of Clinical and Experimental Hypnosis. Anesthesiology. Toward a theory of pain relief: Relief of chronic pain by prefrontal leucotomy.. Alimentary Pharmacology and Therapeutics. American Journal of Clinical Hypnosis. V. Tactics and strategies in clinical hypnosis. (1985a). The presence of chronic pain or a life-threatening condition can change patient motivation.. M. 172-183. . 526535. it is sometimes the improvements achieved in mitigating non-pain related symptoms that convinces patients that hypnosis can make it possible to reduce pain (Chaves. (1999). 17-22. E. 25. Hypnosis in the management of behavioral components of Prader-Willi Syndrome. J. J. 301-310). Chaves providers. Hypnosis and biofeedback in the treatment of migraine headache. Accordingly. Evidence seems to suggest that the relationship between hypnotizability and clinical outcome is complex. Cangello. (1959). 430-460. R.284 John F. and make acceptable interventions that might not have been welcomed under other circumstance. 62. Brown. 9. and J. Barber. W. Psychological Bulletin. hypnosis should not be ruled out on the basis of apparent low hypnotizability alone. 493-501. 119-142). (1976). F. Chaves. Chaves. Chaves. 356-363. L. Chaves. J. W. T. (1974). E. D. and Benson. (2001). 242-272)." American Journal of Clinical Hypnosis. Koopman. Healy (pp. Chaves. (1997). experimenter modeling. Fobair... (1993). Chaves. J. and expectation in the attenuation of pain. Giese-Davis. J. D..C. T. Hypnosis in the management of phantom limb pain. Chaves. F. J.) Hypnosis-The cognitive behavioral perspective. 217-236. and I. F. R. D. F. S. N. Boston: Allyn and Bacon. F. Buffalo. Hypnosis in dentistry: Historical overview and current appraisal. Gur. F. Hypnosis in the management of anxiety associated with medical conditions and their treatment (pp. I. H. A.. 5-23. (1993). 8(2). Recent advances in the application of hypnosis to pain management. Skolnick. (1994). B. Gur. 198-209). J. Journal of Behavioral Medicine. Archives of General Psychiatry. and Barber. Hypnosis in chronic pain management: Some pragmatic considerations in patient preparation. Washington. F. American Journal of Clinical Hypnosis. S. I.. J. P. From Mesmer to Freud: Magnetic sleep and the roots of psychological healing. J. 1. and I.. D. Crawford. C. J. 37(2). Lynn. DiMiceli. Psychological Hypnosis. J. Chaves. NY. Bongartz (ed. M. J. 83(4). 131-151). 10(3). Germany. Handbook of clinical hypnosis.. C.. C. Kirsch. Konstanz: Universitätsverlag Konstanz. Crabtree. Spontaneous cognitive strategies for the control of clinical pain and stress. 117-129. DC: American Psychological Association. Barlow (eds).. C. Council. X. S... Hypnotic procedures and surgery: A critical analysis with applications to "acupuncture analgesia. and Brown. 511-532). and Hafner. F.. Kraemer. Spanos. Chaves. J. 4-5. Butler.. E. J.. Classen. J. Chaves. (eds. F. M. F. R. Hypnotic analgesia: The social-psychological perspective. Chen. (1987). 50(1).) Hypnosis: 175 years after Mesmer-Recent developments in theory and application.. J. H. S. J. New Haven: Yale University Press. Kirsch. M. E. Chaves. T. International Journal of Psychophysiology 42(2). Washington. F... (1986).: American Psychological Association. J. Hypnotic control of clinical pain (pp. Hypnosis International Monographs. Lynn. Journal of Abnormal Psychology. Chaves. and D. Chaves. F. Mostofsky. 18(4). F. (1989). (1985b). R. (1997). F. and Barber. (1992). (1999). and Dworkin.. The management of stress and anxiety in medical disorders. F.. Expectancy versus absorption in the prediction of hypnotic responding. 45(4). Carlson. (1996). W. (2000). J. J. USA: Prometheus Books. and Spiegel. X. P. Supportive-expressive group therapy and distress in patients with metastatic breast cancer: a randomized clinical intervention trial. 356-376. New perspectives in EEG/MEG brain mapping and PET/fMRI neuroimaging of human pain. 494-501. H. (2001). Miller. J. L. Effects of hypnosis on regional cerebral blood flow during ischemic pain with and without . Dowd. A.Hypnosis in the Management of Chronic Pain Conditions… 285 Chaves. and J. R. 263-276. Journal of Personality and Social Psychology. Hypnosis in pain management (pp. D. J. 182-189. W. Rhue. New York: Guilford. P. Kirsch (eds) Casebook of clinical hypnosis. J. Hypnotic strategies for somatoform disorders (pp. 3. (1993). C. 53-65. Hypnotic control of pain: Historical perspectives and future prospects. (eds). Cognitive strategies. 58(5). International Journal of Clinical and Experimental Hypnosis. and Barber. Dampier. G. M. Somatization of dissociated traumatic memories in a case of reflex sympathetic dystrophy. 82. J.... H. The need for a new medical model. B. G. 194-197. B. P. Friedman. Ellenberger. Edmonston. (1987). American Journal of Clinical Hypnosis. 328-34. A. K.. Boston Medical and Surgical Journal.. K. Delatour. M. H. Journal of Clinical Psychiatry.. literature review. 45(4). R. (1985). 27-33. 676-683. Hypnosis and migraine headache: Reporting a clinical series. J. (1984).. 15(2). (2000). Patterson. 44(3).. 124-131. (1996). (1976). American Journal of Clinical Hypnosis. Everett. Ohene-Frempong. J. International Journal of Clinical and Experimental Hypnosis. Spanos. 25. P.. and analysis of outcomes. (1986). Gillen. and Orne. E. Science. 235-8. M. Journal of Burn Care and Rehabilitation. St. M. and Kaji. L'Hermes. H. Hypnosis: useful. M. 38(6). Physician-scientists and scientific-physicians. Bloom. available. S. B. E. K. untitled report. and Heimbach. B.. Australian Journal of Clinical and Experimental Hypnosis. Behavioral methods for chronic pain and illness. L. 16(5). X. American Journal of Hospital Palliative Care. . Amputation of the leg in the mesmeric state. E. 196. G. Engel. American Journal Clinical Hypnosis. Bauer. F. Biochemical correlates of hypnoanalgesia in arthritic pain patients. 187-200. Orne. Whitehouse. J. International Journal of Clinical and Experimental Hypnosis. (1997). P. D. L. G. From biomedical to biopsychosocial. Engel. 46 (6).. MacAuley. (1844). J. 111-118. Douglas.. 521-528. 129-136. (1970).. Resolving the humanismscience dichotomy.. Jr. N. Domangue. 208-231. H. D.. Louis: Mosby. 32. B. and Taub. F. 14(6). Shapiro. N. International Journal of Psychophysiology. Chaves suggested hypnotic analgesia. G. Forbes. (1993). American Journal of Medicine. H. neglected. A.. D. Dinges. W. D. C. Fordyce.. Augmenting hypnotic suggestibility by providing favorable information about hypnosis. Hypnotherapy and therapeutic audiotape: effective in previously unsuccessfully treated irritable bowel syndrome? International Journal of Colorectal Disorders. B. Deane. Davidson. D. T. C. 259-264. 13(4). 26. Adjunctive interventions for burn pain control: comparison of hypnosis and ativan: the 1993 Clinical Research Award. Dane. The Induction of Hypnosis. (1997). Brief psychological training procedures in migraine treatment. H. (1985). Psychosomatics. Hypnosis for pain and neuromuscular rehabilitation with multiple sclerosis: case summary. New York: Basic Books. (1977). Being scientific in the human domain. Montgomery. L. 107-111. M. A. E..286 John F. 36(2).. Cronin. 665-70.. G. 28. Burns. (1826). The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry. W. American Journal of Clinical Hypnosis. Margolis. D. and Taub. (1999).. Extended follow-up study of the effects of brief psychological procedures in migraine therapy.. New York: Wiley. (1987). R. (1971). 181195. Lieberman. T. Gainer. and Chiotakakou-Faliakou. C. S. Friedman. Self-hypnosis training as an adjunctive treatment in the management of pain associated with sickle cell disease. 15(5-6). E. Carlin... (1993). Engel. 144-146. 15(3). E. Heyman. Harding. 91-109. Journal of Neurophysiology.. P. 24(2). Beliefs and opinions about hypnosis held by the general public: a systematic evaluation. M. 24. American Journal of Clinical Hypnosis. R. W. (1999). and Benrud-Larson.. G. (1967). Journal of Nervous and Mental Disease. 91-5. 33-51. L. Hypnosis in the Relief of Pain. 44-6. (1975). J. and Voevodsky. CA: William Kaufmann. Empirically supported treatments in pediatric psychology: recurrent pediatric headache. L. P. T.. Journal of Pediatric Psychology. 37(4). Pain as a puzzle for psychology and psychophysiology. and LeBaron... and Bushnell. J. Hypnosis in the treatment of migraine. Hilgard. 23(4). P. Genuis. (1969). M. E. Cortical representation of the sensory dimension of pain. J. C. 124-9. L. P.. Gysin. (1975). Rainville. Cooper. M. 165-171. J. 2nd Edition. Hilgard. (1997). and Levy. D. (2001). M. 86(1).. J. (1982). Current Pain and Headache Report. 30(4). and emesis: A review of recent empirical studies. (1996). Holroyd.. J. 42(1).. E. 10(1). and Davidson. Goldberg. R. Duncan. (1967).. American Journal of Clinical Hypnosis. and Hilgard. Alimentary Pharmacology andTherapeutics. E. Los Altos. . (1998). 417-442. J. 42(8).. J. (1999). and Tosi. Holden. and Whorwell. B. J. Morgan. and Hilgard. International Journal of Clinical and Experimental Hypnosis. J.. Lenox. 257-69. CA: William Kaufmann.. L. Johnson. Psychological assessment and treatment of patients with neuropathic pain. Haythornthwaite. Canadian Journal of Psychiatry. 6 Suppl 1. K. 10-20. C. E. D. J. D. L. R. 835-40. 23(3). and Blanchard. 44(1). (1999). Hilgard. M. J. R. E. Lassner. R. Hypnosis in the relief of pain. S. (2001). Reardon. 5(2).. E. C..Hypnosis in the Management of Chronic Pain Conditions… 287 Galovski. Graham. M. Houghton. 316-325. G.. chronic and episodic headache without migraine and other defined headaches in children and adolescents]. W. Hypnosis treatment of clinical pain: understanding why hypnosis is useful. The use of pain-state reports in the study of hypnotic analgesia to the pain of ice water. H. International Journal of Clinical and Experimental Hypnosis. R. J. E. Deichmann. The use of hypnosis in helping cancer patients control anxiety.. Hilgard. (1982). New York: Springer-Verlag. American Psychologist. 506-513. Forschende Komplementarmedizin. Applied Psychophysiology and Biofeedback. Howard. Hofbauer. The treatment of irritable bowel syndrome with hypnotherapy. Los Altos. (ed. Hypnotic treatment for migraine headaches. quality of life and economic features of irritable bowel syndrome--the effect of hypnotherapy. R. A.. R.. 219-32. 30(3). A biopsychosocial understanding of the irritable bowel syndrome: a review. 103-113. (1995). 144(6). 40211. International Journal of Clinical and Experimental Hypnosis. T. [Clinical hypnotherapy/self-hypnosis for unspecified. and Hauck. (1996). Hilgard.. Relief of anxiety and pain in children and adolescents with cancer: Quantitative measures and clinical observations. A. Symptomatology. M. Modifying migraine headache through rational stage directed hypnotherapy: a cognitive-experiential perspective..) Hypnosis and psychosomatic medicine . (1983). H. International Journal of Clinical and Experimental Hypnosis. pain. A. H. Clinical hypnosis in palliative care. Psychosomatic treatment of phantom limb pain with post-traumatic stress disorder: a case report. Changing expectations: A key to effective psychotherapy. A. van Tulder. C. L. 374-381. Chronic Pain: Its Social Dimension. 458-72. and Wiesner. (1996).. NIH Technology Assessment Statement. M. R. Kirsch. A. H. (1999). R. Klapow. Treatment of chronic tension-type headache with hypnotherapy: A single-blind control study. and Patterson.. L. K. Australian Journal of Clinical and Experimental Hypnosis. I. M. 38(4). Hypnotically-induced vasodilation in the treatment of repetitive strain injuries. P. and anxiety for young children with cancer.. I. (1991). H. (1996). H.. Bowman... E. 271-276. and Hoogdiun.288 John F.. A meta-analysis of hypnotically induced analgesia: How effective is hypnosis? International Journal of Clinical and Experimental Hypnosis. Lynch. 12(3). The hypnotic control of intractable pain. Pain. (1988). American Journal of Clinical Hypnosis. Australian Journal of Clinical Hypnotherapy and Hypnosis.. Muraoka.. Komiyama. C. 150. Jauhiainen. and Teasdale. and Ellenberg. Liossi. Spierings. 4(1). Malmivaara. (2000). . American Journal of Clinical Hypnosis. (2000). Psychological principles of burn wound pain in children. D. W. American Journal of Clinical Hypnosis. American Journal of Clinical Hypnosis. A combination of hypnotherapy. R. 122130. 42(2). T.. 1-34. (1983). (1996). Nolan. K. 11(1). (1999).. 138-153. Developmental and Behavioral Pediatrics.. Moore. Martin-Herz. Beverley Hills: Sage... H. Thurber. How expectancies shape experience. P. G. 31.. P. (1990). S. CD002269. European Journal of Palliative Care. 97-104. and Redd. and Koes. Chaves Karjalainen. Kotarba. 379-394. Cochrane Database Syst Rev. Pacific Grove. pain.. Roine. DuHamel. M. R. D. 39(2).. (1960). (2000). 971-979. Psychological treatment of distress. Mellis. C. M.. E. N. Kellerman. Biopsychosocial rehabilitation for upper limb repetitive strain injuries in working age adults. (1983). Kuttner.. G. K.. Katz. (3). Hypnosis in the reduction of acute pain and distress in children with cancer. and Kubo. II: Treatment applications. megavitamins and "folk" medicine in the treatment of arthritis. Journal of Burn Care Rehabilitation. Rooimans. S. Pain mechanisms: A new theory. C. Patterson. L. E.. A. 9(6). Empowering the patient: hypnosis in the management of cancer. F. D. and Mystakidou. A.. Ware. Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. and Edwards. surgical disease and chronic pain. 686-689. M. CA: Brooks/Cole. B. Hypnotherapy with migraine. A. Journal of Pediatric Psychology. Science. R. M. 3(2). Hypnosis as an adjunct to medical care in the management of Burger's Disease: A case report.. 23-32. W. L. DC: American Psychological Association. Washington. 56-58. P. Mine. (1987). J. Headache. 66(2-3). and Wall. J. 3(3-8). and Monroe. Jr. R. Milne. Hurri. Hosoi. K. Montgomery.. W. P.. M. Lea. 48(2). 21-25. Melzack. D. (1996). J. (1965). R. (1983). October-16-18.. M. Kirsch. 385-8.. C.. L. National Institutes of Health (1995).. 21(5). J. R. M. at Plattsburgh. H. Parssinen. P. 156-163. J. K. Ploghaus. Hayward. 159-71. Hypnotherapy as a treatment for pain in patients with burns: research and clinical considerations. Journal of Consulting and Clinical Psychology. Factors predicting hypnotic analgesia in clinical burn pain.. Patterson. 16. 263-8. 38(3). N.. 20(5). 79(4). and Uden.. Wallis (ed. 593-597. Dissociation of sensory and affective dimensions of pain using hypnotic modulation. E. Journal of Pain Symptom Management. J. Clark. Carrier. K. A. Glover. J. Journal of Burn Care and Rehabilitation. S. D. International Journal of Clinical and Experimental Hypnosis. R. Pan. Ness. Patterson. Patterson. Hypnosis for the treatment of burn pain. R.. 65(1). 1973. R. G. and Leipzig. 14(2). . American Journal of Clinical Hypnosis. D. 377-395. Hypnotherapy as an adjunct to narcotic analgesia for the treatment of pain for burn debridement. (1997).. Journal of Burn Care and Rehabilitation. D. Morrison. G. and Bombardier. and nausea and vomiting near the end of life. Questad. In R.. L. (1995). Journal of Orofacial Pain. 8(4). Y. and Marvin.. P.. I. (1992). T. and Rawlins. Professional deviants and the history of medicine: Medical Mesmerists in Victorian Britain (pp. (1997). The efficacy of hypnotic and nonhypnotic response-based imagery for self-managing recurrent headache. 14(3)... Dissociating pain from its anticipation in the human brain. M. On the margins of science:The social construction of rejected knowledge.. Keele: University of Keele. J. D. T. C. McCreary. K. Journal of Burn Care and Rehabilitation. A. 183-201. A. H. Fugh-Berman. Olness. R.. 284. Science. (1998). Adcock. M. Oakley. Complementary and alternative medicine in the management of pain.. and Kashima. J. R. R.). Hofbauer. H.. Everett.. (1994).. J. M. Imagination. Menon. P. C. 45 (4)... Presented at the Fifth Annual Meeting of Cheiron-The IInternational Society for the History of the Behavioral and Social Sciences. R. A. D.. P.. Non-opioid-based approaches to burn pain. B. (1992). D. Clare. T. 13-8. Patterson. R. (2000). S. dyspnea. (1987).. M.. N. and acupuncture. Matthews.. (1989). Cognition and Personality. Pediatrics. 167175. S. Rainville. A. Hypnosis in the treatment of patients with severe burns. Spanos. [Review].Hypnosis in the Management of Chronic Pain Conditions… 289 Nolan. 200-212. Journal of Consulting and Clinical Psychology. A. (1999). D. Gati.. 31(3). and Duncan. R. R. (1979). and Scott. 13(1)... G. June 10. (1996). Pain.. A cognitive-behavioral approach to temporomandibular dysfunction treatment failures: a controlled comparison. 374-87. S. R. Goldberg. Case studies in nineteenth century scientific rejection: Mesmerism. D. perkinism. R.. Patterson... (1994). L. 60-7. D. 82(2). A. Holston. 103-120). and Gibran.. Carrougher. Nicholas. G.. N. Patterson. A systematic review.. D. Baseline pain as a moderator of hypnotic analgesia for burn injury treatment. R. Hypnosis after an adverse response to opioids in an ICU burn patient.. Quen. L. Ohrbach. C. and Ptacek. T. Patterson. J. 60(5). R. M. Patterson. (1999). Burns.. 8(4). R.. American Journal of Clinical Hypnosis. K. (1987). P. Patterson. P. MacDonald. Comparison of self-hypnosis and propranolol in the treatment of juvenile classic migraine. Tracey. J. Clinical Journal of Pain. (1973). D. X. M.. 397-401.. D. D. and Ehde. J. Practical applications of psychological techniques in controlling burn pain. M. C. 1979-1981. and Boltwood. S. Bushnell. 713-7.. H. S. and psychological well-being in trained meditators and nonmeditators. 38-55.. Hypnosis: The cognitive-behavioral perspective (Psychology series) . 85-87. H.. P. and Hayward.290 John F. 1349-1366). G. P. Cerebral mechanisms of hypnotic induction and suggestion. P. (1983). and Tuttle. F... R. K. 54-63. Cambridge. S. Jr. M. G. J.. J. (1993). M. Cognitive Therapy and Research. and DeGood. C. D. R. and Lewis. C. (1994). Garrard. P. A comparison of treatments for prefrontal muscle contraction headache.. Biofeedback and Self Regulation. Sephton. N. N. Cognitive Neuroscience. 49(1). D. oral medicine. Hofbauer. 677-681. and R. Carmanico. C. and endodontics. hypnotic susceptibility. International Journal of Clinical and Experimental Hypnosis.. T. (1990). International Journal of Clinical and Experimental Hypnosis. 674-683. N. A.. Terr. (1993). D. (1990). 71(2). P. Reeves. L. A. 8(1). oral pathology. Edinburgh: Churchill Livingstone. Shutty. 17(2).. pp.. Rey. Patient knowledge and beliefs about pain and its treatment. Hypnotic suggestion and placebo for the treatment of chronic headache in a university volunteer sample. Buffalo. Scott. Chronic pain patients' beliefs about their pain and treatment outcomes. Effects of Psychosocial Treatment in Prolonging Cancer Survival May Be Mediated by Neuroimmune Pathways. 2nd.. 206-240). P. Experimental research on hypnotic analgesia. N. Spinhoven. S. 47-52. D. 84... C. Hypnosis: The Cognitive-Behavioral Perspective (pp.. G. 35(1).. Chaves Rainville. Neurophysiological processes underlying the phantom limb pain experience and the use of hypnosis in its clinical management: an intensive examination of two patients. M. P. Shutty. Spanos.. A. N. (1998). Duncan. Spanos. and Stites. DeGood. and Rosjo. and Blume. Steggles. Journal of Abnormal Psychology. . 11(1). Melzack (3rd ed. Bartenstein. Spiegel. oral radiology. Spanos. I. Spanos. 128-132.. D. Spanos. S. (2000). 43-54. P. Imagery and hypnosis in the treatment of cancer patients. M. (1980). E.. J. In N. Radtke-Bodorik. D. 88(1). H. Rosen. (2001). C. The effects of two cognitive strategies on pain threshold. S. Chaves (eds). 191-205.. Berner. The history of pain. D. Buffalo. (2000). F. F.. Golden. Sine. Tirabasso.. J. P. Schlutter. 110-125. Archives of Physical Medicine and Rehabilitation.. P. and Rivers. L. (1975). J.. 48(3).. N. and Shapiro. 53(1). L. and J. MA: Harvard University Press.. S. Journal of Abnormal Psychology.. H. S. Liddy. Oral surgery. N. Wall. E. NY. T. Medical hypnosis for temporomandibular disorders: treatment efficacy and medical utilization outcome. D. Heart-rate reactivity to cold pressor stress following biofeedback training. Spanos. 840. Hypnotic analgesia.. M. Spiegel. Spanos. Willoch. J. and Chaves. and ter Kuile... D. 290-305.. E. E. P. 90(1). Oncology. and Moore. 1179-1189. Horton. D. (1997). and Chaves.. F. (1989). Annals of the New York Academy of Sciences.. Rehabilitation Psychology. M. Bushnell. P. NY: Prometheus.. H. Simon. (1999).. P. USA: Prometheus Books. S. British Journal of Medical Psychology. Paus. (1989).. 11(8). M. 87-99.. Journal of. Nonanalytic attending. J. (1979). D. and Price. J. and Ellis. Treatment outcome expectancies and hypnotic susceptibility as moderators of pain reduction in patients with chronic tension-type headache. L. (1987).. 189-198. 23-5. M. S. Donaldson.. Management of pain in sickle cell disease using biofeedback therapy: a preliminary study. 413-20. Linssen. 10th International Congress of Hypnosis and Psychosomatic medicine . F. 187-200.and long-term success in tension-type headache patients.. P. J. (1997). M. Syrjala. Buffalo. (1986). (1987). McGrath. and Chapman. and Lightfoot. P. Journal of the Association of Pediatric Oncology Nurses. 39(3). and Thomas. Hypnosis for oral pain following chemotherapy and radiation. Pain and symptom control in paediatric palliative care. Treating tension headache: Autogenic training and hypnosis imagery. (1997). (1984). Thomas. S. NY: Prometheus Books. S. 29(4). Hypnosis and cancer: an annotated bibliography 1960-1985. and Roth-Roemer. K. Van Dyck. L. . Steggles. Van Dyck. K. M. S. S.. G. M. F. 630-6. and Kilham. W..Hypnosis in the Management of Chronic Pain Conditions… 291 Spinhoven. 3(1). 281-90. and Mayer. C. K.. 1985-1995. Stevens. Stam. Supplement 4.. H. L. M. G.. J. Syrjala. Cancer pain (pp. F. Stam. K. J. Maxwell. C. American Journal of Clinical Hypnosis. L. 48(2).. P. American Journal of Clinical Hypnosis.. (1984). Cavalletto... Journal of Pediatric Oncology Nursing.. and Aucoin. 331-340. Relaxation and imagery and cognitive-behavioral training reduce pain during cancer treatment: a controlled clinical trial. Sutcher. P. E. W. Biofeedback and Self Regulation. J.. A. Damore-Petingola.. (1989). (1992). C. Lightfoot. Autogenic training and cognitive self-hypnosis for the treatment of recurrent headaches in three different subject groups. 14(1). Spinhoven. A. P. Pain. G. Apr. (1997). R. 63(2). P. R.. Davis. N. R... 137-46. and Linssen. Dalla Pozza. G. L. E.. A. (1994).. Norton.. R.. M. M. Hypnosis as adjunctive therapy for multiple sclerosis: a progress report. G.. Headache. Damore-Petingola. R. Responders and nonresponders to autogenic training and cognitive self. S171.. C.. 58(3). The treatment of temporomandibular joint syndrome through control of anxiety. Hypnosis and cancer: an annotated bibliography 1985-1995. and Aucoin. H. American Journal of Clinical Hypnosis. 27-32. W. 35(10). Hypnosis or cognitive behavioral training for the reduction of pain and nausea during cancer treatment: a controlled clinical trial.. H. Steggles. 283-290... and Rooijmans. A.. G. Syrjala. C. 121-157). Zitman. M. W. and Carr. H. G. H. S. Kippes. J. Pain. American Journal of Clinical Hypnosis. Fehr. S.. Steggles. P.. L. Maxwell. (1996). Stamm. From symptom relief to cure: Hypnotic interventions in cancer (pp. Similarities and dissimilarities in hypnotic and nonhypnotic procedures for headache control: A review. New York: W. N. Pain.. H. R. E. Spinhoven.hypnosis: prediction of short. Steggles. L. ter Kuile. and J. Zitman. B. Cooper. and Linssen. Cummings. Cancer Surveys. Koshy. Donaldson. and Brooke. Hypnosis for children and adolescents with cancer: an annotated bibliography 1960-1985. J. J. J. P. 183-194. 9(4).39(4). M.. A. Patterson. K. In N. G.. C. (1995)... Barber (ed) Hypnosis and suggestion in the treatment of pain. 21.. Chaves (eds) Hypnosis: The cognitive-behavioral perspective. Syrjala.. M... Dorn. 41-45. (1995). ter Kuile. 30(3). (1994).. 15(1). I. and Donaldson. C. E. Spanos. Pain. Hypnosis for children and adolescents with cancer: an annotated bibliography. Spinhoven. 313339). Cummings. Fehr.. 221-231. Journal of Behavior Therapy and Experimental Psychiatry. (1988). Pain and Behavioral Medicine. A. B. New York: Guilford. Bailliere. Rapid induction analgesia for the alleviation of procedural pain during burn care. without knowledge of the patient. Prior. 223-225. Wall. Rosen. L. (2000). M. CA: Consulting Psychologists Press. 20-25. (2000). N. 423-425. Wald. Journal of Psychosomatic Research. P. Social History of Medicine. and Faragher. Chicago: University of Chicago Press. C. 349-351. Hypnosis and autogenic training in the treatment of tension headaches: A two-phase constructive design study with follow-up. D. (1983). Winter. Winter. Stanford Hypnotic Susceptibility Scale (Form C ed. Ward. 49-51. (1999). and Genest. (1989). and Sanders. H. T. Hypnotherapy in the treatment of irritable bowel syndrome: methods and results in Amsterdam. Weitzenhoffer. and Colgan.. (1982). and Hilgard. P. Digestive Diseases and Sciences. P. H. B.. (1998). 842-9. American Journal of Clinical Hypnosis. 14. R. Gut. G. Meichenbaum. M. 48(6). T. 13-19. Hypnotic and nonhypnotic techniques for reduction of pain and anxiety during painful procedures in children and adolescents with cancer. R. Irritable Bowel Syndrome.292 John F. (1842).. and Brennan. 1232-1234. Tolle. 101. 31(3). J. H. . London: H. D. Van-Dyck. Phantom limb pain in the human brain: unraveling neural circuitries of phantom limb sensations using positron emission tomography. (1992). Palo Alto. Whorwell. W. (1987). 1032-1035. A. (1836).. A. P. Controlled trial of hypnotherapy in the treatment of severe refractory irritable-bowel syndrome. and Topham. Webster. 28.. 86-93. W. 36(3). G. Wester. Willoch. Hypnotherapy for selected gastrointestinal disorders. and Bartenstein. (1990). 15(3).. E. Urologic Nursing. Controlled trial of hypnotherapy in the treatment of refractory irritable bowel syndrome. 181-191. P.. Boston Medical and Surgical Journal.. and Womack. Prior. A. Wright. and Drummond. 4.. Hypnotic versus active cognitive strategies for alleviation of procedural distress in pediatric oncology patients. Burns.... A. P. (1962). 26(3). Chaves Toomey.. (1983). Mesmerized: Powers of mind in Victorian Britain. 275-282. S. B. Ethereal epidemic: Mesmerism and the introduction of inhalation anesthesia to early Victorian London. J.. Annals of Neurology. F. Turk. Scandanavia Journal of Gastroenterology: Suppl.. American Journal of Clinical Hypnosis. 2(8414). S. Zeltzer. W. I. J. M. C. Whorwell. 230. Zitman. 1-27.. A. (1995).).. F. A. C. (1991). Spinhoven. 26(1). R. J.. Experiments in animal magnitism. Vidakovic-Vukic. T. S. D. Group hypnotherapy as an active control strategy in chronic pain. Berner. V. Schwaiger.. Whorwell. West. J. E... and LaBaron. Self-care strategies used for acute attack of interstitial cystitis. D.. 2(1). (1999). Oye. Lancet.. Account of a case of successful amputation of the thigh during the mesmeric state. and Linssen. Current Treatment Options in Gastroenterology. 8(4). (1984). M.. Journal of Pediatrics. R. 252 age. 253. 218.INDEX A absorption. 177 agoraphobia. 232. 78. 7. 32. 278 adolescents. 247 alleles. 106 accounting. 195. 21. 86. 194 amalgam. 287. 101. 68. 202. 242. 281. 115. 134. 183 acceptance. 227. 231. 220. 167. 193 allergic rhinitis. 137. 70. 181. 166. 240. 288 agent. 169. 277. 126. 166 actuarial. 111. 168. 126. 225 alters. 204 acne. 192. 280 air. 292 adult. 203 alopecia. 106. 122. 75. 188. 168. 243. 47 alcoholics. 239. 123 aid. 11. 46 alertness. 203. 146. 255. ix. 273. 164. 281 activity level. 138. 99. 163. 251 agents. 215. 278 acute stress. 121. 291 adjustment. 274 aggression. 278. 184 adaptation. 280. xi. 198. 246. 192. 124. 278. 278. 202. 118. 46. 289 alternative medicine. 34 adipocytes. 105. 285. 289 affective experience. 118. 247. 132. 271. 70 accuracy. 246 AIDS. 47. 3. 285 abstinence. 255 alternative. 277. 270. 214 adjunctive therapy. 167. 44. 178. 288 affective dimension. 103. 132. 38. 179. 169. 132. 60. 179. 16. 228. 168. 165. 93. xi. 233. 150. 221. 141 ambivalence. 165. 213. 170. 202. 41 afternoon. 132. 54. 288. 220. 176. 123. 193. 231. 235. 191. 239. 198. 25. 220. 111. 204. 129. 37. 230 administration. 209. 199. 7. 197. 106. 101 . 133. 291. 136. 218. 218. 197. 41. 269 alcohol. 181. 9. 180. 86. 5. 149. 56. 4. 273. 197. viii. 204 alopecia areata. 166. 190. 231. 190. 169. 210 acupuncture. 192. 238. 123. 184. 180. 203. 219. 216. 190. 162. 33. 257. x. 62 accidents. 46 alcoholism. 127. 245. 167 addiction. 215 acid. 179. 207. 232. 272 accessibility. 161. 292 acute lymphoblastic leukemia. 197. 271. 69. 10. 69. 16 accidental. 147 academic. 236. 64. 190. 217. 58. xii. 123. 76 altered state. 220. 25. 277. 203 activation. 216 adaptive control. 194. 234 adults. 289 acute. 129. 229. 100. 28. 116. 3 allergy. 121 ACC. 276 ambivalent. 36. 273. 289 alternatives. 197. 169 African Americans. 204 alpha. 181. 186. 235. 186. 274 attitudes. 193 amplitude. 158 authority. 177. 1. 226. 33. 126. 219. 176. 224. 283. 252. 14. 28. 221 anterior cingulate cortex. 204. 230. 135. 188. 18. 31. 276 anxiety. 152. 200. 272 ASCs. 214. 49. 137. 257. 199. 181. 173 assessment. 211. 275. 182. 109. 276 barriers. 271. 4. 239. 103. 192. 210. 273 anger. 280 behavior modification. 124 aspiration. 273. 150 anatomy. 287 assessment procedures. 46. 273. 226. 223. 291. 128. 25. 278. 37. 131. 194. 172 anesthetics. 122. 243. 251. 153. 243. 121. viii. 162. 215. 220 analysts. 56. 153. xi. 123. ix. 109 assets. 254. 40. 195. 152. 65. 153. 266 anxiolytic. 276 attribution. 216 anxiety reaction. 50. 280 antipsychotic. 179. 235. 12. 176. 176. 231. 100. 170. 244. 226. 107. 288. 37. 75 autism. 187. 198. 151.294 Index American Psychological Association. 8. 194. 239. 38. 284. ix. 239. 268. 172. 219. 192. 132 Australia. 81 asphyxia. 280. 236. 195. 163. 126. 256. 30. 60. 175. x. 200. 292 anxiety disorder. 48. 169. 7. 169. 26. 282 bacterial. 249. 70. 27. 202. 38. 150. 128. 111 antidepressants. 50. 196. 50. 84 behaviours. 91. 4. 36. 104. 268 behavior. 3. 154. 36. 271. 286. 219. 292 analgesic. 272. 190. 178. 281 B back pain. 56. 145 asthma. 288. 11. 273. 139. 5. 107. 245. 9. 148. 161. 199. 155. 2. 1. 254. 173. 185. 213 animals. 172. 280 argument. 127. 266 attention. 221 ants. 292 amygdala. 258. 69. 65. 221. 86 attacks. 2 appetite. 193. 276. 139 arousal. ix. 69. 108. 246. 263. 108. 103 antithesis. 149. 61. 102. 103. 15. 197. 3. 29 aversion. 3. 180 analgesia. 238. 179. 200 antibiotic. 284. 74. 192. 257. 218. 126 antipsychotic drugs. 107. 285. 288 amino acid. 46. 8. 203. 268 anomalous. 181. 39. 197. 169. 179 arrhythmia. 242. 27. 138. 204 attachment. 201. 121. 270 arthritis. 267. 71. 129. 75. 150. 215. 65. 178. 75. 245. 224. 235. 219 analgesics. 229 autonomy. 148 antagonists. xi. 10. 161 . vii. 155. 47. 16 autonomic nervous system. 238. 2. 214 amputation. 103. 7. 198 antidepressant. 191. 40. 200. 216. 226 behavioral manifestations. 109. 278 assault. 259. 69. 231. 276 avoidant. 217. 38. 292 automaticity. 277. 286. 153. 256. 287. 285. 35. 188 Austria. 266. 150. 233. 277. 273 beating. 245 atopic dermatitis. 189 barrier. 75. 272. 285. 180. 288 articulation. 253. 192. 222. 125. 23. 280. 86 awareness. 128 antagonistic. 281. 259 behavior therapy. vii. ix. 166. 11. 188. 11 assumptions. 191. 129. 259. 104. 123. 57. 137. 272. 54. 16. 106. 291. 167. 190. 105. 41. 177. 4. 249 application. 232. 287. 168 anti-tumor. xii. 197. 237. 229. vii. 189 bacterial infection. 283 background information. 16. 17. 46. 48. 38. 282. 27. 194. 156. 143. 250. 290. 1. xii. 245. 2. 146. 289. 178. 46. 27. 135. xi. 170 arteries. 105. 130. 281 anxious mood. 59. 161. 12. 280 behavioral change. 106. 95 atmosphere. 242. 69. 103. 108. 292 Amsterdam. 220 Atlantic. 2. 285 appraisals. 233 APA. 217. 44. 244. 143 autogenic training. xi. 221. 33 cerebellum. 213. 9. 216. 169. 210. 230. 189. 129. 214. 143. 143 category a. 109. 201. 216. 28 BMA. x. 260. 45 blood vessels. 19. 240. 46. 1. 250. 285 blood flow. 193. 31. 32. 109. 148. 211. 133. 115. 283 benzodiazepines. 36. 153. 212. vii. 277. 118. 233. 227. 243. 218. 239. 204 cassettes. 290 biological processes. 208. 24. 189. 234. 145. 238. 29. 32. 194. 269. 201. 233. 220. 285. 213 biological rhythms. 291 candidates. 67. 125. 123. 227 cellular immunity. 235. 137. 7. 249 Boston. 101. 133. 263. 192 buildings. 288. 281. 123. 220. 290. ix. 108. 202 bonding. 103 causalgia. 168. 220 borderline. 269. 201. 214 capacity. 59. 285. 236. 226. 122. 54. 203. 208. 224. 155. 278 body image. 284. 46. 128. 188. 266. 59. 212. 48 birds. 212. 27. 233. 217. 287. 203 categorization. 177. 101. 102. 278 brain. 161. 35. 235 caregivers. 26. 235. 282. 130. 222. 48. 281. 232 295 breast cancer. 231. 231. 41. 129. 221. 85 burns. 292 Buddhism. 292 boys. 289 bushes. 292 bowel. 163. 189. 169. ix. 289. 181 black-box. 150. 286. 178. 121 carbon dioxide. 33. 26. 227 cancer progression. 32. 161. 274. 25. 277. 282 Britain. 266 C Canada. 254 catalyst. 290. 278. 278. 283 benign. 181 carbon. 33. 189 bloodstream. 219. 155 boredom. 132. 122. 223. 48. 283. 214. 274. 78 boils. 129.Index belief systems. 192. 25. 20. 189. 292 burning. viii. 179. 291 biofeedback training. 119. 166. 107. 276 causality. 39. 285. 34. 211. 26. 217 cancer treatment. 246 catechol. 220 blocks. 126 bias. 213. 219. 119. 223. 245. 135 bone marrow. 237. 233 cancer cells. 286. 270. 34 blood. 101. 194 . 278 bone marrow aspiration. 284 cast. 275. 232. 265. 268. 226. 220 CAS. 256 breakdown. 100. 192. 177. 175. 209. 220. 183. 48. 200. 103. 200. 63. 165. 46. 278 bone marrow transplant. 193. 169 brain structure. 146. 279. 65. 233. 213 Cellular response. 121. 178. 244. 34. 57. 173. 215. 276 CEO. 69. 191. 207. 276. 236. 191. 207. 169. 12 beliefs. x. 27 cell. 164. 286. 235 breathing. 227. 291 cell culture. 166 biofeedback. 225. 275 cerebral blood flow. 135. 85. 218. 269 burn. 208 bleeding. 133. 134. 201. 123. 233. 38. 218. 225. 285 breast carcinoma. 188 cancer. 292 brain activity. 279. 200. 34. 106. 285 cerebral cortex. 138. 284. 227. 147 binding. 36. 172. 75. 288. 234. vii. 121 carcinoma. 45. 226. 48 blood pressure reduction. 291. 214 central nervous system. 26. 281. 136 C-C. 285 blood pressure. 196 burnout. 133. 9. 194 brain stem. 1. 210. 176. 286. 121. 182. 220. 149. 161. vii. ix. 289. 222. 213 Bible. 289. 45. 290 benefits. 68. ix. 213. 137. 233 biopsy. 284. 233. 230. 232. 156. 99. 287. 111. 1. 190. 278. 149. 8. 229. 213. 292 cancer care. 275. 168 breast. 146 bonds. 21. 217. 105. 172 Brazil. 234 bipolar disorder. 235. 47. 220. 168 cognitive psychology. 94. 257. 234 colors. 126. 233. x. 140. 3. 28. 240.296 Index cerebral function. 33. 253. 67. 41 cingulated. 137. 50 cognition. 20. 147. 255. 247. 137. 135. 222. 181 concentrates. 292 chocolate. 6. 240. 61. 102. 29. 14. 259. 28. 100. 67. 108. 230 classical. 142. 143. 219. 190 chronobiology. 188. 171 cerebral hemisphere. 190 conditioned stimulus. 199 cholinergic. 192 clusters. 124. 291. 197. 128. 78. 89 childbirth. 291 clinical trials. 124 CHILD. 28. 26. 221. 235. 40. 200 chronic pain. 198. 184 complement. 61. 279. 236. 137. 122. 190 chemotherapeutic drugs. 204. 142 CFA. 292 cognitive activity. 27. 223. 256. 232. 50 classification. 292 chronic recurrent. 138. 234. 242. 219. 222. 246. 276. 164. 225. 168 cognitive domains. 27. 223 classical conditioning. 219. 131. 201. 105. 181. 170. 1. 48. 125. xi. 280. 218 components. 173. 282 clouds. 180. xi. 209 competition. 290. 27. 66. 181 classrooms. 103. 229 cigarettes. 137. 178 conceptualization. 215. 240. 207. 140 condensation. 215. 123. 259. 138. 61 cognitive impairment. 135 chronic disorders. 158. 280 chronic stress. 168. 226. 228. 146. 165. 132. 5. 67. 40. 225 chemotherapy. 237. 168. 177 compliance. 138. 23 conditioning. 18. 162. 83. 185. 168 cognitive style. 139. 231. 203. 184. xii. 238. 32. 220. 285. 222. 5. 133. 214. 251 colorectal cancer. 225. 16. 170. 31. 195. 280 complexity. 239. 166. 133. 277. 163. 29. 288. 169. 235. 230. 278. 8 concentration. 36. 248. 30. 136. 233 circulation. vii. 123 cognitive level. 217. 168. 258 cobalt. 214 classes. 9. 62 charities. 101. x. 283. 134. 284. 289. 58. 216. 152. 147 concordance. 274. 140. 191. 37. 38. 238. 272. 245. 220. 190 Co. 237. 133 CNS. 264 clinical approach. 171. 16. 272 competence. 178. 245. 67 cognitive process. 152. 214. 151 conceptualizations. 57. 105. 207. xi. 228 coherence. 215. 151 conditioned response. 127. 237. 29. 181. 10. 34 coding. 8. 124. 220. 218. 136 communication. 152 cognitive-behavioral therapies. 25. 240 clinical trial. 45. 218. 291. 261. 136 chemicals. 119. 180 clients. 209. 233. 60. 165. 61. 274. 172. 232. 246. 243. 61 . 191 childhood. 277. 18. 231. 106. 280. 49. 7. 244. 151. 272. 239. 276. 271. 135. 221. 166 cohort. 67. 134. 240. 136 children. 47. 286. 225 complications. vii. 107. 195. 197. xi. 126. 223. 288. 276 closure. 162. 232. 204 conductive. 278 community. 279. 221. 25. 9. 280. 287. 280 clinician. 12. 219. 74. 273. 20. 285. 28. 133. 275. 212. 193 coffee. 272. 194. 169. 51. 235. 156. 244. 135. 238. 131 cognitive function. 179. 284 comprehension. 55. 131. 224. viii. 276. 284. 107. 277. 75. 275. 236. 85 concrete. 126. 255 complex regional pain syndrome. xii. 29. 12. 109. 70. 50. xii. 234. 250. 130. viii. 243. 185. 161. 287. 105. 74. 291 chewing. 234. 231. 189 Christmas. 24. 186. 109 clinical assessment. 185 circadian rhythms. 247. 9. 107 classroom. 143 cognitive. 218. 186. 231 cognitive involvement. 236 collaboration. 16. ix. 280. 167. 169 cognitive processing. 9. 28. 115. 242. 68 channels. 192. 106 chronic myelogenous. 214. 28. 280. 137 connectionist models. 188 consumption. 83. 196. 156 continuity. 34. 197. 161. 111. 169 decisions. 46. 178. 243. 171 conscious awareness. 7. 214 Czech Republic. 40. 240. 90. 25 defense. 126. 238. 139. 73. 216. 224. 179. 195. 222. 135. 127. 214 cost-effective. 194. 213 cytotoxic. 179. 239 control condition. 168. 188 creep. 183. 220. 26 demand characteristic. 11. 5. 243. 285 criticism. 219. 90. 171. 78. 166. 60. 200. 176. 138 deficits. 45. 68. 147 constipation. 142. 131. 114. 292 cytokine. 107. 234 depression. 184. 47. 20. 147. 194 delirium. 75. 278. 143. 217. 137 connectivity. 289 consumerism. 281 depressive disorder. 216. 76. 221. 279 death sentence. 227 deficit.Index confidence. 185 conviction. 266 debridement. 93. 61. 227. 26 . 275. 98. 46. 251. 33. 28. 14. 102 coping. 211. 77. 40 depressed. 261 death. 147. 103 delivery. 229. 148. 83. 267 credibility. 103. 24. 210. 167. 150 defenses. 13. 147. 224. 11. 125. 210. 219 cough. 279. 169. 213. 266 Congress. 107. 22 dentistry. 144. 94. 48. 222. 223. 43. 11. 231. 136. 35. 78. 77. 166. 150. 289 debt. 178. 38. 240. 165. 211 confirmatory factor analysis. 217. 215. 71. 102. 242. 180. 134. 280 covering. 258 D danger. 40 credit. 60. 213. 186 confusion. 25 delusions. 225 cystitis. 233. 200 costs. 165 definition. 81. 244. 158. 185. x. 200. 220 coughing. 225. ix. 190. 218 conversion. 285 dependent variable. 168. 50 cycles. 199. 182. 185. 7. 277. 100. 195. 15. 180. 107. 6. 261 confidence intervals. 231. 104. 178. 220. 93. 236 cytokines. 176. 24. 107. 281 controlled trials. 232. 182. 146. 37. 146. 121. 68. 141. 73. 171. 119. 130. 213. 183. 207. 212. 214. 101. 266. 172. 43. 217. 291 connectionist. 123. 164. 194. 226 context-dependent. 143. 235. 163. 242 critical analysis. 234. 280 coping strategies. 133 cortex. 147 decision making. 232 crying. 249. 215. 194. 138. 225. 36 crimes. 213. 32. 3 deep-sea. 150. 226. 248. 137. 124. 78. 262 cranial nerve. 158. 23. 47. 282 control group. 105. 69 conflict. 139. 228 correlation. 150 defense mechanisms. 185. 221 delusion. 85 cross-sectional. 45. 65. 178 consciousness. 237. 31. 140. 8. 149. 167. 213. 277 coping strategy. 166. 212. 97. 176. 166. 71. 228. 223. 216. 255. 41. 68. 165. 221 cytotoxicity. 258. 103. 132. 221 consolidation. 280 cornea. 221. 62 counseling. 65. 34. 139. 278. 214. 282 correlation coefficient. 130. xi. 270 consensus. 228 correlations. 186 conversion disorder. 249. 216 degradation. 213. 163 cortisol. 170. 84. 246. 211. 252 culture. 177. 79. 105. 213. 136. 84. 228 controlled studies. 167. 182 297 creativity. 179. 40. 162. 81. 82. 22. 256 cues. 26. 233. 49. 220 construction. 16. 23. 281. 168. ix. 283. 125. 188. 224 cybernetics. 281 cortical processing. 80. 3. 91. 262 Cuba. 73. 125. 282 dysphagia. vii. 253. 50. 217. 69. 65. 154. 280. 196. 200. 20. 25. 165 dosage. 103. 278 doctors. x. 117 eating. 120. 218 dermatitis. 48. 236. 189. 135 duration. 9. 224. 1. 197 ego strength. 222. 57 diabetes. 283. 123 dyspnea. 14. 33.298 Index depressive symptoms. 177. 193. 49. 198. 45. 161. 50 . 255. 232. 9. 167. 9. 216 electrodes. 130 EEG. 163. 65. 188 eczema. 242 dogs. 278. 46 drugs. 224. 276. 194. 143. 276 emotional distress. 203. 234. 153. 151. 179. x. 194 dorsolateral prefrontal cortex. 282 ectoderm. 225. 166 electroencephalogram. 62. 285. 281. 46 drug treatment. 210 diseases. 274. ix. 6. 184. 204 dermatologic. 187. x. 185. vii. 192. 115. 125. 118. 57. 198. 191. 108 division. 137 disability. 109. 281 dream. 198. 268 emotional. 48. 201. 235. 146. 194. 86. 107 disabled. 103. 218. 212. 286 diet. 154. 191. 123. 216. 216. 178. 107. 143. 32. 219. 226 economies of scale. 85. 166. 67. 167. 267 distortions. 265 disaster. 215. 47. 167. 105. 184. 122. 26. 239. 130. 289 E ears. 61. 191 emission. 278 distress. 285 ego. 231. 207. 151 drinking. 123. 235. 280. 247 drowsiness. 1. 179 emotional intelligence. 274 drug addiction. 163. 286 dominance. 9. 72. 32. 178. 190. 225 DSM-IV. 3. 214. 183. 208. 252. 57. 102. 157. 41 dysmenorrhea. 147. 170. 50 derivatives. 147. 163 electromyograph. 194. 254. 100. 282 differentiation. 187. 197. 127 disease progression. 121. 43. 10. 107. 184 discipline. 34. 4 desire. 10. 202. 188. 126. ix. 288. 101. 31. 279 duties. 93. 119 elderly. 191 detachment. 172. 31. 63. 28. 190. 117. 203 domain. 226. 46 diabetic neuropathy. 168. 104. 124. 189 desensitization. 168. 63. 161 distraction. 195 disorder. 24. 34. 176. 21. 280. 180 EMG. 215. 200 education. vii. 191 emotional experience. 218. 102. 184. 219. 154. 42. 19 dopamine. 199. 1. 292 emotion. 166. 122. 65. 151. 280 dichotomy. 268 eating disorders. 218. 181. 231. 219. 167. 196. 200. 288 dissociation. 189. 203 deviation. 47 drive theory. 40. 245 doctor-patient. 104. 246. 38. 155 discomfort. 196. 50. 192. 183 duplication. 166. 199. 248 disclosure. 24. 14. 166. 243. 177. 3 dyspareunia. 216. 90 dizziness. 219 dizygotic. 190 detection. 254. 25 drug-related. 282 discontinuity. x. 226 dietary. 132. 121. 277 disease-free survival. 167 emotional information. 194. 147 dropouts. 68. 22. 115 disappointment. 203 dermatosis. 250. 195 desires. 187. 103 dualism. 101. 129. 90 dizygotic twins. 238. 153. 32. 167. 169. 139. 277. 180. 292 distribution. 281. 108. 222 dysphoria. 249. 216. 38. 203 dermatology. 197 elbows. 245. 231. 102. 61. 217. 278. 226. 207. x. 188. 179. 126. 221. 40. 81 diversity. 194. 250. 65. 150. 173 elementary school. 195. 182. 191. 186. 119. 284 deprivation. 253. 31. 229 expert. 255. 118. 156.Index emotional memory. 188. 116. 182 enzyme. 180. 245. 250. 173. 262. 179. 188 fibers. 246. 60. 292 epidemics. 41. 167. 268. 42. 113. 43. 228. 74. 184 emotional stability. 136 extinction. 13. 135. 244. 57. 99. 251. 118. 40. 185 false belief. 124. 243. 212 entanglement. 106. 275 family life. 280. 282 flavors. 44. 170 energy. 211. vii. 183 excitation. 153. 141. 275. 25. 38. 179. 20. 3. viii. 143 family. 141 encouragement. 132. 179. 287 equality. 185. 51. 230. 150. 4. 112. 19. 47. 186. 37. 183. 188. 124. 188 endocrine. 274. 176. 176 fairness. 30 evoked potential. 190. 35. xi. 178. 228 feeding. 283 endothelial dysfunction. 178. 170. 123. 230 exposure. 31. 132. 288 experimental condition. 47. 121. 102 emotions. 154. 101. 190 end-of-life care. 30. 126 evidence. 215. 222. 228. 177. 264. 209 expertise. 181. 251. 179. 243. 69. 259. 188 family members. 9. 182. 83. 41. 278 fears. 244. 192. 266 fear. 4. 119. xi. 284 evil. 183. 178. 101 evening. 84 environmental stimuli. 68. 276 Europe. 177. 269 F facial expression. 70 failure. 247. 54. 69 executive functions. 181 experimental design. x. 39. 177. 169. 249. 194. 191. 183. 219. 44. 210. 278 empathy. 176. 105. 141. 4. 279. 3. 59. 224 etiology. 8 exclusion. 151. 275 fainting. 274. 267 feedback. 261. 3. 114. 210. 62. 143. 122. 125 flexibility. 36. 150. 41 encoding. 111. 155. 138. 125. 62. 29 eye contact. 275. 278. 105. 190 external environment. 46. 225. 284 . 122. 111. 34. 262 filters. 183 England. 125. 181. 57 ethics. 27. 135. 199 feelings. 251. 140. 198. 262. 12. 253. 203 epidemic. 189. 274. x. 15. 62. 274 fatigue. 265. 26. 155. 183 employees. 193. 105. 252. 154. 138. xi. 276. 239. 214. 132 encopresis. 243. 237. 262. 279. 48. 165 exercise. 104. 103. 3 episodic headache. 67. 221. 266 fixation. 175 environmental effects. 218. 248. 56 fetus. 153. 78. 45. 39. 114. 224. 246. 44. 266. 272. 245. 70. 156. 27. 121. 218. 260. 75. 59. 85. 182. 253. 124. 180. 162. 188. 86 eyes. 253. 162 execution. 125. 11. xii. 251. 28. 130 emotional responses. 242. 266 females. 188. 64. 36. 123. 76. 189. 154 environment. 135 fire. 43. 243. 240. 20. 118. 69. 63. 40. 182 epilepsy. 192. 55. 264. 139. 237. 81. 121. 86. 238. 115. 253 feet. 196. 115. 272. 47 equipment. 66. 132. 175. 284 299 expectations. 190 erythema nodosum. 184 factor analysis. 217 endocrine glands. 268. 132. 32. 33. 243. 189 film. 134 evolution. 134 executive functioning. 10. 111. 9. 68. 58. 116. 59. 277. 115. 156. 193. 265. 269. 196. 212 excitability. 149. 282 flame. 65. 122 flatulence. 227 environmental context. 15 faith. 111 ethical questions. 179. 35. 103. 196 escitalopram. 263 flashbacks. 263. 252. 184. 270 engagement. 37. 165. 267. 153 equilibrium. 246 generalized anxiety disorder. 188. 195 gender. 48 freedom. 215 global management. 114. 48. 134. 269 heart rate variability. 45 hands. 180 grades. 5. 91. 185. 194. 216 hallucinations. 31. 251 food. 279. 33. 190 headache. 134 H H1. 67. 177. 249 HADS. 42. 85. 167. 38. 250 generation. 193 gene expression. 285 focusing. 140 group therapy. 272. 212. 232. 283 health problems. 37. 62 glass. 145. 17. 4. 31. 32. 220. 113. 136. 154. 192. 102. 21. 49. 149. 62 habituation. 256. 249 handling. 273. 200. 292 gauge. 132. 31. 83. 285 Freudian theory. 227. 33. 22. 30. 138. 84. 236. 57. 268. 147 gold. 285 fluoxetine. 46. 49. 136 gestures. 115. 221. 47. 262 harm. 12. 143. 39. 12. 166. 124. 230. 21. 49. 278. 86 hazards. 70. xii. 21. 143 gravity. 267. 132. 227. 141. 170. 150. 171 heartbeat. 185 gift. 232. 117. 290. 283 happiness. xi. 43 fulfillment. 220. 176. 140. 15. 43. 26. 228. 262 fracture. 269. 163 genes. 126. 149 friction. 171. 170. 263. 146. 65. 136. 163. 223. 34. 233. 176. 32. 234 grounding. 229. 64. 262. 176. 265. 181 float. 103. 217. 285 grouping. 30. 57. 279. 200 heart rate. 269 G Galvanic Skin Response (GSR). 192. 284. 200. 193. 261. 33. 125 forgetting. 30 functional analysis. 270 Hebrew. 234. 288. 241 funding. 41 gas. 189. 195. 238. 211. 275 frontal lobes. 60. 122. 123 guilty. 273. 107. 124. 285 gestalt. 139. 191. 111. 269. 171. 60. 66. 219. 223. 266. 3. 212. 157 . 230. 37. 154 grass. 62. 85. 186 gastrointestinal. 122. 216. 188. 197. 275 God. 12. 126 fMRI. 45. 31. 115. 169. 70. 158. 34. 228 government. 227 Germany. 38. 123. 271. 141. 34. 150. 282 gyrus. 71. 273. 26. 275 frustration. 189 gambling. 118. 168. 232. 123. 286. 47 groups. 261. 242. 66. 156. 171. 124. 233 guilt. 290 heart disease. 153 guidelines. 244. 46. 135 Freud. 36 floating. 157. 86 harmony. 31. 245. 191. 179. 142. 42. 272. 17. 171. 200. 24. 224. 250 France. 44. 134 genetic factors. 148. 232. 143. 207. 134. 37.Index 300 flight. 46. 65. 11. 61 H2. 46. 146 free will. 235. 21. 29. 162. 170 furniture. 36. 209. 135. 149 generalization. 31. 28. 278. 289. 232. 126 fluvoxamine. 152. 36 flow. 41. 165. 122. 228 gold standard. 40. 201. 76. 285 health. 125. 133 heart. 147. 30. 29. 259 Greece. 215 grief. 231. 283 health care. 196. 30. 65. 188. 273 guidance. 287. 39. 37. 266 gases. 151. 217. 171. 23. 4 gut. 137. 33. 181. 291 healing. 291 growth. 67. 141. 59. 119. 46. 42 frontal lobe. 164. 40. 264. 155. 153 girls. 90. 36. 278 gene. 30. 121. 235 free association. 46 hearing. 230 goals. 280. 21. 37. 231. 201. 85. 258 illusion. 254 hospitalized. 121 higher order conditioning. 130. 136. viii. 213 IL-6. 151. 53. 182. 196. 122. 252. 9 Hispanics. 90. 213. 277 impotence. 286 humans. 178. 16. 3 hyperthermia. 286. 191 immuno-suppressive. 31. 220. 139 impregnation. 140. 184. 236. 198. 227 immunity. 15. 32. 226 immune function. 233. 220 herbal therapy. 149. 97 hunting. 187. 262. 27. 192. 131. 135. 266 horizon. 214. 226. 190. 223. 26. 165. 141 impulsive. 107. x. 227. 281 hospitals. 220. 230 host. 279 hemodynamic. 240 homosexuality. 81 heroin. 245. 217. 214 hospital. 190. 185. 86. 70 Hungary. 213 IL-15. 28. 47 hyperhidrosis. 216 immune system. 31 immunotherapy. 167. 276 imagination. 292 human cognition. 33 homework. 132 imitation. 156. 291 images. 204 immunological. 202 hypersensitive. 131. 132. 32. 226. 216 implementation. 279 identification. 21. 25. 200. 172. 287 ICU. 46. 156. 245. 131. 268. 54. 217 immune response. 213 Illinois. 9. 23. 214. 22. 32. 140. 139. 213. 16. 221. 148. 146. 148 immune cells.Index height. 240 in transition. 188. 178. 102. 138 holistic approach. 36. 144. 217. 190. 4. 10. viii. 226 incentive. 148. 121. 104 human brain. 131. 177. 289 id. 145. 191. 84. 132. 21. 230. 212. 233. 264. 20. 31. 220 heritability. 30. 104. 104. 28. 185. x. 68. 181. 41 HIV. 224. 225. 167 hypertension. 2 humanism. 41 . 185. 154. viii. 133. 256. 41 herpes simplex. 126. 220 hypothalamus. 142. 218. 59. 190. 213. 190 301 hypothesis. 213. x. 235 immunodeficient. 155. 148 human interactions. 132. 248. 231 hysteria. 186. 148. 46 high risk. 225. 212 HRV. 135. 221. 196 identity. 190. 150. 239 ice. 202. 223. 279. 132. 86 human nature. 16. 124. 143. 156. 217. 193. 136. 185 Hungarian. 156. 186 I iatrogenic. 202. 2. 25. 181. 152. 168 imaging techniques. 31. 143. 41. 192. 201. 148. 229. 252. 105. 153. ix. 212. 142. 16. 289. 203. 227 hormones. 168. 40 hematological. 244. 4. 151 in vivo. 278. 201. 199. 259 imaging. 153. 265. 131. 101. 138 in situ. 30. 124 inattention. 122 husband. 200 herbal. 157. 153. 213 IL-2. 229 human. 176. 276 high blood pressure. 36. 220 hypoxia. 74. 198 herpes zoster. 28. 101. 66. 32. 83. 119. 33. x. 289. 214. 84. 233 impairments. 192. 285. 232 immunology. 132. 253 hospitalization. 218 high school. 140 hives. 284. 41. 182. 211. 137. 198. 176. 84. 236. 214. 182. 21. 15. 226. 187. 111. 146. 180. 69. 221. 198 heuristic. 195. 136 human experience. 3. 26. 197. 108. 216. 212. 103. 138. 229 immunoreactivity. 154. 238. 69. 132. 292 human behavior. 133. 154. 242 imagery. 134. 132. 109. 232 IL-1. 187. 235. 51. 203. 275. 31. 17. 3 hopelessness. 137. 132. 289. 199 holistic. 101. 139 hormone. 183. 17. 278 hyperventilation. 207. 302 Index incidence. 180 insight. 292 inhibition. 24. 8. 200 intravenous. 273. 191. 256. 188 independence. 243. 15. 149. 27. xi. 168. 286. 202. 192. 229. 11. 138. 41 intimacy. 64 indication. 121. 81. 134. 261 interference theory. 19. 10. 108. 155 intelligence. 166. 16. 100 individual characteristics. 29 injuries. 260. 105. 184. 166 inferiority. 245. 22. 140 infrared. 28. 70. 155. 164 individual character. 24. 228. 216 irritable bowel syndrome. 180. 133. 69. 226. 8. 231. 283. 153. 219. 27 internal consistency. 68. 138. 204. 64. 269. 166 interactions. 182. 35. 90 interpersonal interactions. 282. 292 induction methods. 72. 283. 74. 242 insects. 140. 253. 279. viii. 137 inferior frontal gyrus (IFG). 64. 73. x. 179. 283. 58. 62. 49. 278. 143. 77. 213. 51 investment. xi. 250. 116. 292 interstitial cystitis. 182 injection. 127. 218. 48. 108. viii. 194. 246. 237. 207. 176 interrelationships. 247. 75. 26. 125. 288 instruction. 224. 35. 87. 193. 241. 230. 7. 272. 138. 43. 62. 273 interface. 129. 223. x. 107. 61. 210 intervention. 125. 223. ix. 240 industrial. 28 infants. 215. 292 irritation. 69. 161. 76. x. 85. 208. 24. 41 instruments. 217 inclusion. 104. 66. 162. 222. 282. 121. 177. 100 individual differences. 102. 86. 225 indicators. 149. 54. 250. viii. 81. 70. 196. 245. 115. 264. 273. 185. 105 intuition. 133. 219. 200. 86 intraoperative. 195. 135. 77. 6. 139. 275. 266 insecurity. 150 insomnia. 12. 9. 40. 102. 144. 153. 173. 109. 85. 190. 58. 252. 122. 258. vii. 106. 281. 190. 167. 140. 18. 189 infectious disease. 67. 54 interstitial. 21. 57. 221. 285 interview. 236. 217. 15. 198. 42. 125 inhalation. 253. ix. 10. 217. 46. 78. 255. 132. 63. 267 inert. 228 irritability. 280. 181 infection. 15. 107. 3. 188. 164. 148. viii. 141 intentions. 118. 78. 198. 83. 177. 127. 223. 100. 81. 190. 70 internal processes. 228. 84. 1. 69. 216 integration. 157. 119. 187 inflammatory. 49. 24. 5. 193 interest. 250 inducer. 180. 251. 282 iris. 183 inhibitory. 169 intellectualization. 237. 1. 165. 126. 278 interaction effect. 136. 14. 211. 15. 231 investigative. 126. 237. 16. 9. 99. 13. 162. 16. 258. 103. 283. 3. 9. 12. 140. 222 ischemic. 172. 18. 214. 168. 187. 123. 267. vii. 165. 181 induction. 62 insane. x. 129. 1. 28. 56. 260 instructors. 277. 124. 284. 17. xi. 239. 19. 273. vii. 273. 188. 274. 78. 86. 115. 274. 285 . 149 interference. 2. 240. 74. 228 incomes. 68. 129. 157. 92. 169. 86. 73. 225. 38. 188 industry. 202. 281. 149 interaction. 152. 51. 40. 164. 89. 149 interpretation. 75. 132. 3 inflammation. 88. 233. 189. 164. 242. 280. 25 infertility. 220 information processing. 177 inferences. 28. 247. 106. 103 intrinsic. 240. 284. 20. 270. 72. 9. 267 intensity. 187. 150 invasive. 238. 155. 251. 57. 289 inner tension. 220 infections. 73. 169. 164. 53. 77. 27. 214 ingestion. 220. 290. 117. 135. 84. 137. x. 222. 71. 283. 23. 54. 235. 134. 64. 85. 200. 102. 37. 288 injury. 127. 292 interval. 232. 83. 230. 191. 255. 8. 131. 208. 207. 287. 197. 108. 28. 229 indices. 280 intentionality. 48. 212. 102. x. 232 interviews. 182. 65. 272. 209. ix. 31. 137 303 linguistics. 292 loneliness. 220. 136. 258. 236 management. 148. 126 longitudinal studies. 35 lifestyle changes. 32 lymph node. 69. 276 leukemia. 263 job training. 216. 131. 114 main line. 39. 7 lawyers. 156. 29 kindergarten. 35 life-threatening. 28 magnet. 218. 31. 56. 274. 152. 194. 263 learning skills. 44. 108. 218 long period. 32. 271. 32.Index J JAMA. 223. 198. 59. 277. 200. 290. 61. 55. 185. 196. 278. 261. 225. 141 macrophages. 140. 290 mania. 198. 231. 38. 98. 159. 106. 92. 255. 230. 65. 35 lifestyle. 257. 70. 243 London. 76. 165. 262 law. 16. 248. 41 LTP. 135. 103. 172 mapping. 253. 135. 164. 131. 26. 133 linkage. 288. 213 lymphoma. 211 M machines. 232 jewelry. 181. 137. 278 leukocyte. 192. 271. 275. 277. 46. 236. 49 loss of control. 132. 134. 28. 204. 244 language. 15. 129 laughing. 126. 256. 216 limitations. 8 laws. 9 learning. 244 magnetism. 40. 210. 25. 28. 214 lesions. 178 judges. 26. 163. 63. 138 legislation. 247. 243 Likert scale. 180 Los Angeles. 140. 32. 14. 285. 197. 69. 34. 47 listening. 198 life changes. 49. xi. 186. 229. 93. 77. 137. 260 language acquisition. 135. 277. 278 malignant. 165. 142 linguistic metaphors. 155 kinetic studies. 94. 41. 284 malignant cells. 212. 193. 133. 153 LSD. 147 mainstream. 214 long-term potentiation. 66. 237 maladaptive. 213 lymphoid. 220. 256 magnets. 104. 286. 224. 62. 214 knowledge. 214 malignant melanoma. 284. 135. 74. 41. 215. 41. 91. 146 maintenance. 218. 111. 140 linguistic processing. 34 lying. 234. 167. 27. 279. 192. 142. 182 laughter. 50. 282. 176. 224 lenses. 283. 191. 95. 128. 12. 227 LH. xi. ix. 38 left hemisphere. 214. 34 lymphocyte. 283 linguistic. 76 judgment. 196. 278 lungs. 254. 272. 281. 137. xi. xii. 146. 230. 138. 34 lymph gland. 213. 139. 148 large-scale. 284 likelihood. 221. 139. 133. 138. 140 leptin. 292 L lack of confidence. 26 manipulation. 233. 231. 146 lymph. 144. 117. 276 location. 42 jobs. 4 males. 157. 222 love. 42. 183 manic. 180 lumbar. 191. 124 liquor. 231. 117. 289. 232. 289. 200. 198 lichen planus. 184. 140. 179 liquids. 126. 142. 129. 213. 138 lichen. 81 K killing. 136 lover. 190. 96. 250. 188 judge. 278 lumbar puncture. 190. 213. 276. 192. 222. 285 . 138. 143. 185 misconceptions. 286. 149. 199. 232. 124. 231. 288. ix. 287. 178. 287 migraine therapy. 241. 221. 273 migraine. 156. 224. 158. 291 meditation. 90 mood. 195. 149 molecules. 194 methodology. 190 melanoma. 214 memory. 218. 132. 93. 137. 219. 228. 188. 224 mastery. 133. 275. 231. 149. 209. 131. 3 marrow. 233. 223. 212. 172. 139. 144. 129. 277 metastasis. 246. 86. 136. 39 maternal. 143 measurement. 141. 289 modules. 47. 188 marijuana. 133. x. 284. 289. 102. 41 mirror. 107. 137 money. 28. 251. 253. 29. 76. 187. 102. 100. 153. 229 monozygotic. 254. 28. 202. 124. 130. 244. 108. 32 metastatic. 229 momentum. 287. 140 meta-analysis. 202. 271 modeling. 23. 232. 138. 144. 196. 45. 192 medical care. 107. 105. 38 Mexico. 226. 208. 232. 264 moderators. 138. 29. 190 melanocytes. 289 migraine headache. 132. 126. 31. 227. 158. 91. 216. 220. 257 metaphors. 237. 162. 43. 132 mediation. 39. 106. 33. 138. 101. 156. 139. 245. 278 mask. 221. 147 mental activity. 137. 175. 286. 236 motion. 161. 218. 235. 128. 246. 167. 195. 149. 218 mortality. 164. 122. 231. 143. 207. 235. 169 mentor. ix. 74. 214 metaphor. 217. 179. 47. 217. 229. 50. 43. 136. 180. 68. 101. 146 messages. 250 misleading. 200. 54. 182. 102. 213. 59. 43 meanings. 135. 270 mental states. 85. 278. 135 morbidity. 232. 153 . 86. 277. 210. 273 mortality rate. 141. 117. 111. 69. 285 melanin. 41 marriage. 55. 38. 234 morale. 137. 26 mental image. 285 models. 129. 281 medications. 168. 57. 2. 234. 47 mood disorder. 230. 132. viii. 143. 164 mental illness. 273 MOS. 109. 203. 159. 288 medical student. 140. 104. 234. 33. 25. 290. 213. 147. 1. 66. x. 222. 229 monoclonal antibodies. 169 Middle Ages. 156. 81. 282. 78. 288. 15. 273. 252. 209 MEG. 126. 179 matrix. 254 morphine. 74. 213. 280. 46. 146 medication. 21. 233. 260 modalities. 42. 143. 287 median. 183. 279. 131. 136 mental life. 227. 128. 135. 161. 48. 135. 135. 126. 221. 193. 149. 81. 182. 219. 34. 77. 239. 144. 214. 279. 220. 133. 192. 38. 107. 131. 76. 109. x. 101. 151. 258. 221. 188 monitoring. 279 mood change. 197 modality. 127. 282 monoclonal. 279 Mexican. 151. 132. 193. 147. 194 minority. 213. 62. 278. 220. 130. 290 modulation. 153 mathematics. 285 methionine. 29. 105. 221 medicine. 41 minority students. 250. 226 metabolism. 272. 118. 24 mobile phone. 233. 134. 25. 176. 70. 136. 286 mind-body. 144. 252 mental imagery. 99. 123. 231 Medline. 42 morality. 33. vii. 236 melatonin. 211. 42. viii. 148. xi. 222. 136. 188. 71. 140. 221. xii. 109. 141. 38. 181. 284. 169. 35. 195 morning. 102. 214. 140. 11. 178 men. 152 mental state. 288 metabolic. 215. 107. 240.304 Index margin of error. 123. 177. 247. 138. 171. 152. 191. 149 meals. 233. 201 midbrain. xi. 181. 68. ix. 234 measures. 156. 83. 102. 204. 182. 168. 102. x. x. 269 mouth. 151. 290 muscle contraction. 130. 115. 269. 155. 182. 191. 292 Newton. 50. 161. 137. xii. 213. 32. 195 non-union. 214 non toxic. 154. 4. 13. 171. 16. 167. 54. 11 negativity. 143. 188. 144. 285 neuro-immunology. 221. 137. 21. 165. 202 non-steroidal anti-inflammatory drugs. 124. 177. ix. ix. 117. 255. 239. 276 nervousness. 258 National Academy of Sciences. 78. 176. 93. 104 nurse. 128. 213 natural killer cell. 225. 190. 44. 135. 182 mountains. 161. 291 neck. 232. 247. 133. 250. 169. 157. 210. 259. 159. 171. 185 nerve. 170. 156. 183 motor control. 140. 95. 190. 290. 184. 287 neuropathology. 166. 156. 250. 81. 280 neuropeptide. 144. 9. 170. 220 negative emotions. 168. 161. 228 multidisciplinary. 5. 158. 97. 158 motor area. 172. 280 neurons. 275 neoangiogenesis. 96. ix. 163. 149. 268. 188 305 nerve fibers. 273. 137 neuroscience. 134. 284 motives. 145. 156. 263 movement. 237. 285. 47. 289 narratives. 214 nocebo. 220 nontoxicity. 219 negative outcomes. 175. 142. 220 nodes. 137. 234 nicotine. 285 mRNA. 201. 134. 29 nociceptive. 179. 132. 28. 264. 207. 92. 191. 173. 170 neural mechanisms. 75. 167 negotiation. 125. 188 neurophysiology. 243. 131. 189. 103 neurological condition. 161. 223 nurses. 91. 132. 226 neuroleptic. 184. 158. 129. 34. 165. 283. xi. 129. 204. 81 novelty. 229 non-pharmacological.Index motivation. 222. 133. 289. ix. 173. 48. 49. 207 nausea. 182 neuropsychology. 191. 236 multidimensional. 214 neonates. 98. 147. 125. 34 NK cells. 119. 148. 63. 30. 279. 117. 36. 185. 175. 51. 85. 32. 185 neuropathic pain. 29. 200. 164. 180. 130. 236. 166 narcissistic. 256. 288 natural. 155 motor actions. 282. 62. 142. 221. 258. 133. 252. 166. 62. 190. 291. 179. 272. 269. 171. 286. 175. 184. 176. 135. 171. x. 188 nerves. 230 neuroscientists. 207. 181. ix. 276. 136. 125. 282 muscles. vii neural network. 85. 220 nervous system. 148. 252 normal. 287. 143. 168 motor function. 137 motor system. 257. 208. 127. 141. 8. 202. 169 non invasive. 155 narcotic. 101 neutral stimulus. 180 motor skills. 183. 181. 143. 14. 272 multiple sclerosis. 182. 280 neurohormonal. 291 muscle. 162 neural networks. 81 norms. 161. 136. 61. 179 MRI. 286. 168 neural function. 188. 34 nitrogen. 290 muscle relaxation. 146 neuropathy. 94. 181 neurotransmitters. x. 157. 57. 207. 192. 123 negative experiences. 153 mutuality. 23 New York. 134. 158. x. 139. 198. 193. 247 normal distribution. 168. 240. 196 naming. 274. 169. 194 neuroimaging. 274. 205. 137. vii. 34 negative attitudes. 181. 224 . 264. 221. 86 N nail biting. 134. 220. 162 neuralgia. 48. 3. 63. 247. 281 MPI. 270 music. 149. 61. 185 motor behavior. 48. 192. 172 National Institutes of Health. ix. 188 neuropeptides. 144. 264 natural killer. 250. 235. 155. 190. 252. 216 network. 9. 118 negative consequences. 144. 234. 127. 266. 272 perceptions. 104 oceans. 74. 229 paranoia. 212 oscillations. 258 paradoxical. 279. 250. xii. 280 patient management. 186. 215. 216. 18. 292 peer. 27 parasympathetic. 130. 276 pathways. 201. 231. 189 palpitations. 291. 210. 287 observed behavior. 78. 188 oxygen. 220. 210. 246. 253. 218. 138. ix. 59. 291 orbitofrontal cortex. 224. 29. 225. 234. 250. 2. 269 offenders. 276. 18. 215 openness. 219. 260 pepsin. 38 ovarian cancer. 274. 234 objective reality. 172 originality. 196. 252 outpatient. 226. 46. 169 parent-child. 121. 232. 227 organization. 220. 129. 230. 69 paralysis. 198 organism. 148 passive. 183. 230. 163. 202. 103. 275. 205 pathophysiology. 248. 121. 125. 147. 162. 249 observations. xii. 215. 123 P Pacific. 255. 175 pathology. 69. 213. 230. 22. 258 periodic. 220. 234. 124. 279. 221. 252.Index 306 nursing. 46 office-based. 75. 222 panic attack. 234. 154. 27. 131. 133. 104. 283. 239 panic disorder. 211. 210. 253. 277. 266. 170 operator. 179. 198. 194. 287. 291 palliative care. 284 opioid. 176. 233. ix. 78. 272. 278. 285 pain reduction. 276. 196. 233 overeating. 279. 288. 259. 286. 47 pendulum. 258. 221. 40. 96. Ivan. 269 pediatric. 288. 11 overload. 138. 188 organic. 292 one dimension. 249. 46. 218. 186. 67. 180 organ. 137. 257. 280. 267 . 172. 223. 285. 107. 236. 184. 134. 278. 84 parents. 121. 255. 58. 101. 104 obsessive-compulsive disorder. 291. 254. 149. 54 performance. 289 oral. 233. 153 path analysis. 107. 170. 86. 288. 242. 26. 21. 233. 8. 161 objectivity. 164. 169. 164. 275. 214 oxygenation. 274. 214 oxygen saturation. 74. 178. 282. 44. 233. 25 paranoid schizophrenia. 176. 123. 167. 148. 124. 106. 176 parietal cortex. 170. 59. 279. 185 organizations. 126. 290 pathophysiological. 167. 224. 6. 125. 283. 183 obsessive-compulsive. 236. 171. xi. 280. 284. 290. 7. 272. 69. 195 orientation. 290 palliative. 36. 275 Pathophysiological. 207. 106. xi. 232. 233. 39. 155. 223. 135. 53. 290. 215. 76. 216. 224 Pavlov. vii. 233. 2 permit. xii. 130. 40 percentile. 234 oncology. 129 O obesity. 77. 171. 194. ix. 292 pain management. 59. 218. 78. 287. 264 parameter. 198 organic disease. 222. 28. 116. 251. 283 perseverance. 271. 257. 42 perception. 152. 81. 200. 153. 153. 136. 289. 7. 290. 180. 220. 259 osteoarthritis. 17 pathogenic. 192. 281. 25. 229 parasympathetic nervous system. 177 pedal. 222. 21 opiates. 291 pallor. 129. 219. x. 219 paresis. 60 pedestrians. 10 perceived outcome. 83. 271. 278. 29. 168. 171. 44. 235. 273. 192 paternal. 152. 289 opioids. 225 perceived self-efficacy. 230. 254 parallel processing. 235. 230. 274. 277. 236. 207. 201. 281. 288 pain. 231. 199. 232 outside-of-school. viii. 229. 134. 213. 47. 165. 58. 185. 7. 185. 186. viii. 61. 101. 33 personal relations. 204 plasticity. 44. 168. 175. 31. 230. 272. 172. 6. 103. 123. 40 PET. 214. 194. 122. 201. 162. 236. 78 positive emotions. 60. 280. 229 pharmaceutical industry. 139 physicians. 148 primitives. 213. 33. 149. 18. 278 pleasure. 138. 29. 29. 10. 108. 125. viii. 38. 288 posture. 212 positive attitudes. 201. 222. 143. 281. 67. 273. 23 phylogenesis. 200. 67. 38 positive behaviors. 272. 200. 126. 71. 118. 216. 9 polymorphism. 172 premotor cortex. 101. 67. 280 personal communication. 194. 41. 183 politicians. 188 positive relation. 172 POMS. 129. 185. 276. 122. 185 pilot study. 277. 288. 16. 178. 149. 64. 185 political aspects. 171. 153. 282 population size. 176 planets. 3. 68. 232 preventive. 247 population. 181. 37. 243. 280. 133 prefrontal cortex (PFC). 102. 213. 122 . xi. 216 poor. 51. 281. 263. 216. xii. 161. 40. 273. 225. 274. 228. 280 personality characteristics. 7 personality. 169 pragmatic. 30. 100. 258. 101. 269 planning. 7. 9. 25. 101. 40. 125 pluralism. 37. 200. 231 pituitary. 226. 271. 165. 30. 108. 11. 136. 153. 123. 134 physical activity. 273. 225. 136 physical therapy. 226. 229. 207. 84. 223 prediction. 49. 216. 230. 26. 292 posterior cortex. ix. 127 phobia. 38. 25. 125 pharmacotherapy. 194. 230. 85 PPI. 233. 178. 39. 282 pharmacological treatment. 167. 31. 33. 149. 132. 151 primate. 169 phantom limb pain. 230 phenomenology. 28. 45. 96 perspective. 161. 190 placebo. 86 personal life. 57. 143 private.Index personal. 152. 21. 180. 218. 210. 208. 21. 204. 224. 223. 158. 99. 149 307 play. 103. 101. 19. 32. 9. 163. 290 pharmaceutical. 229 pharmacological. 213 portfolio. 34. 33. 9. 51. 280. 260 PHS. 251. 155 personality traits. 25. 245 probation. 75 positive feedback. 75. 169 plantar. 9. 199 post-traumatic stress. 281 Philadelphia. 285 PFC. 75. 291 pre-existing. 285 prayer. 212. 30. 9. 216. 224. 159 poisoning. 134 philosophy. 285. 15. 226 positive correlation. 152. 85. 9. 9. 163 positron. 264 prestige. 207. 17. 40. 68. 67. 65. 36. 196. 100. 34. 166 postoperative. 48. 39. 118 probability. 246 power. 217. 46. 155. 104. 100. 259 philosophical. x. 220. 38. 35. 290. 38 personal history. 273 physiology. 146. 286 physiological. 63. 38. 40. 153. 125. 151 primary caregivers. 123. 243. 210. 100. x. 135. 16. 277. 240. 240 personal efficacy. 163 positive relationship. 179 private practice. 137 principal component analysis. 180 Person-Centered Approach. 85. xii. 50. 111. 54. 28. 195. 43. 109. 276. 169. xii. 155. 148 pressure. 207. 287. 138. 242 powers. 230. 219. 226 physical force. 199 phone. 292 positron emission tomography. 290 plague. 285. 221. 50. 102. 140. 138. 53. ix. 44. 204. x. 39. 18. 22. 213. 179. 291 persuasion. 177 prevention. 258. 107. 123 primary care. 85. 203 polymorphisms. 49 personality disorder. 209. 218. 59. 28. 228. 12. 163. 272. 38 problem solving. 10. 220. 275. 86. 252 physical world. 7 personal relationship. 285. x. 31. 214. 192. 202. 231. 48. 224. 180. 215 quizzes. 45. 216 qualifications. 134. 149. 216. 203. 149 protocol. 147 psychiatrists. ix.308 Index production. 143. 73. 238. 127 psychological well-being. 163 productivity. 246. 42. 223. 162. 24 questionnaire. 103. 224. 284. 224 psychology. 146. 169. xi. ix. 146. 47. 83. 148. 135 pruritus. 271. 198. 184. 229. 209. 272. 111. 201. 266 reasoning skills. 185. 191. 63. 234 rain. 69. 229 prognostic factors. 129. 215. 157. 25. 150. 204 psyche. 234. 107. 212. 43 reality. 33. 138. 145. 25 psychosis. 154 psychotic symptoms. 191. 269 programming. 169. 207. 224. 274. 83. 30. 194. 107. 210. 164. 25 protection. 273 Q QLQ-C30. 207. 219. 44. 57. vii. 208. 62. 152. 105. 229. 233. 179. 214. 26. 24. 150. 173. 1. xi. 48 radiation. 230. 109. 287 psychopathology. 188 protein. 157. 235. 192. 230. 46. 103 rat. 217. 287 questioning. 216. 159. 280 psychological perspective. 131. 228. 2. 140 range. 200. 196. 210. 39 R race. 122. 213. 147. 43. 290 psychologist. 282 psychiatric disorder. 112. 50 ratings. 277. 288 psychotic. 281. 50. 43. 69. 226. 196. 135. 149. 150 psychological resources. 72. 191 propranolol. 43. 47. 149. 230. 287 publishers. 223. 132 radiological. 70. 292 psychotherapeutic. 192. 70. 78. 185. 234 psychoanalysis. 272 psychosomatic. 225. 184. 61. 193. 193. 150. 274. 280 psychotherapy. vii. 271. 151. 202. 229 psychoanalytic theories. 248 property. 109. 282 protocols. 208. 139. 38. 53. 221 psychological processes. 214. 196. 203. 198. 34. 6. 141. 145. 133 . ix. 34. 290 reading. 156. 25. 37. 177. 258. 214. 39 proliferation. 111. 216. 224. 272 psychological stress. 147. 1. 164 reactivity. 289 prostitution. 45 progress reports. 215. 133. 32. x. 235. 25 psychosocial factors. 15. x. 49. 78. 107. 151. 251 reading comprehension. 224. 198. 41. 235 program. 162. 187. 200 psychotic states. 40. 37. 3. 104. 227 psychiatric diagnosis. 283 prototype. 234. 201. 33. 139. 102. 23. 76. 190. 230 QOL. 194. 163. 287 psychoses. 228 questionnaires. 140. iv prophylaxis. 230 PTSD. 273 prognosis. 281 rationality. 138. 94. 216 public. 279. 95. 3. 154. 25 psychotropic drugs. 150. 15. 200. 2. 158. 158. 147 psychogenic. 140. 127. 85. 17. 269 punishment. 291 radical. 214. 86. 11. 186. 208. 288. 59. 149 protein synthesis. 189. 229. 126. 142. 6. 182. 96 psychological problems. 132. 222. 39. 172. 70. 238 psychophysiology. 133 professions. 194. 187. 204. 40. 75. 42. 130. 163. 145. 69 reaction time. 218. 169. xii. x. x. xii. viii. 231. 239. 156. 33. 161. x. 256. 228. 203 psychological distress. 291. 222. 231 psychiatrist. 188. 218. 282. 4. 192. 7. 133. 115. 146 quality of life. 231. 51. 4. 219. 5. 37. 196. 71. 151. 216. 207. xi. 182 psychological variables. 176 psoriasis. 259. 221. 96. 232 pumping. 32. 221. 284 rape. 177. 200 pseudo. 182. 215. 37. 287. 159. 215. 211. 200 promote. 218 reasoning. 33. 220 radiotherapy. 213. 200. 47 resistance. 210. 156. 269 rhythms. 161. 33. 238. 149. 166 rigidity. 207. 177. 103. 44. 83. 232. 198. 250 309 research. 255. 254 saturation. 103. 252. 187. 83. 76. 162. 13. 248. 195. 162. 226 relationship. 102. 249 regrowth. 292 reflex sympathetic dystrophy. 150. 237 reliability. 54. 257. 154. 53. 19. 249. 217. 5. 254. 130 rhetoric. 64. 259 restructuring. 233. xi. 226. 25. 86. 69. 100. 199. 17. 197 regular. 34. 29. 60. 117. 152. 204. 126 SAS. x. 164. 56. 138. 254. 136 responsiveness. 217. xii. 121. 188. 226. 210. 13. 103. 178 repression. 232. 141. 60. 255. 291. 132. 168. 45. 172. 121. 74. 263 risk. 290 sand. 84 relaxation. 165 satisfaction. 216. 153. 168. 218. 282. 148. 197 Scandinavia. 30 religious belief. 151. 227. 212. 239. 166. 164. 187. 213. 223. 224. 254 reimbursement. 30 religions. 242. 14. 235. 273. 221. 197. 33. 143. 217. 139. 286. 178. ix. 72. 121 rosacea. 60. 115. 61. 76. 16. 281 respiratory rate. 38. 226. 198. 35. 256. 236. 186 scaphoid fracture. 21. 214. 179. 236. 214 sample. 104. 208. 28 saliva. viii. 207. 73. 279 reduction. 182. 267. 240. 167. 220. 146. 274. 209. 48. 284. 258 rehabilitation. 121 responsibilities. 3. 68. 234 right hemisphere. 61 rings. 46. 138. 5. 57. 128. 165. vii. 289 relapse. 256. 163. 9. 275 regulation. 183. 57. 288 rehabilitation program. 225. 250. 290. 167. 259. 121. 248. 59. 145. 224. 212. 201. 200. 155. 281. 193. 214. 207. 26. 271. 218. 103. 249. 126. 140 rhythm. 199. 57. x. 214. 254. 30 remission. 252. 13. 1. 108. 69. 190. 190. 135. 196. 83. 214 scalp. 202. 286 reflexes. 78. 191. 76 religion. 13. 163. 50. 198. 138. 162. 81. ix. 171. 188 reciprocity. 6. 229. 255. 212. 54. 271 reconditioning. 107. 108. 7. 140. 167. 197. 65. 282. 84. 248. 121. 122. 263. 39. 227 risks. 194. 226. 290 researchers. 278. 56. 158. 148. 147. 233. 163. 250 . 214. 2. 250. x. 105. 73. 23. 222. 194. 47. 107. 272 respiratory. x. 279. 155. 119. 246. 170. 273 risk factors. 4. 292 regional. 5 recovery. 132. 280. 95. 15. 267 risperidone. 138. 76. 86. 84. 239. 202. 178. 249. 219. 8. 211. 216. 225. 156. 47. 164. 170. 168. 24. 269 role-playing. 280. 250 receptors. 86. 211. 21. 233. 40. 203. 235. 208. 62. 136. 104. 258. 38. 129. 192. 152. 182. 62. 275. 75. 70. 194. 220. 229. 109. 250. 170. 222. 234. 288. xii. 227 resources. 35. 188. 215 sadness. 203. 284 relationships. 166. 210. 147. 122. 36. 203. 194. 228 residential. 204. 138. 221. 74. 173. 171. 230. 156 romantic relationship. 249 safety. 163. 192. 173.Index recall. 8. 233. x. 226. 81. 272. 101. 151 recruiting. 267 relatives. 242. 239 rejection. 189. 152. 67. 81. 288 relevance. 219. 140. vii. 121. 201. 153. 104. 154. 177 saline. 192. 17. 195 reinforcement. 255 recreation. 236. 179. 169. 247. 185 reproduction. 209. 73. 223 resolution. 185 refractory. 20. 232. 77. 128. 214. 17. 238. 167. 245. 253 retention. 278. 107 recurrence. 34. 6. 1. xi. 157. 221. 108. 182. viii. 191 replication. 226 repair. 126. 126 rivers. 129. 211. 142 S sacrifice. 289. 124. 24. 38. 46. 86. 68. 63. 285 regression. 218. 148. 198 Royal Society. 85. vii. 203. 197. 157 recognition. 139. 169. 126. 264. 67. 217. 20. 218. 75. 207. 64. 134. 279. 222. 22 rectal sensitivity. 47. 172. 16. 248. 172. 285 sleep disturbance. 292 sensing. 68. 146. ix. 253. 283. 281. 85 self-efficacy. 84 sickle cell. 169. 78. 287. 268. 230. vii. 119. 225. 135. 137. 190 sexuality. 11. 195. 282 sex. 27. 101. 37. 125. 263. 40. 203 skin conductance. 187. 22 sensitivity. 246. 125. 228 sensory modality. 280. 195 semantic. 85. 183. 84. 256. 41. 224. 28. 168. 254. 4. 279. 242. 219. 152. 71. 43. 215. 3. 190 sex hormones. 188 sentences. 74. 136. 253. 67. 244. 153. 57. 192. 219. 255. 259 short period. 291 side effects. 73. 270 shrubs. 154. 51.310 Index scheduling. 164. 25. 47. 90. 50 severity. 48. 121. 203 sleep. 280. 253. 131. 196. 247. 26. 245. 99. 239. 135. 197. 138. 69. 48 school. 245. 194. 265. 237. 45. 252. xi. 153 similarity. 200. 231. 201. 289. 197 self worth. 214. 78. 105. 195 skin disorders. 61. 258. 225. 72. 192. 190. 161. x. 10. 76. 195. 222. 203. 10. 35. 157 shape. 282 scripts. 228. 251. 53. 140. 258 self-help. 278 self-worth. 270 sensations. 196. 188. 226. 214 skin cancer. 34. 257. 39. 73. 38. 156 Singapore. 46. 135. 187. 194. 254 self-control. 116. 291. 163. 79. 121. 35. 191. 249 separation. 194. 63. 47. 107. 197. 39. 211. 25. 251. 48 self-awareness. 81. 219. 135. 1. vii. 223. 225. 151. 50. 172 skin diseases. 56. 17. 254. 117. 83. 230 shock. 169. 197. 49. 286. 149. 252. 264. 42. 131. 43. 41. x. 121. 85. 283. 275. 190. vii. 37. 130. 11. xi. 290. viii. 161. 277. viii. vii. 194. 215. 65. 164 schemas. 225. 162. 191. 40. 220. 8. 122. ix. 155. 197. 128. 218. 24. 19. 43 self-regulation. 25. 240. 134. 202. 210. 166. 146. 246. x. 31. 86. 103. 84. viii. 195. 219 seeds. 220 scientists. 170. 196. 125. 86 self. 93. 149. 214 self image. 15 shoulder. 1. 262. 275 sharing. 278. 101 seborrheic dermatitis. xi. 288 shaping. 155 social attitudes. 279 skills training. 225. 142. 58. 188. 147 sepsis. 292 self esteem. 286 sclerosis. 190. 221 sequelae. 229 sign. 28 signs. 286. 179. 220. 222. 124. 41. 100. 284 sedation. 144. 155. 134. 108. 197 smoke. 240. 92. 157. 58. 59. 46. 238. 263. 256 self-doubt. 105. 57. ix. 36. 89. 149. 180. 40. 44 seizures. 284. 196. 20. 257. 94. 191. 105. 130. 143. 190. 247. 252. 188. 34 self-actualization. 222. 68. 48. 42. 159 sensation. 118. 41. 137. 286. 256. 238. 98 sites. 43. 192. 238. 202 sedatives. 127 self-image. 84. 7. 111 simulation. 88. 162. 55. 153. 10. 142. 263. 137. 126. 211. 134. 246. 157 social anxiety. 290 set theory. 151 sensory nerves. 255. 1. 179. 275 skills. 53. 220. 83. 29 secularization. 242. 249 smoking cessation. 37. 176 selective attention. 286. 105 smoking. 264. 163 selectivity. 194. 266 sibling. 1. 67. 216. 68. 151. xii. 15. 280 series. 119. 200. 281. 198. 279 skin. 107. 16. 264 signaling. 154 siblings. 133. 237. 217. 245. 188. 247. 38. 260 searching. 221. 245. 163 schema. 28. 197. 136. 195 . 61. 190 secretion. 136 schizophrenia. 254. 258 self-report. 148. 133. 45. 132. 11. 268. 224. 144 semantics. 60. 122. 291 scores. 248. 155 self-confidence. 136. 77. 216. 37. 139. 272. 15. 10 search. 151. 191. 106. 145. 248. 121. 177 subjective. 150. 269. 177 social relations. 213. 153. 181 stupor. 155. 101. 176 stress-related. 274 subjective experience. 55. 118. 195. 42. 282. 107. 230 stereotypes. 120. 207. 203. 226. 143. 140. 30 supervision. 76. 25. 103. 288. 177. 180. 38. 273. 60. 127. 216. 191 species. 9. 154. 181. 288 surgical intervention. 239 subjective judgments. 102 suicidal ideation. 190. 277. 171. 148. 60. 125. 36 spinal cord. 7. 128. 14. 31. 20 sports. 10. 3. 233. 137. 245. xi. 81. 70 standards. 104. 197. 106. 53. 135. vii. 239. 218 stimulus. 214 social relationships. 179. 8. 30. 58. 105. xii. 187. 195. 115. 19. 85. 277. 266. 280 spinal cord injury. 280 spine. 34. 253 subtraction. 34. 56. 284. 51 speech. xi. 245 suffering. 104. 193. 118 speed. 198 superiority. 278 speculation. 184 stroke. 111. 198. 102 suicide. 169. 178 social group. 227. 119. 84. 200. 208. 129. 196. 285. 290 stress level. 155. 255 sprain. 199. 33. 192. 55. 141. 48. 154. 155. 140. 269 statistical analysis. 192 strikes. 123. 107. 250 spontaneity. 184. 252. 108. 107. 37. 41. 3. 191. 229 statistics. 249. 135. 271. 122 social-psychological perspective. 149. 225. 32. 25. 103. 83. 229. ix. 272. 42. 123. 158. 39. 239. 266 stress. 281. 217. 280. viii. 140. 60. 195. 86. 75. 68. 170. 282. 289 social fabric. 205. 35. 199. 66. 176. 60 stomatitis. 129. 106. 111. 280. 114. 53. 254. 32. 250. 288 strategies. 283. 280 surprise. 216. 188. 4. 290 surgical. 194.Index social cognition. 11. 190. 195. 258 social learning theory. 258 Staphylococcus aureus. 81. 65. 141 somatosensory. 145. 243. 170 stretching. 132. 214 social skills. 76. 208. 84 sounds. 219. 65. 285. 68. 158. 194 success rate. 273. 5. 184 soil. 164. 246 stomach. 292 311 strategy use. 39. 232 stressors. 190. 276. 208. 100. 16. 3. 180. 106. 121. 38. 146. 273 spin. 109. 179. 218. 266 . 58. viii. 134. 210. 146. 148. 64. 211. 280 suicidal. 244. 57. 32 spiritual. 121 stabilize. 155 supply. 215 splint. 185. 258. 254. 74. 200 stabilization. 182. 3. 127. 40 substitution. 283. 254. 57. 279 supernatural. 273. 1 successive approximations. 180 social influence. 190. 151. 40. 55. 107. 102. 136. 290. 229 substance abuse. 213. 284 strain. 165. 107. 194. 230 spontaneous abortion. 23. 46. 15. 220. 28. 280 strength. 196. 250 stability. 155. 197 stressful life events. 102. 250. 246 stimulus generalization. 188 surgery. 271. 285. 3 spontaneous recovery. 239 social learning. 47. 264. 273 suppression. 285 sociocultural. 118. 213 standardization. 74. 171 sores. 248. 196. 81. 279. 167. 67. 75. 142. 68. 278. 104. 31. 216 summaries. 73. 63. 122 stages. 181 spectrum. 221. 86. 202. 73 subjectivity. 61. 254. 258 social network. 64. 109. 42 summer. 34. 276 students. 72. 142 social construct. 57. 197 stars. 257. 252. 176. 167. 207. 15. 36. 138. 284. 233. 6. 221. 280. 176. 50. 230. 191. 272. 194. 219. 245. 230. 194. 2. 182 threat. 191. 218. 142. 291 symptoms. 58. 93 tonic. 210. 67. 173. x. 221 tradition. 11. 123. 233. 180. 223. 133 sympathetic. 231. 147. 172. 189. 1. 225. 12. 162. 5. 35. 226. 25. 2. 132. 142. 273 therapeutic process. 279. 157. 220 ToM. 49. 169. 257. 169. 48. 252. 177 threshold. 252. 189. 284 synchronous. 147. 51. 140 therapeutic goal. 280. 215. 217. 42.Index 312 survival. 220. 229. 213. 7. 4. 232. 229. 6. 194 theory. 224. 230. 7. 104. 8. 233. 180 teaching. 169 top-down. 183 testicular cancer. 151. 10. 138. 81. 39. 217. 214 temporal. 279. 203. 261 sweets. 216. 24. 194. 171. 243. 36. 31. 126. 35. 290 sweat. 30. 152. 66. 207. 47. 217. 168 toxic. 278. 155 tobacco. 223. 123. 136. 185. 161. 24. ix. 282. 4. 152. 191. 134. 284 task performance. 170. x. 170. 162. 225. 203. 201. 176. 65. 292 tension headache. 43 swelling. 164. 126 therapeutic relationship. x. 166. 60. 291. 273 targets. 70. 8. 177. 290 tension. 275. 229. 222. 164. 126. 288. 195. 3. 291 theta. 125. 9. 235. 169. 219. 132. 284 therapists. 256. 148. 48. 279. 76. 258 third party. 222 therapeutic targets. 226. 108 therapeutic change. 232 susceptibility. 216. 171. 14. 254 television. 290. 213. 198. 233. 26. 180. 232 terminally ill. 141. 222. 140. 34 tetrad. 135. 172. 272. 93. 249 tolerance. 107. 263. 138. 173 tin. ix. 245. 20. 291. xii. 13. 215 threats. 220. 140. 178. 278 technology. 283. 51. 197. 164. 46. 222. 250. 163. 234. 217. 44. 198. 43. 223. 105. 126. 261. 291. 25. 149. 195. 19. 22. 172. 226. 170. 16. 234. 18. 211. 202. 192. 208. 21. 63. 197. 41. 291. 255. 152. 101. 184 temporomandibular disorders. 235. 57. 253. 106. 166. 165. 192. 179. 216. 212. 133. 121. 122. 43. 13. vii. 42 training. 143. 4. 5. 226. 3. 252. 284. 220. 85. 215. 34. 285. 66. 38. 285. 287. 195. 131. 213. 17. 236. 156. 188. 84. 100. 210. 248. 280. 133. 228. 207. 39. 185. 28. 25. 225. 290. 162. 103. 280. 17. 109. 131. 282. 85. 274. 19. 199. 240. 63. 229. 190. 280. ix. 242. 235. 234 terrorism. 284. 245. 167. 288 telephone. 280. 245 title. 144. 257. 233 teachers. 281. 202. 224. 216. 258. x. 135. 245. 254. 167 taste. 190 timing. 282 transcranial magnetic stimulation. 231. 194 thinking. 33 T-cell. 2. 290 thyroid. 222 syndrome. 103. 21. 5. 189 sympathetic nervous system. 197. 229. 282. 175. 288 therapeutic benefits. 236. 11. 149 tongue. 292 terminal illness. 286. 223. 272. 41. 292 trait anxiety. 102. 134 . 179. 216. 162. 71. 156. 155. 73. 179 threatening. 43. 204. 149. 139. 57. 279. 83. 64. 106 survivors. 18. 85. 286. 153. 147. 279 surviving. xii. 256 therapy. 154. 29. 198. 144. 10. 125. 134. 186. 163. 286. 222. 286 sympathetic fibers. 276. 273 trainees. 203 systems. 215. 45. 48. 134. 123. 72. 260 temperature. 194 T talent. 233. 292 synthesis. 254 symbiotic. 282. 217. 248. 169. 224. vii. 105. 261. 169 symptom. 57 symbols. 5. 7. 183. 172. 189. 107. 37. 191. 49. 44. 143. 281. 212. 280. 210. 208. 230. 244. 214. 225. 22. 240. 164. 136. 219. 134. 188 Technology Assessment. 150. 27. 2. 126. 65. 50. 192. 224. 221 toxicity. 1. 234. 25. 107. 34. 266. 7. 18. 227 treatable. 9. 89. 266 virtual reality. 140. 196. 240. 78 transfer. vii. x. 203 trigeminal. 43. 226 translation. 276 visualization. 229. 135. 88. 63 transference. 171. 266. 173. 203. 233. 152. 146. 107. xi. 240. 194. 255 vertigo. 209. 219 vomiting. 268 trend. 201. 57. 178. 266. 125. 245. 255. 165. 104. 189 veterans. 127. 225. 28. 208. 86. 83. 189 vasodilation. 190. 11. 58 urticaria. 238. 83. 126. 27. 202. 54. 31. 200. 7. 203 313 V Valencia. 210. 190. 30. 249. 209. xi. 288 vehicles. 260. 37. 266 underlying mechanisms. 175. 124 trisomy 21. 105. 33. 123. 65. 70 vascularization. 179. 6 trees. 23. 231. 268 visual field. 280 variance. 123. 187. 156. 227 vasoconstriction. 83. 260 trisomy. 83. 192. 33. 146. 6. 85. 155. 154. 217. 227 traumatic events. 70. 276 triggers. 183. 235. 192 ultraviolet light. 222. 88 variation. 274. 167 transmission. 126. 63. 154. 23. 55. 267 trauma. 238. 279. 289 voodoo. 268 warts. 29 ultraviolet. 207. 152. 247 water. 34. 284. 116. 287 weakness. 228. 254. 118. 228 variability. 237. 124 trust. 253. 258 validation. 214. 214. 239. 252 varimax rotation. 230. 192. 60. 255. 191. 156. 147. 199. 257. 177. 147. 155 village. xi. 238. 87. 128. 229. 84. 187. 170 verbal persuasion. 131. 180. ix. 82. 220 transportation. 265. 103. 258. 180. 197. 136. x. 40 versatility. 78. 220 tumor progression. 212. 201. 57. 177 university students. 97. 220. 108. 260. 217. 65. 204 watches. 186. 266 twins. vii. 122. 100. 221. 216.Index transcripts. x. 224. 213. 212. 256. 265. 292 trichotillomania. 259 walking. 110. 108. 232 variable. 244 trustworthiness. 214. 168 UCR. 40 tumor. 211. 249 vitiligo. 194. 35. 58. 182. 147. 21. 220 wear. 76. 135 transition. 208 United Kingdom (UK). 203. 128. 219. 232. 124. 239. 275 variables. 84. 130 visible. 175. 216 trial. 263 web. 142 visual images. 29 W waking. 77. 185 vignette. 105. 129. 130. 20. 188 universality. 71. 39. 73. 192. 100. 90 U ubiquitous. 291. 6. 134 ventricular arrhythmia. 196. 81. 215. 111 vessels. 282 United States. 153. 193 values. 243. 276 trigeminal neuralgia. 243. 146. xi. x. 227 tumor invasion. 199. 62. 56. 170. 237. 190 uncertainty. x. 282. 281. 177 transplantation. 198. 158 transformations. 227 turbulent. 154. 4. 217 tumors. 141. 188. 120. x. 257. 239. 215. 202. 196 valine. 221. viii. 192 ultraviolet B. 98. 199. 199 voice. 214. 240. 129. 237. 238. 16. 228 vision. 270 voiding. 246. 99. 236. 185. 11. 285. 255 validity. 95. 265. 190. 232. 219. 34. 127. 225. 133 . 225. 242. 70. x. 143. 54. 60. 14. 247. 233. 229. 55. 249. 210. 166 word recognition. 222. 230 wheelchair. 115 wind. 230. 41. 226 Z Zen. 192 . 198 withdrawal. 38. 254 Y yawning. 211. 45 welfare. 140 windows. 44. 83. 20. 137 wine. 146 winter. 126 women. x. 182 yield. 1. 207. 44. 137 worry. 271. 181. 217. 135. 254. 42. 74. 47. 102. 214. 104. 101. 219. 263. 235. 129. xi. 290 western countries. 268 writing. 234. 134. 34. 147. 165. 278 word naming. 258 winning. 48 well-being. 102. 138 workers.314 Index weight reduction. 218. 249 X x-rays. 226. viii.