This is intended to set the scene for the training weekends that it accompanies; you should try to read it before attending the first weekend. The intention is to give you a little of the background information that we won’t have time to cover during the sessions, and to get you thinking about ways in which you might come to employ hypnosis. We would also like to get you thinking more generally about the role and status of hypnosis. It clearly has some of the qualities of an ‘alternative’ therapy, and indeed is often classed as such; in contrast, we believe that much good would be done if its techniques became main-stream and were widely practiced. Perhaps the characteristic which most clearly associates hypnosis with the alternative therapies is the fact that large numbers of the general public seek out the therapy, while few qualified medical practitioners offer it - in fact many are quite sceptical about its merits. We hope that the contents of this booklet and the course will dispel any scepticism you may feel, and give you enough facts to counter the doubts of colleagues.
It hardly seems reasonable to try to convince you that a technique has therapeutic value without first telling you something of what that technique is. That will be the goal of the first session: to explain the nature of hypnosis – or at least attempt to, although that is not easy. The difficulty isn’t a case of trying to put across something terribly complicated; it may turn out to be so, but the problem at the moment is that we still lack a complete understanding of what is going on when someone is said to be hypnotised. Medicine does have a history of using methods that work, without first knowing how, aspirin being an obvious example. However, that sort of situation is not ideal, so what we do know of hypnosis will be explained.
Traditionally, sessions of hypnosis begin with a hypnotic induction, in which the hypnotist may do no more than give suggestions of relaxation. Clearly, doing that can exert little direct effect upon the recipient so, to the extent that anything happens at all, it must principally result from the patient’s own voluntary responses. Unsurprisingly therefore, research has shown that whatever people do in hypnosis it is always what they believe they are meant to do. During the Twentieth Century researchers began to focus on this fact and, observing the apparent absence of any effects intrinsic to hypnosis, they turned their attention to the social dynamics that make one person want to follow the suggestions of another. Certainly the inter-relationship is important, and establishing rapport between therapist and patient in the clinical setting is highly desirable, but focusing upon this aspect exclusively ignored the neural mechanisms that enable a patient genuinely to experience what is suggested and to enjoy proven therapeutic benefits.
The advent of brain-scanning techniques did much to change the research focus. They revealed, for example, that normally inhibited brain regions can become active following suggestions, resulting in realistic hallucinations. Conversely, circuits active during pain can be inhibited, resulting in a reduction of the pain experience. This effect appears to exceed that of a placebo.
It would be convenient at this point to offer a precise description of hypnosis, as currently understood, but a formal definition, with which all could agree, remains elusive. For now, the following will be offered.
A changed condition, in which patterns of brain activity are determined less by external sensory stimuli, and far more by self-generation. A person may allow another to guide the direction of the self-generation.
By the end of the course you may want to modify or extend that definition. As it stands it has a somewhat arbitrary quality; it is a brain state that I choose to label ‘hypnosis’. Nothing is said about behavioural correlates or potential therapeutic effects. Nor is any explanation offered as to how a person might achieve the state, or why some appear better able to do so than others. In fact the only merit in this working definition is that it is rooted in something that can be objectively measured; no one can deny that the condition exists.
How did we get here?
If, as explained above, hypnosis is self-generated, then the phenomenon must have existed throughout history; it would not need to wait for an innovator to devise a special means of inducing it. That deduction does indeed appear to be correct. Throughout history and across cultures hypnosis-like procedures seem to have been known; only the explanations and expectations (and hence resultant behaviour) have differed.
It is traditional to begin histories of hypnosis by describing the work of Mesmer, who was practicing in Paris, not long before the French Revolution. It is a good starting point, because Mesmer’s theories and practices are well documented, and were even subjected to the very first scientific investigation in the field. He attributed the effects observed to the control of an invisible force he called animal magnetism. This was associated with conventional magnetism, so he used iron and made ‘passes’ over patients’ bodies, as if magnetising them. The theory was not unreasonable; magnets clearly had an impact upon iron, could deflect compass needles and so on, and all done without any detectable connection. Similarly, no contact was needed with his patients; they merely responded to the putative force directed into them. The response was sometimes quite dramatic, because it was believed that they would experience a ‘crisis’ as part of their recovery, and as mentioned above, hypnotised people do what they believe to be appropriate.
The scientists in the French Royal Commission that investigated Mesmer soon established that, whatever he was doing, it had nothing to do with magnetism. Nevertheless, when Mesmerism started to be practiced on this side of the Channel it was still widely accepted that, in a literal sense, it was all done with magnets. It was Thomas Wakely, founder of The Lancet, who demonstrated that magnetism could not be involved. He carved a magnet shape in wood (non-magnetic of course) and painted it to look like the real thing. The device proved just as effective as a real magnet at putting people into Mesmeric trances!
By the second half of the Nineteenth Century the Scots surgeon James Braid had announced that what he dubbed hypnosis was nothing more than “a peculiar physiological state of the brain and spinal cord.” Today we might dispute the notion that the spinal cord had a significant role, but in other respects this was remarkably prescient. It was to be about a century before techniques became available that could confirm Braid’s claim; in the interim hypnosis became a research topic for psychologists.
In spite of the undeniably self-induced quality of hypnosis, one of its more striking effects is that hypnotised people have the experience of things happening to them, rather than being the initiator of the effects. Thus, a person told that their arm is becoming light may well begin to raise it. However, instead of saying, “I am lifting my arm,” they will describe it as, “floating up by itself.” Over the years many researchers (e.g. Hilgard, 1977; Woody and Bowers, 1994; Oakley, 1999; Dienes and Perner, 2007) have sought to account for this by variations on the notion of dissociation. Accepting that the brain has a modular quality, it is proposed that some of the normal passage of information between modules ceases, making it possible for a person to initiate an action without recognising that they have done so.
While early researchers, such as Hilgard (1967), were prepared to accept a hypnotised person’s account at face value, another line of enquiry resulted in a far more sceptical stance. We must digress briefly, to point out that people are not all equally responsive to hypnosis. Their degree of hypnotic susceptibility can be assessed formally (a common practice in research, far less so in a therapeutic setting) by employing a hypnotic susceptibility test. These tests generally begin with a standardised hypnotic induction procedure, then deliver a series of suggestions, such as for an arm to become light, to experience the taste of sugar, or to have a negative hallucination (fail to see something that is presented). The test items are of graded difficulty, so that few people achieve the suggested effects for every item, but the number ‘passed’ gives a measure of susceptibility. Barber and Calverley (1963) used such a test, working with two groups of experimental subjects. One group was given a standard hypnotic induction, while the other was not hypnotised at all; instead they were exhorted (the instructions were deliberately worded in a socially pressuring way) to try hard with the test items. The average susceptibility score with this group actually exceeded that obtained by those who were conventionally hypnotised!
A number of observations can be drawn from the Barber and Calverley study. First it should be noted that there are no susceptibility tests that can be passed only if a person is genuinely hypnotised; we can all lift arms, claim to be tasting sugar and so on. This was underlined by Orne (1972) who showed that when low-susceptible people were asked to act as if hypnotised they could not be distinguished by a ‘blind’ expert from those who were conventionally hypnotised. It would be possible to conclude from these findings that all hypnotic responding is a sham, with the people scoring high in susceptibility being those who are prepared to fake more items; some researchers did incline to this viewpoint. Thus, from the perspective of a social psychologist, Wagstaff (1981) proposed that hypnotic behaviour was a manifestation of compliance, a tendency to ‘go along with’ and ‘fit in’ that we all (as social animals) possess to a greater or lesser degree. The hypnotist often has a position of authority, either as a clinician or, in a research setting, perhaps a professor. The person to be hypnotised is probably a patient or student, so there is a clear power differential, which might be expected to lead to compliant behaviour. However, strong social pressure is not required to produce the effects of hypnosis. Kirsch (1997) showed that people who have not been formally hypnotised can still pass susceptibility test items, simply by asking them to try to imagine the experiences. Nevertheless, using hypnosis did slightly increase the number of items passed.
The majority of research psychologists came to accept that some people were able to convince themselves of the reality of their hypnotic experiences, but the explanation for this cognitive effect was still sought in the realm of social psychology. Hence, this school of thought came to be known as ‘socio-cognitive’. A key exponent was the Canadian researcher, Nick Spanos, who’s life was sadly cut short in a flying accident. He published extensively, always devising new ways of demonstrating that hypnotised people merely did as they believed they were meant to do. For example, amnesia can be induced in hypnosis, and highly susceptible people appear quite unable to access the material they have been told to forget. However, Spanos, Radtke and Bertrand (1984) led subjects to believe that really susceptible people were able to access the hitherto ‘hidden’ material, and sure enough, they duly became able to ‘remember’.
The foregoing is all rather disconcerting for a person wanting to ‘believe in’ hypnosis and to see it as a useful therapeutic tool. It seems that there is no point to hypnotising anyone (they can do it anyway) and that what they do will be no more than what they believe is expected. The problem behind all this is the absence of anything that looks ‘hypnotic’; no special procedure is required to get people into a special state, and nothing happens that is peculiar to the hypnotic condition. This was the crux of the debate that raged for much of the latter part of the Twentieth Century: was, or was not hypnosis a special state? People with clinical connections, observing impressive effects that seemed to be achievable only through hypnosis, were inclined to think that they were engendering an ‘altered state of consciousness’; on the other hand, the data emerging from research laboratories suggested something far more mundane.
A New Viewpoint
Fortunately, in spite of the message of the preceding paragraph, there is no need for pessimism. A person who does feel a sense of disappointment has probably not quite thrown off the old beliefs about hypnosis, beliefs that are still widely held. These are that hypnosis in done to a person, and that once ‘under’ they are very much in the control of the hypnotist. Of course, stage hypnotism does us no favours in this regard, since those are exactly the characteristics the showmen would like us to believe in – it adds to that frisson of fear!
It will be recalled that our working definition of hypnosis is of a state where brain activity is more than usually self-driven, rather than from external stimuli. There may well be situations where an external agent (the hypnotist) can assist in reaching that state, but there is no reason to suppose that special forms of words or actions would be needed. Once the hypnotised person has acquired a state where they are able to exert this unusual self-control, how should they direct it? There is no compulsion to take any particular course, but having agreed to undergo hypnosis the obvious thing is to follow instructions or expectations. Surprise, surprise, they do no more than they believe they are meant to do! This is not a reason to dismiss hypnosis as being powerless; it is a reason to ask how the brain is able to achieve these effects. The answer will not be found in the field of social psychology, for the mechanisms all lie within the individual.
Much has been made of the fact that there are no intrinsic hypnotic effects; we have repeatedly stressed that people merely follow expectations. However, this is not entirely true. There is one phenomenon that seems dependably linked to hypnosis: time distortion. For the hypnotised person time seems to pass more slowly, so that at the end of a session they are frequently surprised that it had lasted so long. This is not what a hypnotised person would normally expect (hence the surprise) so it is reasonable to assume that, whatever it is a person has to do to achieve the hypnotic state, the condition in some way acts upon an inner clock (Naish, 2007). This rather esoteric finding is of interest in the present context, because there is another group of people who experience time distortion: those suffering from schizophrenia (Carroll, O’Donnell, Shekhar and Hetrick, 2009). Unfortunately, schizophrenia patients are unable to adopt their condition at will, but in other respects their experience of hallucinations and sense of their actions not being self-initiated make them rather similar to someone experiencing hypnosis. There is an additional parallel: people who score high on scales of schizotypy also score high on hypnotic susceptibility (Gruzelier et al., 2004).
There are things to be gleaned from the similarities between hypnosis and schizophrenia. First, it is worth pointing out that the experiences reported by patients are not denied; they are accepted as an altering of normal consciousness and there are no attempts to explain them away in social psychological terms. The ways in which schizophrenic symptoms are explained have tended to be focused in the field of neuroscience, and the results may provide useful clues as to what happens in hypnosis. There is evidence for unusual inter-hemispheric effects in schizophrenia, with a greater than normal contribution from the brain’s right hemisphere (Caligiuri et al., 2005). Additionally, there seems to be a general reduction in connectivity from frontal regions of the brain to other regions (Lawrie et al., 2002). This may at least in part be explained by an abnormal modulation of fronto-temporal connections by the cingulate cortex (Fletcher et al., 1999) although more recently Shergill et al. (2007) have reported a lack of integrity in the large interconnecting fasciculi. The resultant lack of ‘binding’ between different brain regions is evident electrophysiologically as reduced phase-locking in the EEG gamma band (Haig et al., 2000).
There are remarkably close similarities between the above results and the equivalent findings from people in hypnosis. Fingelkurts, Fingelkurts, Kallio and Revonsuo (2007) have reported a similar reduction in phase-locking, and many scanning studies have revealed unusual activity in the anterior cingulate cortex (e.g. Szechtman, Woody, Bowers and Nahmias, 1998). Obviously, hypnotised people are not presumed to have anything but intact fasciculi, but nevertheless, Blakemore, Oakley and Frith (2003) reported that when movements were felt to occur ‘by themselves’ there was a corresponding lack of neural inhibition, as if an inhibitory link had been broken. The right hemisphere effect is apparent too, and this highlights the remarkable extent of the temporary neural changes that a hypnotised person is able to achieve. Naish (2010) has shown that highly hypnotisable people shift from faster left- to faster right-hemisphere processing when moving from the waking to the hypnotised state.
The neurophysiological findings relating to hypnosis stand by themselves as demonstrating that it is a state in which the brain really is doing something rather different from its normal behaviour. Underlining the parallels with schizophrenia, a condition recognised as having a powerful impact upon a person’s experiences, serves as a pointer to the impact that hypnosis may be expected to have. We will now take a brief look at some of its therapeutic uses. The following serves merely as a pointer to possible applications; more detail will be given as required, in the relevant sections of the course. At this stage the principal intention is to show that the clinical use of hypnosis is not a flight of fancy dreamt up by strange, ‘alternative’ therapists; it has sound theoretical and empirical underpinnings.
Hypnosis as an Adjunct to Therapy
Historically it is undoubtedly the case that hypnosis had its greatest impact when employed as an analgesic, before the advent of chemical anaesthesia. Without direct knowledge of its efficacy, in modern times doubt has sometimes been cast on the old accounts of painless operations. However, even today hypnosis is sometimes used where a general anaesthetic (GA) might normally have been employed. One of the advantages of this is that no recovery is needed from an anaesthetic. We should not be surprised that hypnosis can act in this way, for our current understanding of both hypnosis and pain suggest that one should readily influence the other. It has become clear that there is not a simple one-to-one mapping between painful stimulus and pain perception; the neuro-circuitry involved includes regions associated with cognition and, as with all forms of perception, feedback signals are as important as feed-forward. Given the impact of hypnosis upon cognition and perception described earlier it is not surprising that a ‘disconnect’ may be achieved between stimulus and experience. Brain scanning has confirmed that hypnotic suggestions can modulate not only the experience of pain, but also the activity in the brain’s so-called ‘pain matrix’ (Derbyshire, Whalley and Oakley; 2009). Although hypnosis is seldom used in place of a GA, it can be an invaluable adjunct when procedures are expected to be moderately painful, for example when working with children (Liossi and Hatira; 2003).
A condition that often includes pain as one of its symptoms is irritable bowel syndrome (IBS). It turns out that hypnosis not only helps the pain, but has a good track record in the treatment of the condition itself (Whorwell, 2006). The approach generally involves imagery, an aspect of hypnosis not yet discussed in this introduction. It has been mentioned that hypnosis can facilitate hallucination-like effects; all manner of sensory experiences can be induced, and they can be selected with a therapeutic purpose in mind. IBS patients frequently suffer from either constipation or diarrhea. These symptoms may be addressed by encouraging the patient to visualize a moderate flow through their gut, neither too slow nor too fast. However, for most the alimentary canal will be unknown territory, so an analogy may be used, such as a river, and the patient in hypnosis is encouraged to form vivid imagery of the flowing water. To suit the symptoms, a sluggish river can be pictured, where silt and branches are gradually cleared away to permit an easy flow, or alternatively rushing rapids may be tamed with weirs to form placid pools. The precise manner in which such images impact the condition is not fully understood, but much that is relevant is known. Cerebrofugal pathways are involved in the control of many somatic processes. Control generally takes place outside conscious awareness, although biofeedback techniques have been shown to facilitate the deliberate control of factors such as blood pressure. Additionally, visual input causes somatic effects; the sight of blood can lead to fainting, while witnessing someone hitting their thumb often elicits an instinctive gasp of pain. It is probable that hypnotic imagery exerts its impact via routes such as these, and this may also be the case with its influence upon the immune system. A number of studies (e.g. Gruzelier, 2002) have shown that appropriate imagery can lead to an increase in the numbers of natural killer cells.
Simple phobias are treated very effectively with hypnosis-induced guided visual imagery, and in this case little speculation is required to explain the process. Where in vivo desensitization would be the treatment of choice it is a simple matter to substitute the vivid experiences of hypnosis. A great advantage over real life exposure is that the nature of the stimulus may be precisely controlled. For example, a ‘hypnotic’ spider need not suddenly and unpredictably start to move; it will move in the direction required when the phobia sufferer is ready for the experience. An early literature review by McGuinness (1984) showed that there was already ample evidence to recommend this as an effective and efficient treatment approach.
In working through examples for this brief overview, we have addressed conditions with what might be described as increasing levels of psychological content. Hypnosis is an excellent vehicle for delivering psychotherapeutic treatments. As already indicated, imagery may be adapted to suit a wide range of situations, and the sensations of calmness and safety readily induced in hypnosis provide a situation in which a person may, perhaps for the first time, become able to address difficult issues in their life. It is not surprising, therefore, that hypnosis is effective in the treatment of depression (e.g. Alladin and Alibhai, 2007). In this context it is appropriate to raise some caveats. While few people would be so unwise as to employ hypnosis as an adjunct to physical treatment in a specialism not their own, there are many, particularly in the lay community, who are prepared to tackle psychological problems without any formally recognised training. This is strongly to be discouraged.
We will conclude with one very specific danger that has come to be associated with the inappropriate psychotherapeutic use of hypnosis: the induction of false memories. Undoubtedly a person is influenced by their past, so a troubled person of today is frequently one who lived through difficult experiences some time before. Hypnosis is a helpful vehicle for exploring these events and coming to terms with them; however, it is not a tool for eliciting material that has been forgotten, and there is nothing in the hypnotic mechanisms we have outlined to suggest that it could work in this way. Unfortunately, some people treat hypnosis as if it is a key that will unlock so-called repressed memories, those which are supposed to be so terrible that the mind cannot permit them to be available. To those who entertain these beliefs there is a prime candidate for such awful material: sexual abuse. When a patient denies anything of that nature in their past it is assumed that the memories must be repressed, so hypnosis is used to discover them. The suggestions as to what the patient is supposed to be finding will all too easily generate rich imagery, which in turn lays down apparent memories. ‘Recovering’ these pseudo-memories is of no therapeutic value, and in many cases has led to false accusations and the break-up of families. Anyone contemplating the use of hypnosis in the treatment of psychological problems is strongly advised to consult the British Psychological Society’s booklet on hypnosis (Heap et al., 2001). The pitfalls of misguided treatments cannot be better expressed than in this quotation from the document:
Hypnosis does not have any special property for enhancing memory in therapy … using hypnosis in this way carries a real risk of producing substantial pseudo-memories … some can be so plausible as to beguile the therapist and client alike into accepting them as accurate.
These few pages cannot do justice to the wealth of research material relating to the nature of hypnosis, nor can they hope to cover the great breadth of clinical applications that have been established and the supporting evidence for their efficacy. However, if you have read this far you will now know something of how the brain establishes the hypnotic condition, you will have a feel for the way this can be applied as an adjunct to therapy and you will be aware of associated dangers. Armed with all this you are well equipped to enjoy and benefit from the course, and above all to start finding ways to use hypnosis in your work.
Peter Naish, © 2013