Talking the Hype out of Hypnosis and a Look at Its Entrancing Use in Pain

CuFwentEamments” EUGENE GARFIELD INSTITUTE FOR SCIENTIFIC INFORMATION* 3501 MARK ET ST, PHILADELPHIA, PA 191C4

Taking the Hype Out of Hypnosis and a Look at Its Entrancing Use in Pain Control

Number 3 Januarv ,, 19, 1987 In the most hackneyed depictions of hyp- Chinese, Egyptians, and Gre&s.2 There nosis on television and in the movies, the are even rdlusions in the Bible to activities hypnotic subject is invariably shown star- that are hypnotic in character. Historical ac- ing at a swinging pocket watch or pendu- counts of hypnotism in the modem era gen- lum while repeating the instructions of the erally begin with Franz Anton Mesmer hypnotist in a halting monotone. Once the (1734-18 15), an Austrian physician whose “trance” is broken through a snap of the name survives in the word “mesmerize. ” fingers or some other hypnotically suggested Mesmer is most often associated with the signal, the subject awakens, fully if uncon- theory of “animal magnetism. ” As dis- sciously prepared to perform whatever deed cussed by Henri F. Ellenberger, Universi- the hypnotist has directed. Other popular no- ty of Montreal, Canada, in 7?seDiscovery tions surrounding hypnotism no doubt de- of the Unconscious, the theory involved the rive from entertainers known as stage hyp- existence of a subtle physical fluid that sup- notists, who induce volunteers from their au- posedly filled the universe and connected hu- diences to engage in comic or ribald behav- mans, the earth, and the heavenly bodies. ior for the amusement of the others. Believing that disease originated from an These distorted, inaccurate views do not imbalance of this magnetic fluid in the do justice to the serious discipline of clini- human body, Mesmer maintained that cal hypnosis. Although not entirely free of restoring the fluid’s equilibrium would have controversy and criticism, clinical hypno- a curative effect. 3 His methods included sis has been recognized for more than a cen- rather theatrical sessions in which he would tury as a legitimate tool in the treatment of pass his hands over his patients in an attempt a variety of disorders. In rezent years, hyp- to influence these fluids. The patients would nosis has been associated with behavior often go into seizures and awaken apparently modification in the treatment of cigarette cured. Although Mesmer’s procedures and smoking, overeating, and assorted phobic the theory of animal magnetism were even- disorders. Hypnosis has even been used in tually discredited, this era did mark the be- successfully treating dermatological disor- ginning of serious scientific investigation in- ders, such as warts, according to Harold B. to hypnosis and its applications. Crasilneck and James A. Hall, southwestern Most historians credit James Braid, a Me&al School, University of Texas Health Scottish surgeon, with coining the word Science Center, Dallas. 1 @. 369-82) In this “hypnotism” in the 1840s, although there essay, however, I’ll concentrate on research is evidence that the term was used earlier.4 concerning hypnosis and pain control. The word comes from the Greek hyprsos, In his review of the historical antecedents meaning “to sleep. ” Braid’s theories, of modem hypnotism, William E. Edrnon- though not entirely accurate, did much to ston, Jr., Colgate University, Hamilton, bring hypnosis research into the realm of sci- New York, notes that techniques resembling entific respectability. He recognized, for ex- hypnotic induction can be traced back to ample, the importance of verbal suggestion healing praetiees among the ancient Hindus, in the hypnotic process. s Throughout the

14 latter half of the nineteenth century, theo- ject while listening to the instructions of the ries of hypnosis underwent further refine- therapist. Another technique is to have the ment. Crasilneck and f-fallnote tiat resmrch patient hold a coin at arm’s length on the on hypnosis declined in the early part of the fingertips, while, in response to the twentieth century but stepped up consider- therapist’s suggestions of deeper and deeper ably in the years after World War IL In the relaxation, the arm is allowed to drop slowly US, the stature of hypnosis research was aid- until it rests in the patient’s lap. Another ed by a 1958 policy statement from the technique is to encourage the patient to American Medical Association recognizing imagine that one arm is growing pro- hypnosis as a legitimate treatment tool in gressively lighter as if pulled by a balloon, medicine and dentistry. 1 (p. 13) so that the arm levitates of its own accord. Or the therapist may simply have the patient visualize a scene, such as a beach, or the Hypnotic Technique patient’s favorite place. Once the patient is According to Andr6 M. Weitzenhoffer, relaxed, the therapist may try a “deepen- Stanford University, California, the induc- ing” technique, such as suggesting that the tion of hypnosis consists of three phases: patient is descending on an elevator or preparation, induction proper, and deepen- escalator toward deeper levels of relax- ing.6 One step in preparation, he notes, is ation.g allaying any fears or uncertainties that the There is some disagreement among re- patient may have about the process or ef- searchers concerning the exact nature of the fects of hypnosis. Another step, according hypnotic trance. Reviewing current theoret- to William C. Wester II, Behavioral Science ical approaches to hypnosis, Brian J. Center, Cincinnati, Ohio, involves a careful Fellows, Department of Psychology, Ports- assessment of the symptom or symptoms for mouth Polytechnic, UK, mentions the de- which the patient is seeking help. T Since bate between’ ‘state” and’ ‘non-state” the- some people are more susceptible than orists. The state theorists tend to argue that others to hypnosis. the therapist may choose hypnosis involves a special, or unique, state to administer one of the rating sales devel- of consciousness. Non-state themists, on the oped by researchers to gauge “hypnotic other hand, prefer to view hypnotic response talent. ” As reviewed by Barbara DeBetz, in terms of other psychosocird, cognitive, Columbia University College of Physicians or behavioral factors. 10 For example, aild Surgeons, New York, in A Primer of Theodore X. Barber, director, Mediield Clinical Hypnosis, the scales record such Foundation, Massachusetts, in his book items as eye closure, motor inhibition, age Hypnosis: A Scientific Approach, criticizes regression, time distortion, and other char- the entire construct of’ ‘hypnosis” (includ- acteristics of subjects undergoing hypnosis. ing’ ‘hypnotic state” and’ ‘trance”) as mis- Subjects who score high on such measures leading and unnecessary. The effects of hyp are judged to have heightened responsive- nosis, he notes, may be due to such factors ness to hypnosis. Hypnotizability seems to as the subject’s expectations, or the desire be related to a subject’s ability to become to comply with the therapist, rather than to imaginatively involved in an activity-read- any unique state of consciousness achieved ing a book, or watching a play or fiim, for through hypnotic induction. 11 (p. 7-10) example. Standard tests for hypnotic respon- In A Primer of Clinical Hypnosis, G&ard siveness include such scales as the Stanford Sumen, New York University Medical Cen- Hypnotic Susceptibility Scales, the Spiegel ter, New York, writes that although there Eye-Roll Technique, the Harvard Group is fairly good agreement concerning hypnot- Scale of Hypnotic Susceptibility, and the ic phenomena, there is a lot of disagreement Barber Suggestibility SCaie.g about explaining them. 12This disagreement Actual techniques of induction, as dis- applies to hypnosis and pain relief as well. cussed by Wester and psychologist Alex- Despite considerable research and a good ander H. Smith, Jr., may include having the deal of theorizing, some of which 1’11ex- patient gaze fixedly at a certain spot or ob- amine later, the exact mechanisms at work

15 in hypnosis and analgesia remain unclear. out, involves more than the reduction of anx- As Crasilneck and Hall point out, perhaps iety. It involves reductions in the other as- the one conclusion on which all authorities pects of pain, which they term the senso~ would agree is that we do not know how or and the suflen”ng components. “fiey also why hypnosis controls organic pain. I (p. note that hypnotic procedures are equally ap- 97) plicable to many painfid conditions. 15 (p. 190) Hypnosis and Pain Control One of Ernest Hilgard’s theories in ex- From early in the nineteenth century there plaining hypnotic phenomena involves the have been accounts of hypnotic techniques concept of dissociation. This theory states being used in the control of pain. James Es- that particular cognitive systems may be split daile, for example, a British surgeon work- off from the major (i.e., conscious) cogni- ing in India in the 1840s, reportedly per- tive system and that these systems are sub- formed over 300 major operations using ject to different cognitive controls. In regard mesmerism as the sole anesthetic, according to pain control, hypnotic dissociation seems to Graham F. WagstafY,University of Liver- to involve an amnesia-like process whereby pool, UK.13 (p. 153) pain is diverted from reaching the conscious One of the best-known modem research- level. lb ers on hypnosis and pain control is Ernest Psychiatrist Milton H. Erickson, former R. Hilgard, Department of Psychology, editor of the American Journal of Clinical Stanford. We reviewed his work recently, Hyrmosis, was very influential in his clinical when he received the 1984 National Acade- uses of hypnosis. In his beak Hjptwtherapy, my of Sciences Award for Excellence in coauthored with psychologist Ernest L, Scientific Reviewing for his reviews on con- Rossi, Erickson explains his view of hyp- ditioning and learning theory. 14 Much of nosis as a process of what he calls utilizat- Hilgard’s work on hypnosis and analgesia, ion. “Hypnotic suggestion, ” he notes, along with a general review of literature in “can facilitate the utilization of abilities and the field, is collected in the book Hypnosis potentials that already exist within a person in the Relief of Pain, 15coauthored with his but that remain unused or underdeveloped wife, Josephine, also at Stanford. because of a lack of training or understand- Hypnosis in the Relief of Pain includes ing.”lT (p. 1) severrd case studies in which hypnosis was Erickson and Rossi also outline several employed as an analgesic, including the case hypnotic strategies for dealing with pain. of a woman suffering pain and subsequent The patient might be given a direct hypnot- depression from advanced cancer. Under ic suggestion that all pain has been abol- hypnosis, it was suggested to the woman that ished. Or the patient might be induced to re- when she experienced discomfort she could place a sensation of pain with a feeling of don art imaginay glove that would relieve WWMth. The pain might afso be hypnotically the pairsin her arm. After several sessions, displaced from one area of the body to an- the woman was able to induce this effect on other. 17 (p. 98-101) In one of the case her own using self-hypnosis. Her depen- studies discussed in the book, the authors dence on chemical painkillers decreased, as recount the use of hypnosis to aid a man who did her depression and insomnia, and she was suffering debilitating back pain from a was able to spend her remaining days en- war injury. In the course of hypnosis, Eric- joying the company of her friends and fam- ksonsucceeded in uncovering and utiliiing ily. 15(p. 88) the patient’s pre-injury memories of happy Ins ummarizing their conclusions, the Hil- feelings to replace his pain. IT (p. 129) gards note a strong relationship between a Erickson and Rossi’s Hypnotherapy is one person’s hypnotizability and the ability to of four core publications for the 1985 ISI@ reduce pain through hypnotically suggested research front “Implications of direct and analgesia. They also make certain distinc- indirect hypnotic suggestion for psychother- tions regarding the role of anxiety in pain. apy,” (#85-5267). Hypnotic Realities, 18 Pain reduction through hypnosis, they point another work by Erickson and Rossi, is co-

16 authored with psychologist Sheila L Rossi, The results suggested that there are two and is also included in the core for this topic. components in hypnotic analgesia: one that The other two are books by Jay Haley, is apparently unrelated to the subject’s hyp Family Therapy Institute of Washington, notic susceptibility and that seems to derive DC, Rockville, Maryland, Uncomn from the nonspecific or placebo effects of Zherapylg and Advanced Techniques of using hypnosis; and another analgesic com- Hypnosis and Z%erapy.zoBoth works deal ponent that occurs in highly susceptible sub- with EricksoNan clinical approaches in hyp jects under deep hypnosis, apparently in- nosis and psychiatry. volving an acturd dktortion of Perception,zz In addition to controlling pain associated Thus far I have discussed hypnotic anal- with injury and illness, hypnosis has also gesia solely as it applies to adults, Research- been used in surgery in this century. Dab- ers and clinicians have noted that hypnosis ney M. Ewin, Tulane University Medical can be quite effective when used with chil- School, New Orleans, Lmisiana, reviews dren as well. Karen Olness, Minneapolis cases in which hypnosis was used both as Children’s Health Center, Minnesota, an adjunct to chemical anesthesia and as the reviews hypnosis in pediatric practice. She sole anesthetic .21 Crasilneck and Hall, cites studies demonstrating that 6- to mentioned earlier, also discuss the use of 12-year-old children are capable of respond- hypnosis in surgery. They note that while ing to hypnotic suggestion and other tech- hypnosis is certainly not appropriate as an niques involving relaxation and imagery. In anesthetic in all cases, it does have value in addhion to its uses in the treatment of such certain instances. These might include cases childhood habit disorders as nail-biting and where chemical anesthetics are contraindi- hair-pulling, hypnosis has been used for pain cated because of a respiratory, cardiac, or control in the treatment of injuries, includ- allergic condition on the part of the patient. ing bums and fractures. Hypnosis has also Hypnosis is rdso useful when it is desirable been used in other potentially painful to have the patient in a conscious or semi- medical procedures with children, such as wnscious state and able to respond to ques- cientistry.zs Josephine R. Hilgard, mentions. 1 (p. 125) tioned earlier, and Samuel L.eBaron,Depart- Along with its uses in clinical settings, ment of Pediatrics, University of Texas hypnosis has also been the subject of labo- Health Science Center, San Antonio, have ratory investigations in which pain is in- written about the uses of hypnosis in con- duced under experimental eondhions. In one trolling pain in children with cancer.zq such experiment, Thomas H. McGlashan, In another article on hypnosis and pedi- Unit for Experimental Psychiatry, Institute atrics, by Donald J. O’Grady, University of of the Pemsylvania Hospitrd, Philadelphia, Cincinnati College of Medicine, and Claudia and colleagues sought to compare the effects Hoffmann, Children’s Hospital Medical of hypnotically induced analgesia with Center, Cincinnati, the authors review placebo response to a pill that contained no studies in which the hypnotic subjects were chemical analgesic. The procedure involved as young as three and four years old.zs restricting the circulation of bleed to the sub- They point to evidence indicating that jects’ forearms and then having the subjects hypnotizability is somewhat limited in young undergo vigorous exercise of their forearm children and reaches its apex during the mid- muscles. The resulting muscular discomfort, dle childhood years of 7 to 14. No differ- which builds rapidly as exercise continues, ences have been found in hypnotic respon- is known as ischendc pain. For McGlashan’s siveness between boys and girls .25 study, the pain was induced in subjects, some highly susceptible and others insuscep On HypnosisResearch tible to hypnosis, who received hypnotic induction and in a ~roup of subjects who re- Along with work done in the US, hypno- ceived a placebo m the form of a pill sup- tism has been the subject of research in other posedly containing a powerti analgesic countries. For example, Stanislav Krato- drug. chvtl, Psychiatric Hospital, Kromeru,

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FSmrre 1: Multidiinsicrnrd-scahz mm for C2-level research front #85-0049. “Studies of hnmosis, family characteristics, and other psychological factors in the treatment of behavioral disorders, ” showirig links between C 1-level research fronts. The numbers of corelciting items are given in parentheses following the research-front titles on the map.

Family therapy for the treatment of adolescents (31/329)

Neurolinguistic pro- Hypnosis in the treatment of gramming and bahavioral disorders (14/109) counseling for indi- 0119 vidual learning

Implications of direct and indirect hypnotic (31/348) suggestion for psychotherapy (4/29) 07988

Czechoslovakia, and psychotherapist the control of pain, are being adopted in Michael Van&ra review research on hyp- some countries. nosis in Eastern Europe. They point out that As mentioned earlier, research into hyp- hypnotherapy in the USSR, ahhough popu- notism has engendered some disagreement lar 15 or 20 years ago, has been declining and controversy. Barber, in particukw, has in favor of other forms of psychotherapy. criticized the notion of’ ‘hypnotic trance, ” Stifl, hypnosis is taught as a legitimate pointing out that effects achieved through therapeutic technique. Kratoehvil and Van- hypnotic induction do not seem markedly &ra mention in particular the work of different from those producible in a wak- Vladimir Evgenievi~ Ro;nov, Psychother- ing state. 1I (p. 137) Barber’s book is 1 of apy Department, Institute for Postgraduate 14 core works for another 1S1research front Education in Medicine, Moscow. Ro~nov pertinent to hypnosis, “Hypnosis in the has developed a teehnique known as’ ‘emo- treatment of behavioral disorders, ” tional stress hypnosis,” used in the treatment (#85-01 19). Hilgard’s Divided Consciousn- of alcoholic patients .26 ess 16is also one of the core publications Concluding their discussion of hypnosis that identified this topic. Collectively they in such countries as the USSR, the German were cited by 109 papers published in 1985 Democratic Republic, Poland, and alone. Rumania, Kratoehvil and Van&ra note that Front #85-01 19 and the previously men- hypnosis in Eastern Europe has traditional- tioned front, #85-5267, are both part of the ly been more “authoritarian and manipula- higher-level aggregate of topics constituting tive” than in the US, a situation’ ‘reinforced “Studies of hypnosis, family characteristics, by the expectations of patients that the hyp- and other psychological factors in the treat- notist should possess almost god-like ment of behavioral disorders,” (#85-0069). self-confidence and persuasive powers.’ ’26 The other three fronts in #85-0069 are: However, increasingly permissive imaginat- “Anorexia nervosa,zT bulimia, and other ive techniques, including self-hypnosis in eating disorders, ” (#85-079g); “Neurolin-

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Table 1: Selected list of joumsk that repxt on hypno- Another controversy involves what is sis research. A= title and first year of publication. B= 1985 impact factor. known as forensic hypnosis-the use of hypnosis to enhance the memories of witnesses A B who testify in criminal trials. In the US, American Journal of Clinical Hypnosis 0.41 there has been considerable disagreement in (1958) American Jwmal of Psychiatry (1844) 3.51 the courts as to the reliability of such testi- American Journal of Psychotherapy (1946) 0.59 mony. In one article on forensic hypnosis, Austmhan Psychologist (1966) 0.21 Martin T. Ome, Institute of the Pennsylva- British Journal of Psychiatry (1853) 2,62 nia Hospital, and colleagues point out that British Journal of Psychology (1904) 1.22 hypnosis can lead subjeets to fill in with their Ceskoslovensks Psychologies (1957) 0.04 International Jour-rud of (Xrrical and 0.95 imaginations details that they have not ac- Experimental Hypnosis (1953) tually seen-a process known as’ ‘confabu- Joumrd of Abnomrrd Psychology (1906) 2.54 lation.” The subjects may then report these Journal of Consulting an-d Clinical 1.97 details, which the authors refer to as’ ‘pseu- psycbOIOgy (1968) Journal of Nervous and Mental Dkeaae 1.20 domemories, ” with a confidence and clari- (I 874) ty that can be most convincing to a jury.zg Journal of Personality and Snciaf Psychology 2.19 Table 1 is a list of journals that regularly (1965) Perceptual and Motor Skills (1949) 0.27 report on hypnosis research. The Journal of Psychiatric Annals (197 1) 0.64 Abnormal Psychology is included, having published over 100 articles on hypnosis guistic programming and counseling for in- since 1973. dividual learning styles,” (#85-1672); and Table 1 also includes the International “Family therapy for the treatment of Journal of Clinical and Experimental Hyp- adolescents, ” (#85-1952). The map in nosis, which is published by the Society for Figure 1 shows the citation links between Clinical and Experimental Hypnosis the research fronts that make up #85-0069. (SCEH), founded in 1949. Ome, mentioned Wagstaff, in his book Hypnosis, Compli- above, is the journal’s present editor. The ance and Belief, offers further criticism of SCEH’S membership is composed of physi- hypnosis research. He writes that the appar- cians, psychologists, dentists, and registered ent benefits of hypnosis may derive more psychiatric social workers, all of whom must from the hypnotic subject’s often subtle demonstrate the requisite familiarity and ex- compliance with the hypnotist than from any perience with clinical hypnosis. Ernest Hil- intrinsic effects. Wagstaff points out that the gard served as the SCEH’S president from subject may go so far as to falsely report an 1979 to 1981. The society’s address is absence of pain in order to appear to be a 129-A Kings Park Drive, Liverpool, New “good” subject. He also criticizes the no- York 13090. tion of’ ‘dissociation, ” saying that research Another pertinent organization is the has not elucidated any effects of dissocia- American Society of Clinical Hypnosis, tion that camot be explained in terms of formed in 1957. Composed of some 4,0(Kl compliance or voluntary cognitive strate- physicians, dentists, and psychologists, this gies.lq (p. 183) is the largest hypnosis organization in the In a review of the clinical uses of hypno- US. The society publishes the American sis, Thomas A. Wadden, University of Journal of Clinical Hypnosis, also listed in Pennsylvania, Philadelphia, and Charles H. Table 1 and edited by Thurman Mott, Jr., Anderton, University of South Carolina, Institute of Psychiatry and Human Behav- Columbia, offer severrd recommendations. ior, University of Maryland Schcd of Med- They point out a need for more careful iden- icine, Baltimore. Crasilneck, who current- tification of treatment populations and treat- ly serves as president, has also been presi- ment techniques in hypnosis studies and for dent of SCEH and is the only person to have more attention to the personality character- held that office in both societies. Interested istics of those being treated. They also cite readers can contact the society at 2250 East a need for more and better controlled Devon Avenue, Suite 336, Des Plaines, 11- research.zs linois 60018. The International Society of .&.

Hypnosis, based in Australia, maintains a we have far to go in our understanding of listing of more than 20 of its constituent or- the physiological and psychological factors ganizations throughout the world. The ad- at work in hypnosis and analgesia. I suppose dress for the International Society is the E& that is one of many reasons why interest in ward Wilson House, Austin Hospital, the neumsciencea has been growing by leaps Heidelberg, Victoria 3084, Australia. There and bounds. are many other lay organizations “interested” in hypnosis, but none of them pro- duces a research journal or warrants discussion here. Many of the issues surrounding hypno- * **** sis, including the” state versus non-state de- bate” and the matter of the subject’s expectations, remind me of issues raised in con- nection with meditation. Jo While it appears My thark to Terri Freedman and that hypnosis does provide beneficial effects Christopher King for their help in the prep- in relieving pain, it’s equally apparent that aration of this essay. “ @W871s1

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