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Hypnosis : theories, research, and applications / [edited by] Gael D. Koester and Pablo R. Delisle.
p. ; cm.
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

Published by Nova Science Publishers, Inc.  New York

Chapter 1

Chapter 2

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
Katalin Varga, Emese Jzsa, va I. Bnyai and Anna C. Gsi-Greguss

Chapter 3

Applications of Waking Hypnosis to Difficult Cases and Emergencies

Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

Chapter 4

Language, Metaphor and Neuroscience: Scientific Explanation

and Pragmatic Rules for Effective Communication in Hypnosis
Renzo Balugani, and Giuseppe Ducci



Chapter 5

The Relational (Intersubjective) Approach to Hypnosis

Udi Bonshtein


Chapter 6

Hypnosis, Absorption and the Neurobiology of Self-Regulation

Graham A. Jamieson


Chapter 7

The Neurophysiology of Hypnosis in Mass Psychogenic Illness

Felipe A. Tallabs G


Chapter 8

Relaxation, Meditation, and Hypnosis for Skin Disorders

and Procedures
Philip D. Shenefelt


Chapter 9

Hypnosis and Cancer: A Dead-End Story?

Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon
and Alain Blanchet

Chapter 10

The Valencia Model of Waking Hypnosis and its Clinical Applications 237
Antonio Capafons and M. Elena Mendoza


Chapter 11


Hypnosis in the Management of Chronic Pain Conditions,
and the Acute Pain Accompanying their Treatment
John F. Chaves


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 Ericksons
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



SPCs 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



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 persons 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


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 patients 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



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 patients 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



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, diagnosis, and treatment of many painful
medical conditions. That fact is due, in part, 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. Although the basic observation that pain could be profoundly modulated by
various psychological interventions was already well known, 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. Soon, 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.
Although substantial gains in the clinical practice of pain management have been made
since the Gate Control Theory was promulgated, the biomedical perspective has continued to
dominate contemporary medical practice, even as more sophisticated psychological
interventions for pain management were developed. In recent years, however, there has been
substantial growth in the amount of research, including randomized clinical trials, being
conducted on psychological interventions for chronic pain management. Favorable results
have contributed to a growing acceptance of the notion that interventions like hypnosis, that
can augment more traditional medical or pharmacological approaches, or reduce reliance on
them, have the potential to play an important role in contemporary pain management.

In: Hypnosis: Theories, Research and Applications

Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456 2009 Nova Science Publishers, Inc.

Chapter 1


Alfred Barrios
SPC Center, Culver City, CA, USA

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 Ericksons 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
SPCs application in the areas of: education, welfare, industry, medicine and drug
rehabilitation are presented.

Alfred Barrios

The work and ideas presented herein evolved from my 1969 Ph.D. dissertation in
psychology at UCLA entitled Toward Understanding the Effectiveness of Hypnotherapy: A
Combined Clinical, Theoretical & Experimental Approach and which I am proud to say was
nominated that year for the national Creative Talent Award. 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. This review which comprised the first third of
my Ph.D. dissertation was published as an article entitled Hypnotherapy: A Reappraisal
in the APA journal Psychotherapy: Theory, Research and Practice (1970). One important
point to keep in mind when assessing this review is that although the studies referred to took
place over forty years ago, the results and conclusions still hold true today.

Throughout the years there have been periodic surges of great interest in hypnosis. Many
extraordinary phenomena have been attributed to its effects and great claims made as to its
effectiveness in therapy. Yet, in spite of such claims, there still appear to be relatively few
therapists using hypnosis as a major tool. Why? Is it because the criticisms usually leveled at
hypnosis are true? That it is overrated, actually limited to a small range of problems, unable to
produce lasting changes? Will removal of symptoms by hypnosis lead to new symptoms? Is it
dangerous? No, there is far too much clinical evidence contradicting these statements. Such
evidence can no longer be ignored. It is felt that the major reason behind the rejection of
hypnosis has been that for most people it is still virtually an unknown. It seems to be human
nature to stay clear of or reject anything that doesnt seem to fit in or be explained rationally,
especially when it seems to be something potentially powerful. 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.
The purpose of the present paper is to present some of the recent clinical evidence
contradicting the common criticisms and misconceptions surrounding hypnotherapy, to
provide 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.

Overview of Recent Literature

There have been 1,018 articles dealing with hypnosis in the past three years (1966
through 1968), approximately forty per cent of which dealt with its use in therapy. In the
same period we find 899 articles on psychoanalytic therapy and 355 on behavior therapy.
Contrary to popular opinion that hypnosis is only effective in certain specific symptomremoval cases, a wide range of diagnostic categories have been successfully treated by
hypnotherapy. This includes anxiety reaction, obsessive-compulsive neurosis, hysterical

A New Theory for Understanding and Appreciating the Power of Hypnosis

reactions and sociopathic disorders (Hussain, 1964), as well as epilepsy (Stein, 1963),
alcoholism (Chong Tong Mun, 1966), frigidity (Richardson, 1963), stammering and
homosexuality (Alexander, 1965), various psychosomatic disorders including asthma,
spontaneous abortions, dysmenorrhea, allergic rhinitis, ulcers, dermatitis, infertility and
essential hypertension (Chong Tong Mun, 1964, 1966). Also in the past few years an
increasing number of reports indicate that the psychoses are quite amenable to hypnotherapy
(Abrams, 1963, 1964; Biddle, 1967).

Three Large Scale Studies

Three large scale studies in the past five years contain basic findings.
Richardsons (1963) study dealt with seventy-six cases of frigidity. He reports 94.7% of
the patients improved. The average number of sessions needed was 1.53. 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%. 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. Richardsons method of treatment was a
combination of direct symptom removal, uncovering, and removal of underlying causes, since
he had found that direct symptom removal alone was not always sufficient. He reports no
hypnotic induction failures.
Chong Tong Muns (1964, 1966) study covered 108 patients suffering from asthma,
insomnia, alcoholism, dysmenorrhea, dermatitis, anxiety state, and impotence. The
percentage of patients reported improved was 90%. The average number of sessions was five.
The criteria for judging improvement were removal or improvement of symptoms. The
average follow-up period was nine months. Chong Tong Muns method of treatment was a
three-fold approach. With some patients he would work on reeducating the patient with
regard to the behavior patterns immediately underlying the symptoms. With others he would
first regress the patient back to the original onset of the symptom. Once regressed, he would
reeducate the patient to the fact that the original cause was no longer operative. In addition, he
usually used supplementary suggestions of direct symptom removal.
Hussains (1964) study reports on 105 patients suffering from alcoholism, sexual
promiscuity, impotence and frigidity, sociopathic personality disturbance, hysterical
reactions, behavior disorders of school children, speech disorders, and a number of different
psychosomatic illnesses. The percentage of patients reported improved was 95.2%. The
number of sessions needed ranged from four to sixteen. The criteria for judging improvement
were complete or almost complete removal of symptoms. In follow-ups ranging from six
months to two years no instance of relapse or symptom substitution was noted.
Hussains approach is illustrated by the case of a 35 year old woman exhibiting the
following symptoms: anxiety, alcoholism, depression with suicidal tendencies, sexual
promiscuity, insomnia, and inability to make decisions and future plans.
Prior to treatment, Hussain pinpointed the various fears and negative attitudes which he
felt were underlying the symptoms e.g., the patient feeling unloved and unwanted in regards
to her marriage, feelings of inadequacy at being a mother, fear of her own mother, fear of
responsibility and making decisions, and guilt over her sexual promiscuity.

Alfred Barrios

Hussain then used a therapeutic technique somewhat similar to Wolpes (1958)

desensitization technique to eliminate these fears and negative attitudes. For example, 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. This particular approach
is very often used now in one form or another. Abrams (1963) refers to it as an artificial
situation technique. Through hypnosis the patient is able to experience his new attitudes in
an artificial situation, an imagined situation. 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, 1985, pp. 43-51). It differs
from Wolpes approach in two respects. First of all, Wolpe does not often use hypnosis.
Secondly, Wolpe has the patient go through a hierarchy of imagined situations, going from
easiest to deal with to most difficult. (There is no reason, however, why this hierarchy
approach cannot be incorporated into hypnotherapy.)
With the above patient Hussain also used direct symptom-removal suggestions. For
example, aversion to the thought and sight of alcohol was also built up by direct suggestion.
This patient was discharged from the hospital after twelve sessions. No relevant
symptoms were left behind and there was no relapse during the six-month follow-up period.

Current Method of Using Hypnosis

As one can see in the above studies, and this probably comes as a surprise to most
therapists, the main use of hypnosis is not as a means of direct symptom removal. Nor is its
main use as an uncovering device. The current trend is to use hypnosis to remove the negative
attitudes, fears, maladaptive behavior patterns, and negative self-images underlying the
symptoms. Uncovering and direct symptom removal are still used to a certain extent, but
usually in conjunction with this new main function.
In the past, so much emphasis was directed towards symptoms and disease processes that
some of us were guilty of forgetting the person in the body. 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, 1963).
Psychiatric hypnotherapy, as practiced today by the leading practitioners in the field, 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, 1965).
The objection that the results of symptom removal will seldom be permanent is certainly
not valid. This may have been so in the past, 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, 1965).
This change is being stressed in the present paper because it is part of its purpose to fit
hypnotherapy into the scheme of things. Many therapists have rejected hypnosis because its
direct symptom approach of the past clashed violently with their dynamic approach. Now we
see that such a clash need no longer exist.

A New Theory for Understanding and Appreciating the Power of Hypnosis

The Ahistorical vs. the Historical Approach in Therapy

Some hypnotherapists use, in part, a historical approach, going back into the patients
childhood and changing his attitudes regarding the causes of these patterns (Fromm, 1965;
Abrams, 1963; Chong Tong Mun, 1964, 1966). However, most hypnotherapy is ahistorical
and, it would seem, faster. 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, locating all the tributaries, and pointing each one in a new direction.

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, or the substitution of more damaging symptoms. According
to a number of investigators (Kroger, 1963; Abrams, 1964) these dangers have been grossly
exaggerated. However, whatever dangers there were have been virtually eliminated by this
new approach. 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.
The first type of mishap was produced by a therapist, who would allow, or force, the patient
to become aware of repressed information which he was not strong enough to face. 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.

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, symptoms would
disappear at first, but reappear later if the patient-therapist relationship were disturbed (Freud,
1955, p. 237). In the above studies the only hypnotic induction failures were reported by
Chong Tong Mun (eight failures out of 108 patients.) This can mean one of two things: the
hypnotic induction procedures have improved since Freuds day, or that the reconditioning
approach used in these studies (as opposed to Freuds cathartic approach) does not require
very deep levels of hypnosis. There is evidence that both factors may be involved.
Although many have thought that hypnotic susceptibility was a set character trait, there
are a number of studies which now seem to indicate that this is not the case, and that
responsiveness can be increased by certain changes in the hypnotic induction procedure
(Pascal and Salzberg, 1959; Sachs and Anderson, 1967; Baykushev, 1969), as well as by
means of a pre-induction talk aimed at insuring a positive attitude, an appropriate expectancy
and a high motivation toward hypnosis (Dorcus, 1963; Barber, 1969; Barrios, 1969).
With regard to the depth of hypnosis required for the reconditioning approach to work,
there are a number of therapists who feel that only a light state of hypnosis is necessary (Van
Pelt, 1958; Kline, 1958; Kroger, 1963) A study by Barrios (1969) gives this contention some
support; 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.

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. Judging from the work of Wolpe (1958) it would
appear that hypnosis is not an absolutely necessary requirement. This would also be supported
by the work of Barber (1961, 1965) who found that hypnotic phenomena could be produced
without a prior hypnotic induction. However, the real question to be answered is not whether
hypnotic induction is absolutely necessary, but whether it can further facilitate the
conditioning process. Wolpe, himself, concedes the hypnosis apparently does facilitate the
Patients who cannot relax will not make progress with this method. Those who cannot
or will not be hypnotized but who can relax will make progress, although apparently more
slowly than when hypnosis is used. (Wolpe, 1958, p. 141; italics added).
Also, although Barrios (1969) study indicated that conditioning could be increased
during lighter levels of hypnosis, it was also found that there was no increase in conditioning
with those subjects indicating no response to the hypnotic induction.
As pointed out in the theory (Barrios, 1969), 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. The next
question to be decided now is not so much whether hypnotic induction procedures increase
responsiveness (this is fairly well accepted e.g., Barber, 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.

Comparison with Psychoanalysis and Behavior Therapy

In Wolpes comparison of his and the psychoanalytic approaches (Wolpe, Salter, and
Reyna, 1964), we find the following: Based on all psychoneurotic patients seen, 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). 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, or an average of approximately 600 sessions per patient. For Wolpes approach we
find that, based on all patients seen, 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. The duration of treatment for the improved patients was an
average of thirty sessions in the former and fourteen in the latter.
Averaging the above figures, we find that for psychoanalysis we can expect a recovery
rate of 38% after approximately 600 sessions. For Wolpian therapy, we can expect a recovery
rate of 72% after an average of 22 sessions, and for hypnotherapy we can expect a recovery
rate of 93% after an average of 6 sessions.
It is interesting to note the negative correlation between number of sessions and
percentage recovery rate. At first sight this seems paradoxical. However, if a form of therapy
is truly effective, it should not only increase recovery rate, but also shorten the number of
sessions necessary (as well as widen the range of cases treatable).

A New Theory for Understanding and Appreciating the Power of Hypnosis

The Need for a Rational Explanation

In spite of all the encouraging reports, there continues to be considerable hesitation on the
part of psychotherapists to use hypnosis. Hypnosis is still looked upon as an unknown by
most therapists. They are as yet not aware of any reasonable rational explanation for hypnotic
phenomena that would satisfy them, one that would tie these phenomena down to observable
facts and laws. As long as hypnosis continues to exude an air of mysticism and charlatanism,
it will continue to be rejected by many, no matter how great the claims on its behalf.

An Explanation Based on Principles of Conditioning

The experienced therapist really should not be so surprised at the effectiveness of
hypnosis in facilitating therapy. Hypnotic induction can be looked upon as a technique for
establishing a very strong rapport, for establishing a greater confidence, a greater belief in the
therapist, whereby the latters words will be much more effective. As Sundberg and Tyler
(1962) point out, 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, as their experience
increases, come to place much more emphasis on this variable (pp.293-294).
The question still remains, however what exactly is the process whereby mere words
can produce such great changes in personality.
As pointed out in Barrios (1969) theory of hypnosis, 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.
First of all, we know that words can act as conditioned stimuli.
Pavlov recognized this fact:
Obviously for man speech provides conditioned stimuli which are just as real as any other
stimuli Speech, on account of the whole preceding life of the adult, is connected up with all
the internal and external stimuli which can reach the cortex, signaling all of them and
replacing all of them, and therefore it can call forth all those reactions of the organism which
are normally determined by the actual stimuli themselves (Pavlov, 1960, p. 407).

Now, 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. Thus, for example, if we wanted to condition a person to
be more relaxed in the presence of people, we would pair the words people (A) and
relaxed (B), using a sentence or suggestion such as, From now on you will find yourself
more relaxed in the presence of people. Mowers theoretical formulations on the sentence as
a conditioning device (Mowrer, 1960) tend to support this contention.
Of course, we know that under ordinary circumstances suggestions are not always
accepted (and thus conditioning doesnt always result when an appropriate suggestion is
given). Why is this? Osgood (1963) holds that a suggestion will tend to be rejected if it is
incongruent with the subjects previously held beliefs and attitudes or his present perceptions.
It would seem that if there were some means of eliminating the latter we should be able to

Alfred Barrios

have a suggestion more readily accepted and thus facilitate the higher-order conditioning.
Hypnosis is such a means.
Thus we come to the reason hypnosis is so effective in facilitating therapy: the
incongruent perceptions, beliefs, and attitudes are kept from interfering with the suggestion
(and thus with the conditioning). As put by Pavlov:
The command of the hypnotist, in correspondence with the general law, concentrates the
excitation in the cortex of the subject (which is in a condition of partial inhibition) in some
definite narrow region, 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].
This accounts for the large and practically insurmountable influence of suggestions as a
stimulus during hypnosis as well as shortly after it (Pavlov, 1960, p. 407; italics added).

As an illustration, let us say we wanted to change a patients self-image from that of an

inadequate person to a more self-confident one. If under ordinary circumstances we suggested
that he would no longer feel inadequate, it would most likely accomplish little. This is
because the patients negative self-image, usually ever-present and quite dominant, would
quickly suppress any positive image suggested, or at least keep it from being too vivid or real.
But in the hypersuggestible hypnotic state conditions are different. The patients 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. As a result, the conditioning
can take place and new associations can be made. The person can truly picture himself feeling
self-confident in various situations and these new conditioned associations in turn can lead to
new behavior. This new attitude can now become permanent by means of self-reinforcement,
just as his old negative attitude had been kept permanent by self-reinforcement. As long as the
patient has negative attitudes, these are self-reinforcing. They lead to his tensing up, acting
awkward and making numerous mistakes. Also, he is unlikely to believe any praise or any
positive occurrences should they chance his way. But if this negative self-image has been
replaced by a positive one, the opposite cycle can result. Being more confident and relaxed he
will naturally be more likely to be accepted. Also, he will now be more open to believing and
accepting praise and positive outcomes.


In the theory (Barrios,1969,2001) 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. Hypnosis is defined then as the state of
heightened suggestibility, also referred to as a state of heightened belief, produced by a
hypnotic induction. What occurs during a hypnotic induction to increase suggestibility is a
process of conditioning of an inhibitory set. The latter increases responsiveness to suggestion

Much of the remainder of this chapter is taken verbatim from my commentary articles, Part I & II, in
Contemporary Hypnosis (Barrios, 2007 a & b)

A New Theory for Understanding and Appreciating the Power of Hypnosis

by inhibiting thoughts and stimuli which would contradict the suggested response. The more
effective the hypnotic induction, the greater this inhibitory set.
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, some more strongly than others. This is referred to
as the stimulus dominance hierarchy. 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. 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.
From the theory, a number of ways can be deduced for increasing responsiveness to
suggestion and thereby increasing the effectiveness of hypnotic induction. These include: the
amplification of minute responses to suggestion such as with the use of biofeedback devices;
the minimization or inhibition of competing stimuli such as in sensory deprivation or under
the influence of inhibitory drugs; and the subtle introduction of stimuli that would naturally
evoke the suggested response.
Since the theory defines hypnosis as a state of heightened belief, one can see that
hypnosis can be a natural everyday occurrence. Salesmen, lawyers and politicians are
constantly benefiting from a variation of hypnosis (the powers of persuasion). So too are
doctors (the power of the placebo) and ministers (the power of faith).


Comparison with Sociocognitive Theories
Both perspectives discuss the importance of the part played by individual differences in
affecting initial responsiveness to suggestion. The following are included as individual
influencing factors in both perspectives: subjects' expectations and beliefs about hypnosis;
motivation and imagination (or fantasy proneness).
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. It is expected that sociocognitive theorists would
agree that these are also important individual difference factors. However, the explanation for
how these factors play a part according to the theory might differ from the sociocognitive
With regards to age, for instance, the theory states that the reason initial suggestibility
varies with age,
may be traced to certain factors that vary with age. One of these is language ability. Since
[according to the theory] hypnosis is dependent to a great extent on the conditioned response
evoked by words, we can understand why very young children whose language ability is not
yet well-developed would make very poor subjects for hypnosis, and thus why we would
expect an initial gradual increase in suggestibility with increasing age ...


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, knowledge increases with age) and a corollary to the 'reciprocal inhibition'
or 'stimulus dominance hierarchy' postulate is that the more stimuli in the hierarchy, the lower
the probability of a reaction to any one of them ... with increasing age there will be a greater
number of possible contradictory stimuli [competing with] a suggestion; that is, subjects have
more information available with which to verify or contradict the suggestion. (Barrios, 2001:
With regards to prestige,
It is fairly well accepted that the more 'prestige' a hypnotist has in the eyes of subjects, the
better his chances of success. It is felt this is so because the statements, commands or
suggestions of a person with prestige tend to be questioned less, that is, such a person evokes
a greater inhibitory set to begin with. In general, people have previously been conditioned to
accept at face value the statements of someone who is an authority in his field. That is, 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).
This is so because what the authority says has usually turned out to be true! (Barrios, 2001:

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
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). GDFs
are defined as 'imagined situations which, if they were to occur, would be expected to lead to
the involuntary occurrence of the motor response called for by the suggestion' (Spanos,
Rivers and Ross, 1977: 211). In other words, the more cognitive stimuli used associated with
the suggested response, the more likely the response. In the theory, Hypothesis IV states: 'A
suggestion produces the desired response by first evoking a cognitive stimulus which is
associated with that response.' And a corollary to this hypothesis, Corollary 8, states: 'The
more (compatible) cognitive stimuli associated with the response evoked by the suggestion,
the stronger the response to the suggestion. For example, to increase the probability of
producing the involuntary response of salivation and/or the secretion of pepsin, you might
want to suggest that the subject was eating a delicious steak or, better yet, a thick juicy steak
smothered in onions.
A third similarity between the two perspectives is how they apparently both seem to fit in
with Milton Erickson's strategic approach to therapy. How Erickson's approach fits in with
the sociocognitive perspective is discussed in a very extensive article by Lynn and Sherman
(2000). The following includes some examples of how Erickson's ideas parallel those
presented in the theory:

In the section of Lynn and Sherman's article where they are discussing Erickson's strategy
of using scripts, they point out that

A New Theory for Understanding and Appreciating the Power of Hypnosis


Erickson found this technique useful in engendering a 'yea saying' response pattern. He would
start with questions with an obvious 'yes' answer; to establish a pattern or response set, he
would keep asking such questions. Patients would [then] apparently agree to things that they
would not have agreed to in the absence of such a response set. (Lynn and Sherman, 2000:

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. If we can look upon these
'questions' as a variation of suggestions, then in both cases the individual is being put through
a form of hypnotic induction according to the theory. 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, 2001: 178).
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, or more broadly to whatever response the patient made (Erickson, Rossi
and Rossi: 1976). Certain naturally occurring responses, such as lowering of an outstretched
arm, provide immediate positive propioceptive feedback' (Lynn and Sherman, 2000: 307). To
see the similarity of this to what is said in the theory, see Corollary 6 following Hypothesis III
of the theory: 'The response could be "artificially" induced in a number of ways. For instance,
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, 2001:

Erickson's Altering Accessibility

According to Lynn and Sherman (2000: 306), 'Response sets can be established and
reinforced by altering the accessibility of facts or events in memory ... For example,
imagining negative outcomes of smoking and overeating and positive outcomes of not doing
so can make it easier to resist these urges.' This very same procedure is referred to as the
'Punishment-Reward' technique, one of several visualization techniques for facilitating
reprogramming, in the self-programmed control (SPC) program for improving behavior (see
Barrios, 1973b and Barrios, 1985: 49 and 50). 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. (Barrios, 2007b)
Reframing was a technique of Erickson's to make general positive suggestions or treatment goals more attainable. For example, one of his approaches to break a patient out of
depression over certain deficits was to 'turn the patient's deficits into assets'. This is very
similar to one of the positive attitudes, Positive Attitude 4, 'Learn to look for the good in even
the worst of situations,' in the chapter on positive attitudes in the SPC program (see Chapter
IV of Barrios, 1985). If the goal of therapy is to help the patient break free of a depression
caused by some negative life occurrence, for instance, instead of the hypnotherapist giving
only the general suggestion that the patient will no longer be depressed, 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, in this way turning the patient's deficits into assets.


Alfred Barrios

In essence, 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. This basic premise will be explored again later in Part II in
the section on faith healing when pointing out that belief alone (e.g. a placebo) is not as
effective as belief plus guidance. In so many words, this is similar to what Lynn and Sherman
(2000: 307) mean when they state that 'As implied by these examples, Erickson's approach
involves considerable reframing of behaviors [so] as [to be] consistent with treatment
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. According to Lynn and
Sherman (2000: 305):
Erickson's appreciation of the crucial role of response sets is further revealed by his
(Erickson, et al. 1976) observation that, '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. 58). In fact, 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 ... that are usually experienced as involuntary by
the patient (p. 20). All of these comments concur with the general thrust of response set
theory [except for the concept of trance].
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, it is felt,
provides an especially effective means (the inhibitory set) whereby interfering stimuli can be
readily inhibited' (Barrios, 2001: 194-5).
What Erickson refers to as 'the limitations of one's usual conscious sets and belief
systems' the theory refers to as interfering stimuli, 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, 'inhibited,' in order for the new patterns to be
made; or as Erickson puts it, 'so that one can be receptive to an experience of other patterns of
association and modes of mental functioning' (Erickson, Rossi and Rossi, 1976: 20).

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. The sociocognitive
perspective seems to feel that hypnotic inductions increase suggestibility only to a minor
degree whereas the theory does not agree with this. As Lynn and Sherman (2000: 298) put it,
'Suggestions can be responded to with or without hypnosis, and the function of a formal
induction is primarily to increase suggestibility to a minor degree (see Barber, 1969; Hilgard,

A New Theory for Understanding and Appreciating the Power of Hypnosis


The problem with this perspective is that it implies that all hypnotic inductions are able to
increase suggestibility only to a minor degree, and thus it is implied that hypnotic inductions
are really not that necessary. Yes, it may be true that the standard hypnotic induction
emphasizing relaxation used in many of Barber's studies, for instance, is capable of increasing
suggestibility only to a minor degree, but as indicated by Corollaries 5 and 6, following
Hypothesis III of the theory, there are ways of increasing the effectiveness of hypnotic
inductions even more (see: Wilson, 1967; Wickless and Kirsch, 1989; Kirsh, Wickless and
Moffit, 1999 and Wickramasekera, 1973).

State vs Non-state
Another significant difference between the sociocognitive and the theory's perspective
revolves around the state vs non-state issue. According to Lynn and Sherman, because
researchers like Barber and his colleagues (Barber, 1969; Barber and Calverley, 1964, 1969;
Barber, Spanos and Chavez, 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. This research supported
the idea that despite external appearances, hypnotic responses were not particularly unusual,
and therefore did not require the positing of unusual states of consciousness. Accordingly,
there is no need for clinicians to insure that their patients are in a 'trance' before meaningful
therapeutic suggestions are provided. (Lynn and Sherman, 2000: 298)

There is some truth to this last statement. Some meaningful therapeutic changes can be
produced with suggestions even without a formal hypnotic induction for some individuals.
This would be true especially amongst those subjects who were highly suggestible even
without a hypnotic induction. 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, motivation and fears, as pointed out on pages
183 and 184 of the theory (see Weitzenhoffer, 1953; Dorcus, 1963; and Barber and Calverley,
1965 as cited in Barrios, 2001: 183 and 184).
However, by following such recommendations as those presented by corollaries 5 and 6
following Hypothesis III of the theory, 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, 1967;
Wickless and Kirsch, 1989; Kirsch et al., 1999; and Wickramasekera, 1993). If it is true that
certain hypnotic inductions can produce significantly higher levels of suggestibility (even in
already highly suggestible individuals), then I feel we can talk in terms of a hypnotic and nonhypnotic state. A hypnotic state could be defined simply as the heightened state of
suggestibility (or as Skinner would put it, a heightened state of belief; see Barrios, 2001: 171)
produced by the hypnotic induction.
Yes, it is true that on an inter-individual basis, i.e. comparing one individual to another
individual, some people can respond to suggestions without a hypnotic induction at the same
level as another person who has gone through a hypnotic induction. In this sense there is no
difference between states. But if we go on an intra-individual basis, i.e. comparing the same


Alfred Barrios

individual before and after a hypnotic induction, the hypnotic state for a given individual can
be different than the waking state, especially after an effective hypnotic induction.
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.

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. Many in the field,
especially those from the sociocognitive perspective, seem to feel that a measure of
suggestibility after the hypnotic induction is more than sufficient to measure hypnotizability.
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, 1997b: 213).
However, 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, which tends
to increase suggestibility 'only to a minor degree'. As more effective hypnotic inductions are
used, 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, 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.
In discussing ways that determine what actions a person will take at any one time,
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 is very
similar to the stimulus dominance hierarchy referred to in the theory except, as per the theory,
sensory stimuli are also included along with cognitive stimuli in this stimulus dominance
Hilgard proposes two possible means for determining which subsystem will be in the
dominant position of the hierarchy determining which action will take place. One, which he
considers the old way, is where the subsystems would fight for control of the final common
path leading to action according to their relative strengths. The other possible way of
determining dominant position, and the way he seems to have finally leaned towards, is by
way of a central regulatory mechanism. As he puts it, the subsystems
are actuated according to the demands and plans of the central system. This central regulatory
mechanism is responsible for the facilitations and inhibitions that are required to actuate the
subsystem selectively. A hierarchy of subsystems is implied, although it is a shifting hierarchy
under the management of the central mechanism. Once a subsystem has been activated it
continues with a measure of autonomy. (Hilgard, 1977: 217-18)

A New Theory for Understanding and Appreciating the Power of Hypnosis


He then states 'Suggestions from the hypnotist may influence the executive functions
themselves and change the hierarchical arrangement of the subsystem' (p. 218).
According to the original version (Barrios, 1969), the theory leaned more to the old way
of looking at how the subsystems arranged themselves in the hierarchy according to their
individual strengths, 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. But now I also see the possibility of a central function playing a part
in certain situations. This central control function I would describe as the will of the hypnotic
subject, which can be listed as another of the individual differences of hypnotic subjects
which can influence a hypnotic induction, i.e. everyone has a different level of willpower or
free will that they bring with them.
As presented in the paper 'Science in support of religion' (Barrios, 2002), free will is
defined as control over one's involuntary functions (one's subconscious) via the power of
belief, belief in one's ability to control one's destiny (control one's involuntary functions).
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.
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. If the individuals see the
suggestions given as working to their benefit, it would work in favor of a deeper induction. If
against their benefit, it would work against a deeper induction. 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; or if the induction is
presented along the lines of self-hypnosis, i.e. as a means of developing even greater self
control over one's involuntary behaviour. Now with regards to how according to Hilgard, does
the hypnotic induction rearrange the hierarchy of subsystems, Kirsch and Lynn (1998: 110)
feel that Hilgard 'leaves many unanswered questions: How do the hypnotist's words produce
this rearrangement? ... and how does this contribute to the production of suggested
In fairness to Hilgard, I feel he does present at least a partial explanation or answer to
these questions. He posits two ways that hypnosis facilitates this rearrangement of the
hierarchy (Hilgard, 1977):
(I) 'Looked at in other ways, 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, through selective attention and inattention, and through stimulating the
imagination appropriately' (p. 226)

(2) 'The stress on muscular relaxation, familiar in hypnotic inductions assists in disorientation
... The lack of appropriately aroused memories makes the hypnotically responsive person less
critical. To be critical requires comparing a present observation with familiar ones to judge its
veridicality. If the memory context recedes, criticism also recedes. Hence imagination more
readily becomes hallucination ... These illustrations show how memory interference has


Alfred Barrios
helped produce the dissociations found in hypnosis ... Under such circumstances, 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'. (p. 227)

In somewhat different wording, Hilgard is saying the same thing that the theory is saying as
to how and why hypnotic phenomena occur. 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 - something Hilgard does not include in his
explanation. Something else that Hilgard does not include, which the theory does, is how this
inhibitory set referred to is built up during the hypnotic induction through a process of
conditioning. Hilgard does talk about selective attention and inattention (both of which have
inhibitory components) and stimulating the imagination appropriately (i.e. triggering a
cognitive stimulus) as part of the power that words exert through direct suggestion, but he
does not explain why or how the hypnotist's words have become even more powerful after a
hypnotic induction - which the theory explains as the build-up of, or conditioning in, of a
strong inhibitory set.
With regards to the part suggestions of relaxation play in producing the state of hypnosis,
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, 2001: 172). However, the theory makes clear that a hypnotic state
can be produced without any suggestions of relaxation or sleep.

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 Hilgards (and the sociocognitive & response set
perspectives as well). It has to do with the automaticity of most behavior. It appears that all
current theories concur with this apparent fact. One difference is that I have gone on to label
this behavior as subconscious behavior or the subconscious:
The subconscious, or subconscious behavior, 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, if any (i.e. below conscious awareness). Driving a car is an
example of learned subconscious behavior. When first learning to drive, you had to be
aware of (be conscious of) every little movement. Now all the movements have pretty
much become automatic. The subconscious is to be differentiated from the
unconscious which can be defined as engrams or memories below immediate conscious
accessibility. Most adult human behavior falls under the heading of subconscious
behavior. The advantage of subconscious behavior is that it allows us to do many things
at once, and relatively quickly. The main disadvantage is that once programmed in, the
behavior is so automatic that it becomes difficult to change. (Barrios, 2002, p.7)
It is the latter fact, i.e. that certain automatic behaviors are so hard to change, that makes
hypnosis such a valuable tool. Hypnosis provides us a systematic means of controlling the
subconscious, of being able to rearrange the hierarchies of automatic behavior. And the more

A New Theory for Understanding and Appreciating the Power of Hypnosis


deeply imbedded this automatic behavior that we wish to change is (i.e. the higher in the
hierarchy it is), the more effective a hypnotic induction is needed.
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.
The biggest problem with most people is that it is very hard for them to change. So anything
that can facilitate change or re-programming will play a major role in achieving therapeutic
In a way one can say that all humans are automotons because most of their behavior is
automatic. But one major difference between humans and robots is that humans have the
potential (through the free will factor) to reprogram themselves when necessary. Keep in
mind, however, 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.
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. The other way the therapist can help is by providing the patients
with some good guidance, a good idea of what habits and cognitions need to be changed.
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. But if the negative behavior is too high in the
hierarchy for the patients own level of free will (own willpower) to rearrange it, this is when
an effective hypnotic induction can be especially beneficial.

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, 1985, 1997a, 2000). The following will present both the
similarities and the differences.
First, a major difference between the two is that Kirsch believes, as do most sociocognitivists, that 'The induction of hypnosis, for example, has a relatively small effect on the
degree to which people respond to typical hypnotic suggestion' (Kirsch, 2000: 276). As
already pointed out, although this statement might be true for the standard relaxation-type
induction, it is not for other more effective types of hypnotic induction (see: Wilson, 1967;
Wickless and Kirsch, 1989; Kirsch et a1., 1999; and Wickramasekera, 1973).
The second major difference (and similarity) between the two revolves around his use of
the term 'response expectancy'. Kirsch seems to feel that the key to increasing hypnotic
responding is by increasing the subject's response expectancy (see Kirsch 2000: 275).
I would be more inclined to agree with Kirsch if he were to use the term 'belief' in place
of 'response expectancy'. 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'. As Kirsch puts it: 'A
path analysis supported the hypothesis that hypnotic inductions enhance responsiveness by
altering response expectancies' (1985: 1195).
In the original theory I do refer more to 'suggestibility' as to what is being manipulated by
a hypnotic induction. However, I have come to see the term 'suggestibility' as having some
negative connotations, with some people possibly relating it to the term 'gullibility'.


Alfred Barrios

Consequently I now prefer to follow Skinner's lead of using the term 'belief' in describing
hypnosis. As Skinner put it:
With respect to a particular speaker, the behavior of the listener is also a function of what is
called belief (a term very similar to suggestibility) ... our belief in what someone tells us is
similarly a function of, or identical with, our tendency to act upon the verbal stimuli which he
provides. If we have always been successful when responding with respect to his verbal
behavior, our belief will be strong ... Various devices used professionally to increase belief of
a listener (for example by salesmen or therapists) can be analyzed in these terms. The therapist
may begin with a number of statements which are so obviously true that the listener's behavior
is strongly reinforced. Later a strong reaction is obtained to statements which would otherwise
have led to little or no response. Hypnosis is not at the moment very well understood, but it
seems to exemplify a heightened 'belief' in the present sense (Skinner, 1957, pp. 159-160).
(See Barrios, 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. Yes, you can get someone to produce the visible response of 'arm rising' if he has
a strong response expectancy of 'arm rising'. 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.
Next comes the question of how response expectancy or belief produces responses.
Kirsch himself poses the question thusly: 'To accept a suggestion is to believe or expect that
these events will in fact happen. So the real problem is to understand the effects of response
expectancy on experience, behavior and physiology. How does response expectancy produce
these changes?' (Kirsch 2000: 279). (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.)
Kirsch's answer to this question is to posit some underlying substrate or connection
between actual responses and the expectancy of that response. As he puts it, 'if we assume
that there is a physiological substrate for any experiential state, then a change in perception is
always a change in physiology, as well. For that reason, expectancy induced changes in
experience will always be accompanied by at least some physiological change' (Kirsch, 2000:
280). And, 'Just as the expectation of an experiential response tends to generate that response,
so too the expectation of an overt automatic response promotes its occurrence' (p. 280).
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 - see the Pavlov quote on page 167 of the
theory, Barrios 2001); and second, 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.
A third major difference between our perspectives is how we explain how response
expectancy/belief can be increased in hypnotic situations. 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

A New Theory for Understanding and Appreciating the Power of Hypnosis


hypnotic responses; (b) perceptions of the response as being appropriate to the role of a
hypnotized subject ... and (c) judgments of one's hypnotizability. (Kirsch, 1985: 1194)

As for his first two ways (a and b) I agree. These are covered in the theory under the heading
of 'Subjects' expectation' in the section on 'Individual differences factors influencing hypnotic
induction' (see Barrios, 2001: 181-3). It is pointed out that (a) as a result of the expectancy of
being hypnotized, subjects are more likely to ascribe correctly the occurrence of the 'strange'
phenomena to the hypnotist than to some external cause' (p. 182); and (b) 'Subjects'
expectations of what hypnosis is like can influence hypnotic induction in other ways. For
example if the subjects are told that a catalepsy of the dominant hand occurs when they
experience hypnosis (Orne, 1959), then as subjects feel themselves responding, they are also
indirectly being given the suggestion of catalepsy of the dominant hand. This response can, in
turn influence the hypnotic induction, as can any positive responses to previous suggestions'
(p. 183).
With regards to how Kirsch describes methods of affecting response expectancies by
manipulating 'judgments of one's hypnotizability', I differ significantly with Kirsch. 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, 1989: 762), I would directly refer to as an actual hypnotic induction according to
Corollary 6, following Hypothesis III of the theory, which states that surreptitiously provided
feedback would facilitate a hypnotic induction (p. 180).
As indicated on page 171 of the theory, 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. 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.'
It is interesting that Kirsch states that: 'According to response expectancy theory, 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, 1989: 762). 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, he would
be coming very close to saying what is said in Hypothesis III of the theory.

Summary of the above Similarities and Differences

There were a number of similarities and differences presented between the theory and
three current theoretical perspectives. 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; how
both the theory and the Sociocognitive theories seem to fit in with Milton Erickson's strategic
approach to therapy; 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'. 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.
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


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'. And related
to this, the theory, as opposed to these other two perspectives, concludes that there can be
such a thing as a 'hypnotic state' which is significantly different from the 'waking state'.

Support for the Theory

Numerous studies and experiments in support of the theory were presented in the original
publication of the theory (Barrios, 1969). 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). The results supported the three predictions made from the
hypothesis: (a) The hypnosis group (N=43) showed greater conditioning (p<.01) than the
control group (N=42); (b) the amount of conditioning for the hypnotic group was correlated
with hypnotic depth (p<.01); and (c) this conditioned response, once formed, was a strong
one, as evidence by little extinction and the phenomenon of spontaneous recovery. (Barrios,
Further Support for the Theory
Further support for the theory since its original writing (Barrios, 1969) comes from at
least three areas:
(1) studies on the use of subtle sensory reinforcement;
(2) the area of biofeedback; and
(3) studies on sensory deprivation.

Subtle Reinforcement Studies

Corollary 6 following Hypothesis III of the theory states: 'An hypnotic state can be
facilitated if, along with each of the first few suggestions given in a hypnotic induction, the
actual sensory stimuli which would ordinarily evoke these suggested responses accompany
the suggestions without the subject's knowledge.' There are at least three studies whose results
support this corollary. The first was part of a Ph.D dissertation submitted in 1967 (Wilson,
1967), which I did not become aware of until after I had submitted my dissertation. Wilson
had subjects experience surreptitiously provided reinforcement of suggestions. 'After
suggesting that subjects imagine the color red, for example, Wilson imparted a faint red tinge
to the room via a hidden light bulb. Subsequent testing of waking suggestibility on the Barber
Suggestibility Scale (Barber, 1969) revealed substantially higher scores among these subjects
than among controls' (Wickless and Kirsch, 1989: 762).
A subsequent study by Wickless and Kirsch (1989) essentially confirmed Wilson's
findings. They found that 53% of the group that had been given surreptitiously provided
experiential feedback scored as highly hypnotizable as compared to only 6.7% of the control
In a follow-up study Kirsch et al. (1999) found that, once again, surreptitiously provided
experiential feedback significantly increased responsiveness to suggestion. And this time an
additional important fact was determined - 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).

A New Theory for Understanding and Appreciating the Power of Hypnosis


Those subjects that were allowed to detect that the reinforcement was artificial showed no
increase in responsiveness.

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. For the most part, the typical
responses have been relaxation-related such as Galvanic Skin Response (GSR), heart rate,
Electromyography (EMG) and fingertip temperature, although biofeedback need not be
limited to just relaxation responses. 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; for example, slowing the heart rate down or
raising fingertip temperature.
As I see it, the reason biofeedback has proven to be so effective for gaining control of
involuntary physiological responses is that in actuality, subjects being treated with
biofeedback are being put through a form of hypnotic induction as defined by the theory.
Remember, 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, 2001: 17). Suggestions (or goals) of relaxation, whether instigated by the
biofeedback operator or by the subjects themselves, produce initial minute relaxation
responses which are immediately amplified by the device and thus made more visible to the
subject. These act as an immediate reinforcement letting the subjects know that they have
responded positively to the suggestions of relaxation. The resultant heightened belief should
in turn allow the subjects to respond even more strongly to succeeding suggestions of
Although the widespread use of biofeedback devices has been around only since about
the 1970s, 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; for if you stop to think about it, the Chevreul Pendulum is in actuality a biofeedback
device. What the pendulum does is amplify minute ideomotor movements of the hand when
the thought of a particular movement is suggested. 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.g. see Lynn and Sherman, 2000: 202). In fact a complete hypnotic
induction procedure starting with suggestions of movements of the pendulum has been
devised (see pendulum technique in Barrios, 1985: 36-8).
There has been at least one study where the use of autonomic biofeedback did lead to an
increase in suggestibility. Wickramasekera (1973) using forms A and B of the Stanford
Hypnotic Susceptibility Scale found a significant increase (p = 0.001) in suggestibility upon
using EMG biofeedback to reinforce suggestions of relaxation. There is, however, one caveat
to this study. One does not know whether it was the deepened state of relaxation or the use of
biofeedback, or a combination of the two that increased suggestibility. One way to truly test
the hypothesis that the use of biofeedback devices, per se, sans relaxation suggestions, can
increase suggestibility is to not use relaxation suggestions. For instance, one could use a
temperature biofeedback device with suggestions of coldness in the hands (e.g. 'as if you were
placing your hand in cold or ice water') to cause the device to indicate a drop in hand
temperature. One could also use a heart rate biofeedback device to feed back heart rate


Alfred Barrios

increase in response to suggestions of heart rate increase ('as if you were in an athletic

Sensory Deprivation Studies

Corollary 9 following Hypothesis V of the theory states that 'suggestibility should be
increased if sensory stimulation is curtailed'. 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. Also using SHSS forms A and B, Wickramasekera in
two separate studies (1969, 1970) achieved similar results.


The main problem in many hypnosis experiments prior to the publication of the theory
(Barrios, 1969) and very possibly afterwards as well lies in their methodological
shortcomings. This problem was specifically addressed in the above-mentioned study on
testing Hypothesis VII of the theory (Barrios, 1973a):
Several such shortcomings are reviewed below with reference to the way in ' which the
present study attempts to eliminate them. (Shortcomings 1-4 will be familiar to most readers
as those expounded upon recently by Barber [1969b] and Barber and Calverley [1966a].)
1. In many cases there was no comparison with a non-hypnotic control group. In such
studies one could not be sure that presenting the suggestion, without inducing hypnosis might
not have achieved the same results. (This is especially true of the clinical studies.) In the
present study not only was there a non-hypnosis group, but, in addition, each S acted as his
own control.
2. When control Ss were used, the experimental Ss were usually pre-selected for their
high hypnotic susceptibility, whereas controls were not, or, even worse, the controls were
sometimes selected for their poor hypnotic susceptibility. In such cases one could not be sure
that it was the actual hypnotic induction, and not the high initial level of suggestibility of the
experimental Ss, that produced the difference in effect. .
In the present study there was no pre-selection of Ss for hypnotic susceptibility, directly
or indirectly. The standard procedure for recruiting college Ss was followed, and Ss were
randomly assigned to one of the two groups. It should be mentioned that still another often
referred to shortcoming was eliminated by the design - there was no more time or special
attention spent on the hypnotic Ss than on control Ss.
3. In experiments where hypnotic Ss have been used as their own controls it is usually
obvious to these Ss which is the control state. As Barber (1962) points out, these Ss could
ensure a worse performance in the control state, sensing that this is what E expects of them.
This point was also brought out in the study by Scharf and Zamansky (1963). According to
Orne (1959), 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, thus, we might also anticipate they are more likely to do poorer during the control phase

A New Theory for Understanding and Appreciating the Power of Hypnosis


(see also Barber, 1969b). In most hypnosis experiments this may very well be the case since
the "own-control" session is run after the hypnosis session. In the current experiment the
own-control" session was run first for all Ss, and before they even knew hypnosis was to be
4. In experiments where controls have been used, E has not usually controlled for
difference in tone of voice or other subconscious differences in treatment of the groups, thus
possibly biasing the results in favor of his hypothesis. That differences in tone of voice can
have an effect was shown in a study by Barber and Calverley (1964). This shortcoming was
taken care of in the current experiment by the extensive use of tapes.
5. 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 - just performing the response to please the hypnotist. In the
current experiment use was made of the salivary response, a response that is considerably less
subject to voluntary control than most responses previously used in PHS experiments.
6. Controls have usually not been run for the effect of the hypnotic state, per se. Some
might feel that the posthypnotic changes can be produced by just the state itself, rather than
any specific suggestion. This shortcoming was taken care of in the design by means of a
neutral stimulus. If the salivary responses obtained were due solely to the effects of having
been hypnotized, we should find no difference between the response to the conditioned
stimulus and the response to the neutral stimulus. As can be seen by the results, this was not
the case.
7. Perhaps the most prevalent, as well as the most insidious, of the shortcomings is that
the usual indicants of hypnosis are misleading. 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.
(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, when
actually they hold only for the particular hypnotic induction used. For example, 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," and where he
concludes that task motivating instructions (TMI) can produce hypnotic phenomena as
effectively as a hypnotic induction. 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,
operationally-defined band on the hypnosis continuum. Apparently this has not been done
sufficiently, for many have mistakenly interpreted Barber as implying that hypnosis is not as
effective as had previously been thought.
Underlying such overgeneralizations are two basic assumptions, both subject to
questioning. First, there is the assumption that hypnotic responsiveness is a fixed charactertrait, heretofore accepted as fact. Recent studies (e.g., Barber, 1964) seem to indicate that
such an assumption is not justified, and a considerable number of studies indicate that
responsiveness can be increased with improved methods of hypnotic induction (Barber,
1969a; Baykushev, 1969; Dorcus, 1963; Klinger, 1968; Pascal & Salzberg, 1959; Sachs &
Anderson, 1967; Wilson, 1967).


Alfred Barrios

Thus, 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.
The second assumption open to questioning is that hypnotic induction primarily involves
the giving of suggestions of relaxation, drowsiness, and sleep (after S has been properly
motivated and a positive attitude and expectancy toward hypnosis established). According to
the definition of hypnotic induction (discussed later in the paper) given in the theory proposed
by the author (Barrios, 1969), this is just one form of hypnotic induction. Barber's TMI
followed by his test suggestions in ascending order of difficulty would also classify as a
hypnotic induction. Thus, when Barber states that his TMI are just as effective as hypnotic
induction, one should realize that he is merely comparing, the relative effectiveness of two
forms of hypnotic induction.
Thus, 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."
(b) The trouble with the consequent type of indicant is that it is merely a measure of
responsiveness, not increase in responsiveness. 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 - Tl). Using T2 alone as the
indicant can be misleading in a number of ways. For example, a hypnotic induction could be
ineffective and we could still get a high T2 score if Ss were high responders to begin with.
Conversely, a hypnotic induction could be effective but not show up as such if Ss were very
low responders to begin with.


Explaining the Effects of Hallucinogens
One of the benefits of the theory is that it led to my theory on the hallucinogens (Barrios,
1965). 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. These effects are seen as resulting from the hyper-responsive,
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
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. In the controlled state positive suggestions can be properly directed at whatever positive
therapeutic changes are needed. If uncontrolled, the hypersuggestible, hyper-responsive state
can lead to a number of problems. It can lead to uncalled for hallucinations and delusions
which to someone not fully understanding what is going on, not in control, can become quite
frightening. 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

A New Theory for Understanding and Appreciating the Power of Hypnosis


delusions and the (heightened) belief that they would be permanently occurring; the latter
being possibly the main reason for the psychotic state continuing long after the drug effects
wore off.

An Explanation and Possible Cure for Schizophrenia

One may wonder if something very similar to this frightening state of uncontrolled
hypersuggestibility isnt at the bottom of non-drug induced psychotic-breakdowns. One
question that would need to be answered here of course is what could have led to this state of
uncontrolled hypersuggestibility, hyper-responsiveness, in the first place? We know that a
certain percentage of the population is highly suggestible to begin with. (Could this
possibility be because some individuals have a higher concentration of hallucinogenic-type
chemicals in their bloodstream than others? If so, this would fit in with the idea that
schizophrenia is caused by a chemical imbalance.) 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, such as
schizophrenia, could a form of controlled hypersuggestibility (such as hypnosis) be used to
somehow reverse the psychosis; i.e., 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, anxiety or negative thinking. There are
some interesting possibilities here. (See the above mentioned studies by Abrams, 1963 &
1964 and Biddle, 1967 on the successful use of hypnosis in the treatment of psychoses.)
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 negative beliefs underlying her
Maria, a woman in her late thirties, was brought to me by her sister out of desperation.
The woman had been suffering from paranoid schizophrenia for the past three years and she
was getting worse. Her primary symptom was the delusion that people were out to get her.
She had also recently shown signs of being homicidal - having so scared her husband with
very real threats on his life that he moved out.
As with many psychotics, Maria had been put on a drug treatment program and sent
home, even though not cured. The drugs had only served to mask the symptoms, and little had
been done about getting rid of the root cause of her problem. When I saw her, she had stopped
taking the drugs, without approval.
One advantage I had was the fact that I had cured her 27-year-old nephew of heroin
addiction - in a total of only three sessions, incidentally. The all important belief or prestige
factor was thus quite high from the beginning.
The first half of the three-hour session was devoted to getting some idea of the root
causes of her problem. 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.
Judging from her background, I could see why she might have thought this. Coming from
a minority background, she had been conditioned to think of herself as inferior from an early
age. Her subsequent life experience only served to add to this low self-image. She had been a
heroin addict for a good part of her life and had resorted to prostitution as well as dealing in


Alfred Barrios

heroin to support her habit. The latter had resulted in her spending five years in prison, so she
was an ex-con as well. The breakdown had been triggered by a younger sister who, in a fit of
temper, one day threw all this in her face.
How did I cure her in just one session? Using the Pendulum technique (p. 36) I put her
into a state some people refer to as hypnosis, but which I prefer to think of as a state of
increased responsiveness to words. Once she was in this state, I was able to convince her that
she was indeed capable of being loved. I pointed out all her good points and assured her that
her family, and especially her husband, did love her. Others before me had tried to convince
her of this, but to no avail; the words had gone in one ear and out the other. But in this state of
increased responsiveness to words, I was now more able to get through.
Within a week every one of her symptoms hallucinations, delusions, etc. - were gone.
She had gotten back with her husband and was happily looking forward to a trip to San
Francisco with him. 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.
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. Such a feat is considered so
extraordinary that I hesitated mentioning it lest I be labeled a charlatan by my fellow
professionals - for paranoid schizophrenia is a most difficult mental illness to cure. It usually
takes months, even years and many are never cured. 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
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. This is not to say, of course, that all such
problems can be cleared up in just one SPC session. But still, it should take a lot less time and
be more effective than if a standard approach were taken. (Barrios, 1985, pp. 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, cognitive stimuli can be amplified to cause psychotic delusions and
hallucinations, 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, 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.

Explaining the Effectiveness of Biofeedback

As pointed out in Part I, 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.

A New Theory for Understanding and Appreciating the Power of Hypnosis


Helping Towards a More Comprehensive Theory of Learning

We know that dramatic, all-encompassing changes can take place in hypnotherapy,
sometimes overnight. This often means that all the negative habits, 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, 1985, a case of paranoid schizophrenia).
'Understandably, a learning theorist might hesitate before accepting the possibility that it
is a process of conditioning which underlies the dramatic changes produced in hypnotherapy.
One-trial conditioning and functional autonomy are not commonly encountered in the
laboratory' (Barrios, 2001: 196). How is this possible and yet explainable in terms of
principles of conditioning?
First of all, we would have to establish that, as stated in Hypothesis VI of the theory:
'Suggestion leads to behavior change by a form of higher-order conditioning called C-C
conditioning.' This hypothesis is given considerable support by Mowrer's theoretical
formulations on the sentence (a form of suggestion) as a conditioning device (Mowrer, 1960:
141-2, 147).
But we would still have to explain the fact that suggestions are not always readily
accepted, that sentence conditioning does not always take place. As pointed out in the theory
(Barrios, 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. 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. According to Osgood (1963), 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), it will tend to be suppressed ... Since incongruent or incompatible beliefs,
attitudes, perceptions, etc., tend to suppress the cognitive stimuli to be paired, they thus
interfere with the conditioning. Therefore, we hypothesize that anything that would eliminate
such interfering stimuli should facilitate C-C conditioning ... This leads to the part played by
hypnosis in the facilitation of conditioning. Hypnosis, it is felt, provides an especially
effective means (the inhibitory set) whereby interfering stimuli can be readily inhibited.

And this inhibitory set can be so efficient as to have the conditioning take place in only one
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. This
theory states that in order for a response to become extinguished, another incompatible
response must become conditioned to the CS. An implication from this interference theory
would be that if the CR is stronger than a potentially interfering response, the latter will be the
one inhibited. Thus, as long as there is a strong enough CR to begin with, it can keep itself
from being extinguished. (Barrios, 2001: 195)


Alfred Barrios

As implied above in pointing out how the strong inhibitory set aspect of hypnosis can lead to
strong one trial conditioning, we can see how this strong inhibitory set can also lead to
functionally autonomous posthypnotic responses.
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. He considered much of learning to involve the inhibition of what he referred to
as error-producing factors, referred to in the theory as competing stimuli (Barrios, 2001: 195).

Explaining the Placebo Effect

In discussing the broad implications of the definition of hypnotic induction, 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: 171). The question is how? The
section of the theory on prestige helps throw some light on this question:
[T]he statements, commands or suggestions of a person with prestige tend to be questioned
less; that is, such a person evokes a greater inhibitory set to begin with. In general, people
have previously been conditioned to accept at face value the statements of someone who is an
authority in his field. That is, an inhibitory set which inhibits contradictory stimuli has been
previously conditioned (in much the same way as in the hypnotic induction process). This is
so because what the authority says has usually turned out to be true. (Barrios, 2001: 181)

The placebo when given by a doctor or person of authority works in the same way as
hypnotic suggestion, for the person is in a heightened state of belief. For example, when the
doctor gives a patient an injection 'to kill the pain', he is essentially giving the suggestion 'this
is going to ease your pain'. The actual pain relief occurs even if the injection is an inert saline
solution because of two factors associated with suggestion. First, the cognitive stimulus 'pain
relief' with its associated endorphin (the body's natural pain killing substance) release into the
bloodstream. And second, the inhibitory set of the suggestion is evoked that would inhibit
anything that might interfere with the cognitive stimulus, such as any doubts about the
doctor's skills, or doubts about the painkiller's effectiveness, or even the sensory pain stimulus
As another example, when the doctor gives the patient any medicine or treatment that he
says will cure the patient, the cognitive stimulus 'healing' is evoked with its attendant immune
associated response (e.g. release of t-cells, macrophages, etc.).
The next question that needs to be answered is from whence do the cognitive stimuli 'pain
relief' or 'healing' derive their meaning: i.e. 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. As Pavlov (1960: 407) so aptly put it: 'Speech, on account of the
whole preceding life of the adult, is connected up with all the internal and external stimuli
which can reach the cortex, signaling all of them and replacing all of them, 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. 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, 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).

A New Theory for Understanding and Appreciating the Power of Hypnosis


call forth all those reactions of the organism which are normally determined by the actual
stimuli themselves.'
In other words, at some point in a person's life, the words or thought 'pain relief' were
associated with the body's own natural pain relieving endorphin secretion response; and the
word or thought 'healing' was associated with the body's own natural healing response while
the person was experiencing the same.
There, of course, is another way that a placebo response can occur. This would be more
from a form of first-order classical conditioning. For instance, when a person or animal is
injected a number of different times with a pain killing medication, the stimuli associated
with the injection (e.g. the syringe, the person giving the injection, etc.) are the conditioned
stimuli (the CS). The pain relief (the UCR) produced by the actual painkiller, let's say
morphine (the UCS), becomes associated with the CS such that the CS can eventually
produce a conditioned response (CR) of pain relief. This CR can then also be looked upon as
a placebo - in this case produced via first order conditioning. I believe this is what is behind
the conditioning explanation of the placebo response of such researchers as Gliedman, Gantt
and Teitelbaum, 1957; Hernstein, 1962; Knowles, 1963; and Wickramasekera, 1980.
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. 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, and
see that conditioning is also a factor in the 'expectancy' placebo, although higher-order as
opposed to first-order.
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,
the placebo effect increased over the course of 10 extinction trials. This is inconsistent with
classical conditioning, models of placebo-effects, but is consistent with clinical data indicating
that placebo effects can be remarkably persistent. (Kirsch, 1997: p 75)

However, one can see from the previous section 'Helping towards a more comprehensive
theory of learning', how one can establish some fairly strong functionally autonomous
responses via the conditioning power of the belief or response expectancy aspect of placebos.

The Nocebo and Voodoo

Related to the placebo effect are the nocebo and voodoo effects. Just as one can produce
positive health or bodily effects through th power of the placebo where positive expectations
are created, in the same way (i.e., via similar mechanisms as presented above) negative
effects are possible when negative expectations or beliefs are created via the nocebo or


Alfred Barrios

Providing a Natural Explanation for Faith-based Phenomena

In the theory, 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 theory
also provides a natural (as opposed to supernatural) explanation for how the power of
religious faith (belief) is developed. Understanding how this power can affect human
behavior can help provide natural (as opposed to supernatural) explanations for various
religious phenomena.

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, expectations or prophecies. The following are four key examples of such
predicted or suggested outcomes in religion: (1) the fulfillment of religious prophecies; (2)
miracles produced through the powers of the religion's prophet; (3) positive responses to one's
prayers to God; and (4) the positive occurrences in one's life resulting from following the
religion's guidelines.
This would fit right in with Hypothesis III of the theory that states that belief, or response
to a suggestion, is built up if you have a positive response to a previous suggestion.
The following are examples of religious phenomena that the theory helps provide a
natural explanation for.
Demons, 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. As put in the article, 'Science in support of religion: from the
perspective of a behavioral scientist' (Barrios, 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 ... 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'; how it can indeed be possible to be reborn or born again as a result of such
an intense heightened belief experience.
The Phenomenon of Free Will
Religious practitioners tell us that of course we have free will; that God gives us a choice
in life, gives us the power to choose between good and evil, between happiness and misery.
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, again we need to define our terms. As presented in Towards Greater
Freedom and Happiness (Barrios, 1985: 16) free will is defined as the ability to transcend
one's automatic side, one's subconscious, by means of inner speech or thought ... by focusing
sufficiently on the appropriate thought. The key words here are 'by focusing sufficiently on
the appropriate thought'. Not all people have developed the ability to focus on the appropriate
thought when they wish to. Very often, conflicting and opposite thoughts interfere and do not

A New Theory for Understanding and Appreciating the Power of Hypnosis


allow the full positive response ... This is why the belief factor is so important ... Belief is the
key to allowing an individual to tap into his free will potential. Remember, the definition of
belief used herein is: concentration on a thought to the exclusion of anything that would
contradict that thought' (Barrios, 2002: 7 & 8).

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.

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. This includes, for example, the
effect of stress on diseases such as stroke and heart disease (Friedman and Rosenman, 1974)
as well as the effect of the mental state of hopelessness on the immune system and resultant
diseases such as cancer (Cousins, 1989; Temoshok and Dreher, 1993). The following excerpts
from Barrios (2002: 11-16) help present the case for the power of belief and faith to heal the
If we accept the fact that a person's state of mind and lifestyle can play a significant role
in affecting the body, then it should be obvious that anything that can playa major role in
affecting the mind, such as belief and faith, could be a major factor affecting health and well
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, 1996 by Herbert Benson, and the section on placebos in Cousins' book
Head First, 1989) ... However, there is something that needs to be made clear. 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), in order for this temporary improvement to
remain permanent, 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, 1985, pp 124,125 & 154). 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.
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. I worked with


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- PN1) approach
presented in the chapter on cancer in Towards Greater Freedom & Happiness (Barrios,
1985)] and left her with a very strong belief that her body's natural defenses would clear away
the tumor. The tumor did disappear (in fact overnight) much to the astonishment of her doctor
and Jolee did live cancer-free for one more year. However, upon experiencing another similar
emotional upheaval one year after my first and only session with Jolee, the cancer returned
and this time Jolee soon succumbed to it.
The strong belief that she would be cured was apparently sufficient to heal her for one
year. However, in the case of Jolee, the complete SPC-PNI approach (which now also
includes helping the patient make certain necessary lifestyle changes) had not been followed.
(Unfortunately, at this point in time I had not fully realized that belief alone was not enough.)
Because of this, 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, and this
time fatal, emotional upheaval that occurred a year later.
This is in stark contrast to other cancer patients I have worked with where the more
complete SPC-PNI approach was followed. 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, etc.):
Adele Bucanan: As opposed to just one session with Jolee, I saw Adele once a week for
eight weeks. At the time I first saw her, Adele, age 45, was suffering from a fast moving
cancer of the spine, lymph glands, the rib cage and the base of the brain - a metastasis from an
original cancer of the breast. (At this point in time the only treatment she was undergoing was
a very low dosage chemotherapy, as she had had a strong negative reaction to the standard
Because of the extended amount of time with Adele, 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. In particular,
she was able to develop a more assertive personality. 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 now able to stand up to her very dominating and
controlling husband. Six months later the cancer had disappeared in all four areas and three
years after that, when last contacted, Adele was still very much alive.
John Roswick: John had been given radiation treatment for cancer of the tongue.
However, he refused the recommended follow up radical surgery. At this point he discovered
SPC. The following letter was written in August of 1985 upon my request for him to
summarize for me what had happened:

Dear Dr. Barrios,

August 5, 1985

Almost 6 years ago on Oct 19, 1979 1 was told I had cancer of the tongue and had a year
or less to live. I hit the bottom of the pit. I started praying. Knew nothing of God or Jesus,
never read the Bible, but I started. I received 35 massive radiation treatments in the neck. I
said to the doctors am I healed. They said we now have to do surgery. I said, What surgery?

A New Theory for Understanding and Appreciating the Power of Hypnosis


They were going to take out half my neck. I said no. I contacted you in the summer of 1980.
You agreed to see me once a week for 8 or 9 weeks, instructed me on SPC techniques and
other counseling on belief and visualization. I used your garden technique and visualized
myself 'well' on a mountain top. During my first visit with you, you gave me your book
'Towards Greater Freedom and Happiness.' You said: you now have two good books
(meaning yours and the Bible) and told me to read them both. I thank God for you and your
book, you strengthened my belief in what Jesus said in Mark ll:23 ['Believe and all things are
Dr. Barrios, in my opinion your program is bridging the gap between the mind, and the
spirit then the body. Your program SPC was the beginning in my healing, reinforcing my
belief in Jesus teachings, ridding myself of all pent up fear, especially fear, guilt, doubts,
anger, unforgivness, and a bringing together of the Mind, Spirit and Body.
My saliva returned to me during my sessions with you, my voice, and I forgot to mention,
MY TASTER. [After radiation] I couldn't taste anything. The doctors said my saliva would
never be the same, that my taster, taste buds, would be about 50 to 75% returned. Well today I
enjoy full saliva, and full tasting abilities I had before radiation.
It is sad to note that medical doctors dont, or wont advise patients on positive principles
laid down in your book or the bible. I would urge anyone who has an illness of any nature to
seek out the SPC program. It works. It puts you in tune with the real you, the spirit. It has for
me and I know it will for others. I firmly believe you are an instrument of God's. And I thank
him for you. I am not the same person you first met, frightened, confused, oh yes confused!
My condition is healed. Your holistic approach is a blessing."
Pam Roth: When I first started working on Pams case, she had just gone through
chemotherapy and radiation for metastatic breast cancer. She was also having great difficulty
breaking free of a 30 year two pack a day cigarette habit. 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, 1996

As CEO of P.J. Roth & Associates and President of The Public Service News Bureau, I
have had the honor of knowing Dr. Barrios and observing his work since 1983.
Through his SPC approach, Dr. Barrios has developed a program that has allowed people
worldwide to tap into their own personal power to change their health, their happiness and
their lives for the better! He has made the mind/body link accessible and understandable to
the world.
Over the years, I observed the extraordinary development of the clinical applications of
his pioneering theories, and his enormous influence on the American public. At the same
time, I felt it had little to do with me on a personal level. That is until 1992, when I was
diagnosed with metastasic breast cancer. It was then that Dr. 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, my physicians encouraged me to
undergo the most strenuous chemotherapy and radiation; which I did.
At the same time, even faced with my own mortality, I could not summon up the
resources to make necessary changes in my personal lifestyle. In many ways this was not


Alfred Barrios

surprising, after all, 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..
Years of therapy, 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. 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. I was in trouble and I knew it. I had tried
everything including traditional hypnosis but nothing seemed to work.
I was depressed, anxious about the cancer that I was sure was still with me, debilitated by
my treatment and more out of touch than ever with the body that had betrayed me. It was then
that Dr. Barrios stepped back into my life bringing all the benefits of his years of clinical
experience in mind-body health.
Within two sessions, I made the remarkable breakthroughs that years of therapy and prior
hypnosis were unable to achieve! And it was all so easy. Dr. 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.
Within weeks, 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, I
was transformed into a person in touch with and caring for her own physical and emotional
Today, I am a committed ex-smoker, who exercises, eats well and takes care of herself in
every way possible. I am also, according to all tests, cancer free [still free as of October,
2007]. More importantly, 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. In her book, 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, the cancer had eventually spread to his lymph
nodes, chest and lungs. One tumor on his neck had grown so large he was forced to keep his
head at an odd tilt. His doctors told him that even with the best treatment at the time (a
combination of surgery, radiation, cobalt and nitrogen mustard, which he did undergo) he had
only three to four months to live and that he had zero chance of survival. At this point he
sought the help of a psychotherapist who used hypnosis along with traditional psychoanalysis.
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. Within six
months, he had resolved his love problems and gotten married and was ordained as an
Episcopal priest - a lifelong goal. On the very day he was ordained he got the news that his
follow-up x-rays showed no more evidence of cancer. His lymph nodes and lungs were
completely clear. This seeming miracle occurred six months after his original
diagnosis...Today, thirty three years later, Irwin is alive, well and cancer-free. (Temoshok,
1993, p. 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, rather than definitive proof
of the ability to cure cancer by using a mental/spiritual, faith healing, approach. For this
definitive proof we will need larger, controlled studies. In such studies, among other things,

A New Theory for Understanding and Appreciating the Power of Hypnosis


all the important variables can be studied systematically and under scientifically controlled
conditions. For instance, 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. 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. The ideas to be discussed were first presented in a
paper delivered at the 6th International Congress for Hypnosis on 3 July, 1973 in Upsala
Sweden (Barrios, 1973b).
With regards to a proper pre-induction talk, several basic areas that need to be addressed
according to the theory are: (1) eliminating misconceptions regarding hypnosis; (2)
eliminating the fear of losing control; (3) eliminating fear of the unknown; and (4)
minimizing the negative effect of failure.
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. In fact, 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. As for eliminating the fear
of losing control, one can see that by referring to the induction as a means of developing selfprogrammed control, you help the individual see that they will in fact be gaining greater
control rather than losing control.
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 power of thoughts and the power of belief to control automatic responses. The
demonstration of salivating to the thought of biting into a sour lemon is one way to help get
across this point.
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, and therefore it should not bother them if they do not respond to a suggestion.
In such a case they should just wait for the next one.'
As for providing for more effective hypnotic induction techniques, as suggested by the
theory, anything that would ensure a positive response to suggestion would help heighten the
belief factor and thus increase the effectiveness of the hypnotic induction. Several ways of
doing this are recommended by the theory: the use of easy to respond to suggestions to begin
with (see Corollary 5, following Hypothesis III); the use of naturally-occurring responses and
the use of subtle reinforcement of suggested stimuli or responses (see Corollary 6); and the
use of biofeedback devices.


Alfred Barrios

The following are some of the SPC techniques I developed as a result (see Barrios, 1985:
One of the techniques developed by following these guidelines was the already mentioned pendulum technique. 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. First, swinging from left to right is suggested; then swinging in a circle. 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.
This response occurs naturally as the hand slowly begins to bend at the wrist as suggestions
are given that the hand will relax. 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).
The concentration spiral technique (Barrios, 2006) also takes advantage of naturally
occurring phenomena. This technique involves having the subjects looking at a spinning
spiral. 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.
The following suggestions are given: as your mind becomes more and more concentrated, you
will begin to see a fuzziness or waviness in the lines of the spiral; you will see a yellowish
fluorescent-like fringe to the black lines; dark rays will appear to spin off the edge of the disk;
you will feel as if you are riding backwards on a train in a spiral tunnel looking out the rear
window. Throughout, suggestions that the spiral is concentrating the power of the mind
continue to be given. Then, to emphasize this point, 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. This very dramatic effect,
unbeknownst to the subject, is a naturally-occurring effect as a result of looking at the spiral
spinning in a clockwise direction. Of course, as per the theory, by having responded
positively to the series of previous suggestions, the effect is magnified that much more.
To minimize any feelings of deception for the few that may think of the spiral technique
as pure illusion, 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, everything will be seen that much more clearly and strongly (which is true). 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).
Other SPC techniques making use of naturally-occurring phenomena are the light bulb,
the rapid deep breathing, and the hand levitation techniques. In the light bulb technique, use
is made of the after-image produced after staring into a 40-watt light bulb for a short while. 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). Suggestions are also given
that the balloon will begin to float up and the head will also begin to float up. The subject is
told that the latter will occur with each breath they take in. Unbeknownst to the subject, there
is a natural tendency of the head to rise with each breath taken in. (Conversely, 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.) The rapid deep breathing technique (an adaptation of the
hyperventilation method discussed by Kroger, 1977: 77-8) takes advantage of such naturallyoccurring responses to hyperventilation as tingling, light-headedness, greater awareness of
heart beating, etc.

A New Theory for Understanding and Appreciating the Power of Hypnosis


In my adaptation of the hand levitation hypnotic technique, I have the subjects begin by
first pressing the hand as flat as possible against the surface, with the fingers spread as far
apart as possible. I tell them to push down as hard as they can initially. Thus, 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,
thus reinforcing the suggestions.
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.

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, 'The more compatible cognitive stimuli
associated with the response evoked by the suggestion, the stronger the response to the
suggestion'. 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
For example, 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. Compare the effectiveness of (1) just giving the
simple, general, 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, more positive about oneself; and then
having the patients visualize themselves in a number of different typical situations responding
in these more positive ways.
Along the lines of enhancing posthypnotic suggestion with imagery, I have developed
five variations of visualization for effectively programming in one's goals. These include: (1)
the simple projection method; (2) the approximation version; (3) the negative positive
method; (4) the punishment reward method; and (5) the success technique (see Barrios, 1985:
Following along the lines of enhancing posthypnotic suggestion with positive guidance,
the second part of the book Towards Greater Freedom and Happiness (Barrios, 1985: 57196) offers a wide range of positive guidelines to choose from. This includes positive
guidance in the following areas: mental attitudes, emotions, health and education.
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, including a comprehensive guidance component,
led to the development of a general program for helping people achieve self-actualization
which was christened self-programmed control or SPC.
Although Maslow, in defining self-actualization, had done a magnificent job of outlining
the ultimate high goals one should strive for in life (Maslow, 1971), I feel he never really
outlined an effective systematic method of achieving these goals. It is one thing to tell a
person what he needs to strive for to feel more fulfilled in life; it's another to get him to
change in this direction. I feel the SPC program by facilitating change provides this missing
link to achieving self-actualization.


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,
welfare, industry, medicine, and drug rehabilitation.

After my PhD dissertation (Barrios, 1969), I developed a program to help college students (primarily Mexican American) on scholastic probation avoid dropping out. I used a
three-pronged approach (see Barrios, 1973b). The first part consisted of the set of self-hypnosis techniques I had developed from the theory (see the techniques mentioned above).
Soon after the school administration asked me if I could avoid using the term hypnosis
because of all the associated misconceptions. 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.
The main purpose of the SPC techniques was to help the students develop a greater belief
in the power of their minds. This combined with the other two parts of the program leads to a
greater belief in their capabilities. Eight years later, Albert Bandura would coin the term 'selfefficacy' for such belief in one's capabilities. As he at the time so correctly pointed out,
without such a belief, people would not even make the effort to help themselves. Or as he put
it, 'It is hypothesized that expectations [belief] of personal efficacy determine whether coping
behavior will be initiated, how much effort will be expended, and how long it will be
sustained in the face of obstacles and aversive experience' (Bandura, 1977: 191). In a prior
study by Losak (1972), 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.
The second part of the three pronged approach was aimed at helping eliminate any
school- or outside-of-school-related stress/anxiety problems that can also often interfere with
learning and test-taking capabilities. 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. (The book Psycho-Cybernetics [Maltz, 1960] was used initially to
introduce the students to these positive attitudes towards life.) 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, 1995).
The third part of the program, the part especially geared for improving students'
scholastic abilities, was made up of study, problem solving, and test-taking techniques many
of which were taken from Studying Effectively (Wrenn and Larsen, 1955).
Following from the theory, 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. As previously indicated, 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. For instance my invention, the stress control biofeedback card
(originally called the 'Colorimeter') was used to immediately reinforce the relaxation
response. And with regards to the learning skills section, 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; 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

A New Theory for Understanding and Appreciating the Power of Hypnosis


association techniques. 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.
Another source of immediate feedback was the progress reports, a form of journal I asked
the students to keep. 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. At the beginning
of each class meeting I would ask for people to stand up and share any successes they had
already achieved. 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. (See pages 2007 in Barrios, 1985 for examples of these student progress reports.)

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. Bandura (1977: 195200) refers to four basic ways in which self-efficacy can be built: performance
accomplishments, vicarious experience, verbal persuasion and physiological states. 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, to build self-efficacy, include: (1)
the use of the stress control biofeedback card to reinforce the effectiveness of relaxation
techniques in a stressful/anxious situation; (2) the demonstration of the 'numbers' and 'names'
memory techniques as well as the SQ3R studying techniques to instill belief in one's learning
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. 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. They
persuade themselves that if others can do it, they should be able to achieve at least some
improvement in performance' (Bandura 1977: 199). 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.
Verbal persuasion: SPC is of course to a great extent founded on the potential power of
verbal persuasion (in the form of hypnosis). However, although Bandura does acknowledge
that suggestion can influence one's level of efficacy, he tends to downplay it a bit. As
Bandura puts it: 'People are led, through suggestion into believing they can cope successfully
with what has overwhelmed them in the past.' However, Bandura then goes on to say,
Efficacy expectations induced in this manner are also likely to be weaker than those arising
from one's own accomplishments ... In the face of distressing threats and a long history of
failure in coping with them, whatever mastery expectations are induced by suggestion can be
readily extinguished by disconfirming experiences ... Simply informing participants that they


Alfred Barrios
will or will not benefit from treatment does not mean that they necessarily believe what they
are told, especially when it contradicts their other personal experiences. (Bandura, 1977: 198)

Nowhere in his section on verbal persuasion does Bandura bring in the potential usefulness of
hypnosis in making verbal persuasion more effective. But judging from the following
statement of his, it would appear that he should agree that heightening the state of belief(e.g.
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, their prestige,
trustworthiness, expertise, assuredness. The more believable the source of information, the
more likely are efficacy expectations to change' (Bandura 1977: 202).
There is one more important point that Bandura makes regarding the overall effectiveness
of verbal persuasion at building self-efficacy: 'However, 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). This is of course why the SPC program for students also
included giving them effective study, 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, Maltz, 1960).
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. The way he puts it
is to say that self-efficacy level will definitely be affected by emotional or anxiety problems.
'Because high arousal usually debilitates performance, 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).

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 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. 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. During this period the dropout rate for the study
skills only (control) group was 56% (not surprising considering Losak's 1972 finding). The
dropout rate for the SPC class (the experimental group) was 16%. As for the grade points,
there was an average increase of 3.80 grade points for the experimental group and an actual
average 5.45 grade points decrease in the control group (also not surprising to Losak). The
total difference of 9.25 grade points between the two groups was statistically significant at the
0.02 level (Barrios, 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. 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). In those students indicating excess in the following areas
these percentages cut down:

A New Theory for Understanding and Appreciating the Power of Hypnosis



(65 of 90)
(37 of 53)
(48 of 53)
(84 of 102)
(9 of 12)

pills (uppers & downers)


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. No concentrated attack had been made on curtailing excesses. It
is felt to have occurred mainly because of three major changes resulting from the program:
the general increase in the ability to relax; the greater enjoyment of other areas of life; and the
greater amount of self control. Most excesses or addictions can usually be traced to a deficit
in one or more of these areas.
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. Interestingly enough, one of the students benefiting from
this 1972 UCLA class, a former high school dropout prior to taking the class, 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%).

Welfare and Work Incentive Programs

The positive results achieved with incorporating SPC into work incentive programs to
help get people off welfare (see Barrios, 1985: 32, 208, 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. I don't believe this. 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. (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. First the comments of Maria-Luisa
Lopez, CETA instructor in East Los Angeles. She stated that after much searching, 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. 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, or if they did they projected a
negative or insecure attitude and were rejected in many instances. Since SPC exposure,
al1 have acquired a more positive, self-confident attitude which has helped them during
the interviews and subsequently while learning their duties as new employees. Of the 18
trainees I had in my class when I started using SPC, all have found jobs, ten of them
completely on their own - something unheard of before as in the past those who had
found work found it as a result of the Job Developer's efforts. Needless to say, I am
completely sold on the SPC concept. (Barrios, 1985: 32)


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.
Barrios' concepts and techniques, I feel strongly that this is an important part of job training
that has never been previously recognized. CETA can train a person to obtain job skil1s but if
he has no self-confidence, no sense of control over his own destiny, no previous pattern of
success, he has great difficulty getting and holding down a job. It is this strategic area of Dr.
Barrios' course which applies so directly to our CETA trainees. (Barrios, 1985: 209)

One can also see that there could also be a positive use for SPC in industry. Inefficiency
and absenteeism would be diminished; work morale would be higher; there would be a
definite lessening of friction among personnel; there would be considerably fewer stress
problems; absenteeism due to illness would be much less. All these would result in increased
productivity. 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, Health and
Education (Barrios, 1975; see also Barrios, 1985: 209-13):
The SPC class at Rockwell had a total of 11 participants - 3 women and 8 men - from all
levels, including management, and met once a week for two hours for a total of six
weeks. Three simple measures were used to get some idea of the effectiveness of the
program: (1) The Willoughby test (p. 224) before and after, (2) A before and after selfrating of the goals chosen to be worked on by each participant, using a scale of 0 to 10,
and (3) Each participant's own summary of his progress written at the end of the class.
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, the average self
rating went up from 3.36 to 6.80, (see p. 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
Learning Ability
Weight Control
Tension Control

Excessive Drinking

Eternal Youth
Physical Attractiveness
Leadership Ability

Reading through the following summaries of progress (all 11 are included, including the
one failure) will give you a better feel for the type of results achieved. In each case, after the
initials of the participant, I have included the before (B) and after (A) Willoughby percentile.
(The lower the percentile the better.)
J.B. B-62, A-53
Procrastination - Have done one or two extra chores every night instead of putting it off
until there is no time left. This includes paying bills, letters, etc.

A New Theory for Understanding and Appreciating the Power of Hypnosis


Diet & Health - Started doing exercises at home. Have also done pretty well with my
meals. Have already lost a few pounds.
Smoking - Have cut down considerably. Have gone without one as much as four hours at
a time at work where the pressure is the greatest.
Work - Work running more smoothly now. Not as many redo's from frustration or
aggravation and the time element is no longer creating excessive tension.
I am convinced the program works. For years I've read books oriented along these lines,
but this course seemed to show how to accomplish your goals.
E.B. B-60, A-5
This course has been helpful in many ways toward improving my self-image.
My confidence and positive thoughts have strengthened a great amount.
My life is a much happier one which gives off a glow of warm vibrations to others
around me. I'm able to concentrate on a positive thought whenever I desire. Problems, large
or small, at work or at home, no longer pose a threat of failure because I am assured I can
solve any.
Since my self-image has improved, I find that I like myself even more and am able to do
much more than I've done in the past. Now that I realize I have the ability, I know I will be
successful most of the time. I am confident I will accomplish my goals, both short and long
range. Without this course, I wonder where would I be today?
R.O B-30, A-12
I have greatly reduced tension. My sex life has improved considerably and I feel I have a
more positive attitude toward the future. My memory and reading comprehension have
improved. And I am able to shut out outside interference when thinking.
While my problems were not as great as many people, I can see where everyone could
benefit from this course. I feel it was worth the time and money.
A.P. B-89, A-57
I have learned the techniques, I have the tools - now the rest is up to me.
The class has definitely helped me. For instance, no one could have hated a job more than
I did; I despised going to work in the mornings. Now, I really enjoy my job - I don't mind
getting up and going to work. I really like the people I work with now. I just changed my
attitude (after I started the class and started reading Psycho-Cybernetics) and everything
just seemed to shape up.
Also, I have lost 7 lbs. I have started and am continuing an exercise program every day at
noon. Have been running a mile at noon instead of eating lunch. I have something light at
dinner - absolutely no sweets and sweets were my weakness.
So, I will have to say the class has been a success for me. 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 Ill be able to make it).


Alfred Barrios
D.P. B-85, A-52

This has opened my eyes to a lot of little things that are really big. Find myself thinking
clearly again and normal. Also, I've noticed that more done lately in shorter time and with
less effort. I find that I'm now able to get vivid blue on the Stress Card more and more
frequently. I'm definitely going to continue working with this program.
L.P. B-88, A-96 (The one apparent failure)
I do not feel that SPC has helped me a great deal, but who knows what seeds have been
R.P. B-81, A-41
I am convinced now I have made relaxation a habit. I am confident, too, that my new
positive, winning attitude can accomplish the results I need to meet all my realistic goals.
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.
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.
I think an SPC program is absolutely essential in a corporate organization in order to
develop maximum performance and output among its members.
Corporation work programs such as North American Rockwell have impossible
schedules, almost impossible goal requirements and a need for maximum cooperation
between all members. 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. 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.
B.R. B-98, A-93
In the past, under pressure, I'd run. Now I don't. Example - In a night class I am taking I
have noticed a complete change of attitude. Before I would easily become discouraged and be
quick to give up and drop the class. Now I find myself sticking to it and no longer so afraid of
the teacher.
I find that SPC has also helped with my job - because I can keep calm long enough to
learn it. Previously I would be so upset during the learning period it took twice as long. I use
the quick count-down when I get in a tight spot and it seems to help quite a bit. Also, there is
an annoying person whom I work with - I can for the most part, with the countdown, keep my
feelings in control so as not to upset the entire office.

A New Theory for Understanding and Appreciating the Power of Hypnosis


R.R. B-86, A-63

I feel that I have learned the tools to help myself over the past six weeks. I probably
would not have read Psycho-Cybernetics at all. Now that I started the book I feel I will
complete the book within the month.
Before the course I rated myself low in self-confidence and positive thinking.
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. When I think negatively I immediately
disregard the thought and think of a positive thought. I think I have reversed my negative
As far as habits are concerned, I am working on one that has grown since childhood. I
recently have had success in controlling this habit for the first time in approximately 30 years
- three successes in a row. This has helped my ego and my confidence to a great degree.
Also, I had trouble sleeping at times. Now when I go to bed I go through a complete
programming input and relax much more than before, thereby getting to sleep earlier and
more relaxed. As a result I am on time for work and more relaxed during the day. And my
mind is not as cluttered up with negative thoughts and fears during the day. Therefore I am
able to get more work accomplished.
I look forward to working hard on all areas with the tools learned in the class.
P.S. B-68, A-12
Have achieved positive results from the 6 week program; feel that this is only the
beginning. This course gave me the tools, now I must continue to use them to continue the
I was particularly impressed with my ability to remember names. This was always a weak
point with me. 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.
I was quite pleased with the "before" and "after" results of the Willoughby test.
I really "dig" the "positive thought" technique. I use this every day. This is the basis of
Maltz' book [Psycho-Cybernetics] but I didn't really get it until this class. This is the biggest
thing I have learned to date. I now try to concentrate on my successes as much as possible.
A.S. B-82, A-40
I thought the course was well presented. I have obtained positive results in my blood
pressure reduction goal and find I am more relaxed now. I have also made some slight
progress in my weight reduction goal.
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.

One can also see the possibilities of SPC in the area of medicine. Although no study has
been done with the specific purpose of testing the effectiveness of SPC for improving health,
one can see from many of the above reports as well as others scattered throughout the book


Alfred Barrios

[Towards Greater Freedom and Happiness] that SPC can be considerably effective with such
health problems as: high blood pressure, ulcers, arthritis, asthma, pain, headaches, insomnia,
anxiety, depression, smoking, obesity, diabetes, alcoholism, heart disease and cancer.
(Barrios, 1985: 213)

Drug Rehabilitation
As has already been reported, 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.
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. Both
are rehabilitative centers for hard-core drug and alcoholic offenders many of whom had been
sent to prison for drug-related crimes. The types of results achieved are illustrated in the two
letters presented on pages 214-16 of Barrios, 1985.
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. Now I'm a resident at Bridgeback.
For a long time I thought there was no hope. I had been told that once a dope-fiend
always a dope-fiend. Not having too much on the ball, as far as a future, I let this saying make
a nest in my subconscious. Because of this I would not deal with anything. Through the years
I tried several times to break the habit but each time would go back. Well, I finally gave up
and said it's time to get help. I signed up for the Bridgeback Drug Program. 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. So along came Dr. A.A. Barrios. He had a very unique program called SPC (selfprogram control).
At first I just sat in class and didn't get involved, then he started saying things that
sounded good. He said he could change a person's entire life if they got involved. I didn't
believe it at first. So, I said what can I lose.
I started out by using the Spiral Mind Technique. I began getting so involved, I purchased
a kit. Every morning I would use it. Then it started taking effect. The next thing I know I had
no desire whatsoever to use or even be around dope.
Then I had this Mural to paint, 75 feet long and 25 feet high. I just knew I wouldn't finish
it. So I programmed in that I would complete the Mural, and now it's one of the best in the
city of L.A. and I'm always getting recognition for it.
Now, still using Dr. A. A. Barrios' SPC program, I'm enjoying life in a much more
rewarding way. I attend L.A. Business College where I'm studying accounting. Upon
completion, I hope to become an accounting clerk. Next, I applied for a job for the State of
California as a claim's examiner's assistant. My application was accepted. I took the test and I
found it was so easy; it was as if I had taken it before. It's really something to see how these
techniques work. I just know I did well on it because I got under the Spiral that morning.
Oh yes, let me include this in this short story of my changed life-style. My grades in high
school were C's and D's; now they are, believe it or not, A's and B's.
I'm going to close with these last few words. There was this young lady that came to the
program. I saw where I could help her with this new program. She was like me at first,
skeptical; now she's getting involved and she's really doing fine now.

A New Theory for Understanding and Appreciating the Power of Hypnosis


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. First of all Mr. Anderson,
allow me to state that this program, Self-Program Control (SPC), works! It is a truth, in that
by means of it one can be in control of his life and destiny.
Unhealthy habits, such as over-eating, excessive smoking and drinking, 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.
I know this is possible because I've seen the program work not only with me but many others
as well, thanks to being in the SPC class Dr. Barrios taught here this past semester.
At the beginning of the class we were asked if there was anything that we wanted to
focus upon within ourselves. One of the goals I set was to become adept at tension control.
Before utilizing the SPC techniques I experienced headaches often, lost my temper at the drop
of a hat, and underwent mood changes quite frequently (depression, despondency, self-pity,
etc.). Now, as I'm sure you are aware of, my temper and mood variations have displayed
positive movement toward a more balanced equilibrium, and my headaches are almost nonexistent.
In March of this year my husband was incarcerated, and would be away for 18 months.
As a result of this occurrence, I felt afraid and completely alone. I started drinking alcohol
everyday. I'd get off from work, stop at a liquor store and after getting home, would drink
myself into a stupor. During this time I had forgotten about SPC and just about everything
Then one evening after I had taken my first drink, I remembered the SPC 20 to 10
Countdown Technique for relaxation. I went through the technique twice, programmed in the
goal of not having to drink to deal with my fears, insecurities, and poured the pint of bourbon
down the kitchen drain. I felt and continue to feel good about myself!
With the continued usage of the techniques learned through SPC, and reading excerpts
from the book Psycho-Cybernetics by Maxwell Maltz, I became more confident and aware of
my abilities to change and control my life as I deem fit.
In regards to Self-Program Control being incorporated and implemented as an on-going
therapeutic phase of the Uhuru's philosophy, I am strongly in favor of the idea. Not only have
I seen the positive effects of the class on myself and the others taking it, but I have also seen
that we ourselves could very easily teach it to others in turn.
During the last four classes ten clients participated who were from the residential
component. These ten clients were taught SPC by us without Dr. Barrios. We, the class,
introduced to them a few of the SPC techniques that were ideal for tension control and
relaxation. At the end of the very first session, all of the residential clients were very enthused
and expressed a desire to attend and learn more from additional sessions.
At the conclusion of the fourth session, clients were relating to me how they had used the
Deep Breathing Technique to relax and had as a result stopped taking sinnequans, a
tranquilizing medication. Also while participating in the regular intensive grouping sessions,
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. 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. One client especially stated she had gotten so upset one day that


Alfred Barrios

her blood pressure went up high enough for our doctor to feel medication was necessary to
restore it to normal. At this time the client went through the techniques learned in SPC, and as
a result her blood pressure returned to normal without her having to be administered
Each day SPC is being heralded by these ten residents who were fortunate enough to be
included in the SPC class, and they themselves are now teaching the techniques of SPC to
new residents.
These are some of the incidents that lend credence to the benefits that can be acquired
through SPC.
The above letter illustrates once again a major advantage of the SPC program - how easy
it is to teach. Please also note the chain reaction effect. The students I taught in turn taught
the program to ten other residents who in turn started teaching the program to others. Again
this is all in keeping with the "demystification" approach of Ivey and Alshuler (1973) that
says we don't have to be Ph.Ds or so called experts in order to help others. I believe strongly
that we need this chain reaction effect if we are going to help turn this world around in time.
As I alluded to in the beginning of this book, we are currently in a life or death race, ... for at
the phenomenally fast rate at which technology has advanced during the past century, man
now has the means to totally destroy himself, and will unless we can get to him first.
(Barrios, 1985:217)

A significant number of benefits were derived from the theory. These include: (1) a
further understanding of the hallucinogens, schizophrenia & bipolar disorder, biofeedback,
higherorder conditioning, placebos and faith-based phenomena including free will and faith
healing; (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), a positive-oriented behavioral improvement program which
provides a systematic means of achieving self-actualization. Although Maslow (1971) did an
excellent job of introducing the concept, he never really developed a systematic approach to
achieving self-actualization. Key factors in achieving self-actualization in the SPC program
are the greater levels of self-efficacy (Bandura, 1977) and emotional intelligence (Goleman,
1995) achieved. Positive results of SPCs application in a number of important areas were
presented: education; welfare; industry; medicine; and drug rehabilitation. This emphasis on a
positive psychological approach to behavioral improvement fits right in with the current
positive Psychology movement (Seligman, 2005).

Bandura A (1977) Self-Efficacy: Toward a unifying theory of behavioral change.
Psychological Review 84: 191-215.
Barber TX (1969) Hypnosis: A Scientific Approach. New York: Van Nostrand Reinhold.

A New Theory for Understanding and Appreciating the Power of Hypnosis


Barber TX, Calverley DS (1964) Toward a Theory of hypnotic behavior: Effects on

suggestibility of defining suggestion as easy. Journal of Abnormal and Social Psychology
68: 585- 592.
Barber TX, Calverley DS (1969) Multidimensional analysis of hypnotic behavior. Journal
of Abnormal Behavior 74: 209-220.
Barber TX, Spanos NP, Chavez JF (1974) Hypnosis, Imagination, and Human Potentialities.
New York: Pergamon.
Barrios AA (1965) an explanation of the behavioral and therapeutic effects of the
hallucinogens. International Journal of Neuropsychiatry 1: 574-92.
Barrios AA (1969) Toward Understanding the Effectiveness of Hypnotherapy: A Combined
Clinical, Theoretical and Experimental Approach. Doctoral dissertation, University of
California at Los Angeles.
Barrios AA (1970) Hypnotherapy: A Reappraisal. Psychotherapy: Theory, Research and
Practice. 7: 2-7.
Barrios AA (1973a) Posthypnotic suggestion as higher-order conditioning: a methodological
and experimental analysis. The International Journal of Clinical and Experimental
Hypnosis 21: 32-50.
Barrios AA (1973b) Increasing the effectiveness of hypnotic induction. Paper presented at
the VIth International Congress for Hypnosis. July 3 rd, 1973, Upsala, Sweden.
Barrios AA (1973c) Self Programmed Control: A new approach to learning. Proceedings of
the Sixth Annual Conference of the Western College Reading Association. (See also
articles section of www.stresscards.com.)
Barrios AA (1975) Self Programmed Control: Towards Greater health happiness and
productivity. Recreation Management: The Journal of Employee Recreation, Health and
Education, pp, 18-21.Barrios AA (1985) Towards Greater Freedom & Happiness. Los
Angeles, SPC Press.
Barrios AA (2001) A theory of hypnosis based on principles of conditioning and inhibition.
Contemporary Hypnosis 18: 163-203.
Barrios AA (2002) Science in Support of Religion: From the Perspective of a Behavioral
Scientist. Banning, California, Cancer Federation Press. (This article can also be found in
the articles section of www.stresscards.com)
Barrios AA (2006) The Concentration Spiral on DVD. See additional products section,
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.
Contemporary Hypnosis 24: 109-122.
Barrios AA (2007b) Commentary on a theory of hypnosis based on principles of conditioning
and inhibition Part II: Benefits of the theory. Contemporary Hypnosis 24: 123-138.
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characteristics. American Journal of Clinical Hypnosis 5: 163-70.
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Hypnosis and Forms of Indirect Suggestion. New York: Irvington.
Friedman M, Rosenman RH (1974) Type A Behavior and Your Heart. New York: Fawcet
Columbine Books.


Alfred Barrios

Gliedman LH, Gantt, WH, Teitelbaum, HA (1957) Some implications of conditional reflex
studies for placebo research, American Journal of Psychiatry 113: 1103-07.
Goleman D (1995) Emotional Intelligence: Why It Can Matter More Than I.Q. Bantam
Harlow H (1959) Learning set and error factor theory. In Koch, S (Ed.). Psychology: A Study
of a Science. New York, NY: McGraw-Hill; 492-537.
Hernstein R (1962) Placebo effect in the rat. Science 138: 677-8.
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Hilgard ER (1977) Divided Consciousness: Multiple Controls in Human Thought and Action.
New York: Wiley.
Ivey AE, Alshuler AS (1973) An introduction to the field (Psychological Education).
Personnel and Guidance Journal 51: 591-597.
Kirsch I (1985) Response expectancy as a determinant of experience and behavior. American
Psychologist 40: 1189-1202.
Kirsch I (1997a) Response expectancy theory and application: A decennial review. Applied &
Preventative Psychology 6: 69-79.
Kirsch I (1997b) Suggestibility or Hypnosis: What do our scales really measure? The
International Journal of Clinical and Experimental Hypnosis 45: 212-225.
Kirsch I (2000) The response set theory of hypnosis. American Journal of Clinical Hypnosis
42: 274-292.
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Kirsch I, Wickless C, Moffit K (1999) Expectancy and suggestibility: Are the effects of
environmental enhancement due to detection? The International Journal of Clinical and
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Clinical Hypnosis 43: 294-311.
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A New Theory for Understanding and Appreciating the Power of Hypnosis


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Wickramasekera I (1969) The effects of sensory restriction on susceptibility to hypnosis: A
hypothesis, some preliminary data and theoretical speculation. The International Journal
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Wickramasekera I (1970) Effects of sensory restriction on susceptibility to hypnosis. Journal
of Abnormal Psychology 76: 69-75.
Wickramasekera I (1973) Effects of electromyographic feedback on hypnotic susceptibility.
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In: Hypnosis: Theories, Research and Applications

Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456 2009 Nova Science Publishers, Inc.

Chapter 2


Katalin Varga, Emese Jzsa, va I. Bnyai
and Anna C. Gsi-Greguss
Center for Affective Psychology, Etvs Lornd University, Budapest, Hungary

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
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 we compared their
subjective experiences along their scores on the PCI factors. Later we 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. 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. We exemplify the special possibilities of the
interactional approach of phenomenological data by a recent empirical result: we


Katalin Varga, Emese Jzsa, va I. Bnyai et al.

demonstrate the very different pattern of heritability in the case of subjective data as
opposed to the behavioral score of hypnosis. In our 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 we encourage every researcher to follow this interactional
approach and methodology.

Interactional Approach in Hypnosis Research
As Shor noted in 1959, the flesh and blood of hypnosisits multidimensional clinical
richness and variationonly appears when hypnosis is viewed in terms of the dynamic
interrelationships between real people (p. 594). This implies that we cannot really
understand hypnosis on an individual basis; no matter how deeply the subject is investigated,
we miss the real target. Since the early 1980s more and more theoretical and empirical work
emphasize the interactional nature of hypnosis (Diamond, 1984, 1987; Fourie, 1983; Levitt
and Baker, 1983; Nash and Spinler, 1989; Sheehan, 1980), and more and more theories
conceptualise hypnosis as an interactional process, as a social encounter between hypnotist
and subject (see, e.g., the chapters of Bnyai, Lynn and Rhue, Nash and Sheehan in Lynn and
Rhue, 1991).
These theories place particular emphasis on rapport, the special relationship between
the two participants. Interestingly, however, even the very interactional approaches
investigate the hypnotic process from the perspective of the subject, so the hypnotist is just a
participant of the subjects hypnotic dreams (Sheehan and Dolby, 1979) or just the target of
the subjects perceptions, emotions, transference, deprived attachment needs, etc. (see Baker
and Levitt, 1989; Levitt and Baker, 1983; Perry and Sheehan, 1978; Nash, 1991; Nash and
Lynn, 1986; Sheehan, 1980; for a review see Diamond, 1984 or Bnyai, 1991). At the same
time, the social-psychobiological approach (Bnyai, 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, we investigate both of them.
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, i.e.,
not only the subject, but the hypnotist as well. Our empirical research in hypnotic interaction
includes the attitudinal, behavioral, relational, psychophysiological and phenomenological
investigation of the participants (for results on these levels see Bnyai, 1985; Bnyai,
Mszros and Cskay, 1982, 1985; Bnyai, Gsi-Greguss, Vg, Varga, and Horvth, 1990).
We think that, as in the other measures, the phenomenological level of hypnosis also must
and can be investigated in an interactional way.
In this paper we summarize our steps, here providing an archival accounting of our
research on interactional phenomenology. That is why we present our original research data
in detail, serving those who would like to study the subtleties. First we introduce our data on

Patterns of Interactional Harmony


hypnotists phenomenology, as there is no other systematic study about experimental

hypnotists involvement in the process. The subjects subjective experience of hypnosis is not
discussed in detail here because the subjects phenomenology is a classical topic in the
literature described by several authors (Shor, 1962; Field, 1965; Matheson, Shue and Bart,
1989; J. Hilgard, 1979; Pekala and Kumar, 1989; Fromm, 1977; Fromm, Brown, Hurt,
Oberlander, Boxer and Pfeifer, 1981; Fromm, Lombard, Skinner and Kahn, 198788; Eisen
and Fromm, 1983; Kahn, Fromm, Lombard and Sossi, 1989 and so on). 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. Finally, with the help of two examples, we will show the
special possibilities of phenomenological analysis within interactional framework. The details
of the studies summarized in this chapter are introduced in Table 1.
Table 1. Some details of the studies discussed in this paper
TRH (5
hypnotists) or
AAH (2
1st series: waking
control and a
hypnotic part
(SHSS:B) in a
2nd series:
The participants
were hypnotized
twice, first with
the HGSHS:A,
and then later
with the SHSS:C.



Free reports
(PEAT, written or


103 experimental
hypnosis sessions

7 hypnotists
(4 female
and 3 male)

1st series: 12 (5
males and 7
females, 4 high, 4
medium and 4 low)
2nd series: 12 (6
males and 6
females, 4 high, 4
medium and 4 low)
104 students (52
men and 52

2 hypnotists:
1st series) 1
female, 42
years old
2nd series) 1
male, 33
years old)


5 different

PCI after SHSS:C

Varga, Jzsa,
Bnyai, GsiGreguss and
Kumar (2001)

232 healthy
volunteer Ss (168
(=72,4%) females,
64 (=27,5%) males


Varga, Jzsa,
Bnyai, GsiGreguss


110 healthy
volunteer Ss (79
(=71,8%) females,
31(=28,2) males

(in 25% of
the sessions
a male, in
75% female
3 female


Varga, Jzsa,
Bnyai, GsiGreguss

Varga, Bnyai
and GsiGreguss
Varga, Bnyai
and GsiGreguss


Katalin Varga, Emese Jzsa, va I. Bnyai et al.

Table 1. Continued

Free induction,
free analgesia
suggestion, tested
by a standardized
cold pressor test.
Standardized age
regression and
suggestions, free



32 subjects: for
each H 8 young,
healthy volunteer
subjects (4 females,
4 males / 2 highs, 2
mediums, 2 lows
and 2 simulators),
32 subjects

4 hypnotists
(2 females, 2


62 MZ twins, 60
DZ twins, 62
siblings, and 94
parent child pairs,
altogether 278
healthy volunteer


judgement of
hypnosis styles



Bnyai, GsiGreguss,
Tauszik (n.d.)

Varga, Bnyai,
Jzsa and

TRH: traditional relaxational hypnosis. AAH: active alert hypnosis. PEAT: Parallel Experiential
Analysis Technique. PCI: Phenomenology Consciousness Inventory (Pekala, 1982, 1991). DIH:
Dyadic Interactional Harmony Questionnaire (Varga, Jzsa, Bnyai, Gsi-Greguss, 2006). WSGC
Waterloo-Stanford Group Scale of Hypnotic Susceptibility, Form C (Bowers, K. S. 1998).
HGSHS: A Harvard Group Scale of Hypnotic Susceptibility, Form A (Shor and Orne, 1962).
SHSS: A or B Stanford Hypnotic Susceptibility Scale, Form A or B Weitzenhoffer and Hilgard,
1959). SHSS: C, Stanford Hypnotic Susceptibility Scale, Form C (Weitzenhoffer and Hilgard,
1962). Ss: subjects. H: Hypnotist.

In his influential paper, Orne (1959) stated that the real essence of hypnosis lies in the
subjective alterations experienced by hypnotized individuals. 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, 1983; Field, 1965;
Fromm, Brown, Hurt, Oberlander, Boxer, and Pfeifer, 1981; Fromm, Lombard, Skinner and
Kahn, 198788; Kahn, Fromm, Lombard and Sossi, 1989; Lombard, Kahn, and Fromm,
1990). All of these papers obviously were speaking about the hypnotized subject. But to be
truly interactional, one has to investigate both partners in the hypnosis session. That is why
we wanted to first test whether, if hypnotists are really involved in the process of
experimental hypnosis, they would give rich and meaningful phenomenological data about
their experiences.
For a long time hypnotists have been almost completely neglected in hypnosis research.
The question arises: why? At the beginning of the history of hypnosis, the hypnotist

Patterns of Interactional Harmony


(magnetiser) was considered central in the process; later this approach was reversed, because
in 1813 Abbe Faria concluded that the process was more due to the subjects. During the past
decades both hypnosis research and clinical reports stressed the subjects skills rather than the
hypnotists contribution to the process (see Baker, 1987; Frankel, 1987; Fromm, 1987;
Gravitz, 1991; Hilgard, 1987; Lazar and Dempster, 1984).
In spite of these there are excellent works regarding hypnotherapists that describe (a)
their countertransference (Gill and Brenman, 1959, Brown and Fromm, 1986); (b) the
phenomenon of mutual hypnosis, and the possibility of the therapists' trance state (Diamond,
1984; Tart, 1969; Scagnelli, 1980; Vas, 1993); (c) the therapist-patient relationship (Brown
and Fromm, 1986; Gill and Brenman, 1959) and (d) the determinants of a successful
hypnotherapist (Diamond, 1986, Lazar and Dempster, 1984).
But we can find very limited information about the experimenter hypnotist: one cause of
this can be their reluctance to be analysed, and to uncover their own regressive, unconscious
material in a professional setting (Gill and Brenman, 1959; Lazar and Dempster, 1984). This
important limiting factor raises special methodological, motivational and even ethical
Experimenter hypnotists are often regarded as immovable figures, functioning
unflappably according to the protocol of the (standardised) experiment. There is no mention
about the possibility of their emotional involvement, of real transference or
countertransference, of the possibility of leaving the normal, waking state of awareness, etc.
Some influential theoreticians even explicitly deny the possibility of the development of
archaic involvement within an experimental context (Shor, 1962).
Early research data about the hypnotists from our Budapest Hypnosis Laboratory are very
important objective, empirical signs of their deep tuning in to the subject, the signs of
interactional synchrony: hemispheric prevalence influenced by the subject's susceptibility,
synchronous electromyographic activity during hypnotic suggestions (Bnyai, 1985),
changing the duration of the induction procedure (Bnyai, Gsi-Greguss, Vg, Varga, and
Horvth, 1990), deviation from the standardised text (Bnyai, Gsi-Greguss, Vg, Varga,
and Horvth, 1990; Gsi-Greguss, Bnyai, Varga, and Horvth, 1992), mirroring the posture
of the subject, swaying motion of the hypnotists body in synchrony with the subject's
breathing, common breathing rhythm and heart rate concordance between hypnotist and
subject (Bnyai, 1991).
Unfortunately, the subjective, inner feelings of the experimenter hypnotist are almost
completely hidden. Even those, who stress the importance of the investigation of subjective
experiences (Hilgard, 1968; Lynn and Rhue, 1991; Sheehan and McConkey, 1982) restrict
themselves to the subjects phenomenological data, it is quite rare, that the hypnotists
experiences were explored in detail (Bnyai, 1991; Bnyai, Mszros and Cskay 1985;
Varga, Bnyai and Gsi-Greguss, 1991; Varga, Bnyai, Gsi-Greguss, and Horvth, 1992). It
is all the more surprising if we consider that Diamond (1987) emphasised that the relational
dimensions of hypnosis (transference, working alliance, symbiotic/fusional alliance and
realistic relationship) operate subjectively.
So, before attempting to interrelate the subjective feelings of both participants of the
hypnosis interaction, we should know what are their experiences at all.
Free reports from hypnotists. Here we summarize our experimental data about the first
step of collecting and analysing subjective experiences of experimenter hypnotists (see Table
1, for further details Varga, Bnyai and Gsi-Greguss, 1999).To get a systematic view on the


Katalin Varga, Emese Jzsa, va I. Bnyai et al.

hypnotists phenomenology, free subjective reports have been gathered under controlled
experimental setting regarding the most important contents of the subjective experiences of
the experimenter-hypnotists. We were looking for the common topics in the independent
reports of different hypnotists, inducing hypnosis either in a traditional way, or using activealert induction (Bnyai and Hilgard, 1976), supposing that the common elements should
reflect the most important points in the hypnotists' phenomenology in general.
Method. Seven hypnotists' free reports were collected regarding altogether 103
experimental hypnosis sessions in which they conducted hypnosis, either by TRH (5
hypnotists) or by AAH (2 hypnotists). In all of the sessions healthy young volunteers
mostly university studentsof different hypnotizability participated as subjects. The basic
data of hypnotists involved in this experimental series are presented in Table 2. In the cases of
TRH, the Ss were hypnotized by standardized relaxational hypnotic induction procedures and
test suggestions of the Stanford Hypnotic Scales (SHSS: A, B, C, Weitzenhoffer and Hilgard,
1959, 1962) which were read verbatim.
The standardized procedures of AAH sessions applied the active-alert versions of the
test-suggestions (Bnyai and Hilgard, 1976, Bnyai, 1980). The subject and the hypnotist
didn't know each other previously, and the hypnotist was blind to the subjects' susceptibility.
The sessions were video recorded in full length. After the hypnotic sessions all of the
hypnotists gave free reports: an encouraging instruction was given to them, stressing that all
of their impressions, feelings, remarks were important, they were asked to relate anything
regardless of its perceived importance. These reports were video-recorded, then contentanalysed.
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, (2) the subjective feelings reflecting the hypnotist's trance-like state, and (3) the
(counter)transference reactions of the hypnotist (for more detailed results see Varga, GsiGreguss and Bnyai, 1999.)
Table 2. Basic data of hypnotists




0 (SHSS:B)
5 (SHSS:B)
1 (SHSS:B)
12 (SHSS:B)
0 (SHSS:B)
12 (SHSS:B)


After the sex (F: female, M: male) the age and the hypnotizability of the hypnotists are presented
according to the standardised scales (Weitzenhoffer and Hilgard, 1959, /SHSS:B Stanford
Hypnotic Susceptibility Scale, Form B/ Shor and Orne, 1962, /HGSHS: Harvard Group Scale of
Hypnotic Susceptibility/). Finally the orientation of the hypnotist is indicated (E: experimenter C:
clinician, the number of the letters roughly represents the ratio of the involvement in these fields).
The hypnotists No. 15 are the ones who applied traditional relaxational hypnosis, while
hypnotists 6th and 7th were using active alert hypnosis.

Patterns of Interactional Harmony


Verbatim quotations will serve as examples for these features. The origin of the
quotations is indicated by the number of the hypnotist (H) and the subject (S) of the given
session. While reading the quotations please note that the demonstrated phenomena occured
independently from the hypnotizability of the hypnotist, regardless of the way the report is
gathered, and regardless of the professional orientation of the hypnotist.

2.1. 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. Both the subjects (patients) and hypnotists (therapists) faith in the
process play a major role in facilitating success (Diamond, 1986). This inevitably requires
unique attitude and special mood in the hypnosis session. The context-generated expectancies
and the role demands of the situations labeled hypnosis are central elements in the socialpsychological account of hypnosis (Spanos, 1986, Coe and Sarbin, 1977; White, 1941).
Research shows that the way subjects conceptualize the situation of the hypnosis sessionfor
instance, whether they label it as hypnosis or as an experiment on imaginationhas
surprisingly strong influence on their (hypnotic) performance (deGroot, Gwynn and Spanos,
1988; Spanos, Gabora, Jarrett and Gwynn, 1984; Spanos, Kennedy, and Gwynn, 1989).
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, since the hypnotist directly or indirectly
communicates his/her own attitude. 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.

About Hypnosis
TRH (H3, S2) The presence of the observer was calming, 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, and stirred, and kept scratching. It didn't disturb me, I just realized, that
she was simply doing her job, without the feeling, that ... this is something, a kind
of holy, having a special spirit and atmosphere (the observers behaviour) is so
vulgar, compared to the feelings between me and the subject.. that silence and all
devout attention and relationship in which all tiny hair's breadth trembling has its
own significance
AAH (H6 S8/1): ...There is no doubt, the active alert hypnosis seems to change our
energetic matters as well.. extreme energies are involved here.
Interactional Aspects, Togetherness, Mutual Involvement
TRH (H1, S6) the way I say... a completely equal relationship... I mean let's go
together to this state...
AAH (H1 S8/1) she has turned to me many times, searching for my eyes, and it
disturbed me all along, that I had to look at the text. I think she experienced a kind of
loneliness, and it was bad for me, as well, it has destroyed our relationship.


Katalin Varga, Emese Jzsa, va I. Bnyai et al.

Professional Remarks
TRH (H2, S5) I feel this is very important... in the introduction as a matter of fact, we
repeat the conditions: to co-operate, to concentrate, and just to listen to my
voicethis is the repetition of the rapport....If she stands this without uneasiness, she
will accept the situation!
AAH (H6, S2/1) ...during hypnosis you get the feedback from the face, the posture, the
spinning of the pedal...and you can feel where we are...

2.2. Signs of Alteration of State of Consciousness

The concept of the hypnotized subjects trance state is fundamental in the neodissociation
theory (Hilgard, 1976, 1977/79), and an important element in the state or special process
theories either as causal variable, or just characteristic of the hypnotized person. The
possibility that the other participant of the dyadi.e. the hypnotistmay get into an altered
state of awareness is well documented regarding clinical hypnosis sessions: mutual hypnosis
(Tart, 1969), counter-trance (Vas, 1993), the client as hypnotist hypnotizing the therapist
(Diamond, 1980) and related phenomena have both theoretical and practical significance. But
these studies present this issue as specific for therapeutic sessions and suppose that it is
unlikely to occur in experimental hypnosis. As most hypnotherapist spontaneously
experiences trance when hypnotizing their clients (Diamond, 1984, p. 9.), 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,
1984, 1987).
We think and support by quotations below that the characteristics of trance(like) states
(Ludwig, 1972, 1983) can be documented in experimental hypnotists reports as well. 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. This
subjective element is easily available for the person so s/he can identify this state without
doubt. Many theoriesin spite of the methodological controversiespostulate, that the best
index of an ASC is the persons subjective experience of being in the state (Farthing, 1992;
Haley, 1958; Pekala, Steinberg, and Kumar, 1986; Pekala and Kumar, 1989, Tart, 1972, etc.)
TRH (H1, S10) The rumbling in my stomach was due to relaxation ... it was extremely
good, that I could relax... (...) this arose from her, because why would I relax in a
situation, like this?
AAH (H6, S2/1) When I hypnotize I am at least as hypnotized as the subject.
TRH (H1, S2) Look, I say things like this completely out of my control... I was not
aware of this at all...
AAH (H7 S1/1) (arm rigidity suggestion) I simply had to raise up my arm, I dont know
why...(...) meanwhile once Ive tried to let it down, but it didnt went. I felt that this is
good, so I also do together with him up to the end.
TRH (H5, S10) It is difficult to put my experience into words, because there are mostly
pictures inside me....When I entered my first impression was that this man exists just
inside of his skin (...) I had an image of a man sitting cross-legged...in rather

Patterns of Interactional Harmony


primitive circumstances ...the life goes on. And he is sitting there so calmly, because
the inside of him is lively, colourful, joyful, changing, strange, surprising, mystic.
AAH (H6, S2/1) When I hypnotize, at the dream suggestion, my fantasy begins to work,
I start to dream...
TRH Q (H5, S9) Sometimes I feltthat we were definitely together...feel
togethermaybe it was me, who felt it, but I think she also felt this kind of easiness,
those kinds of effects of the suggestions that I myself felt, what I wanted to get.
AAH Q (H6, S2/1) When I hypnotize, my arm gets heavy firstat the arm rigidity I feel
that my arm is rigid and stiff, in spite of the fact that I am the one who gives the
TRH Q (H1, S1) At this moment I had a feeling in my bodyit was a strange feeling:
don't go further!... as if I entered a circle, and I felt: Backward! It is too quick for
AAH Q (H7 S1/1) ...I had a completely pleasant feeling... throughout from now... it was
comfortable for me...it was very good for meso it was enjoyable to read in this
strange hypnosis.
TRH Q (H1, S9) I definitely remember that I had something in my mind at this point,
but I don't remember what...I have no idea.
AAH Q (H7 S1/1) I was not sure even that he had said 21 years (actually it was half
minute earlier), and it is very difficult for me to remember what they saythe
numbers....The hypnosis is difficult at these times, surely....
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, 1984, p. 32) or as the hidden wish to satisfy his regressive longings (Gill and
Brenman, 1959) and related dynamic/analytic concepts. The signs of ASC are possibly the
natural consequences of the setting of hypnosis and the role of hypnotizing itself.
Hypnotist focuses upon the subtleties of communication, because the message must have
the form that would be most conductive to the subject's frame of reference or awareness (e.g.,
trance state) (Diamond, 1986, p.239.). The intensive concentration, the extremely detailed
observation of the subject and absorbed attention are all factors that may lead to ASC, and
may evoke greater sensitivity to and feeling of intimacy (Lazar and Dempster, 1984, p.32.)
with the subject. To reach this, the hypnotist usually moves from the normal state of
awareness to get closer to the subjects state. Usually deep, physical-body involvement may
help the hypnotist to bridge the gap between himself or herself and the patient (Bnyai, 1991;
Bnyai, Gsi-Greguss, Vg, Varga, and Horvth, 1990; Diamond, 1987).
We can not forget, thought, that parallel with these alterations in cognitive functioning
the hypnotist must keep control and takes responsibility of the whole process. This
requirement involves dissociation on his/her part: at least one subsystem must keep the
functions of reality-testing, planning and monitoring. It is needless to stress, again, that the
notion of dissociation had been reserved for the subjects so far.
In his writings Diamond strongly stresses (1984, 1986, 1987) the therapists trance as one
contribution of hypnotherapists in their clinical practice. This facilitates the ability to be
empathic with and receptive to the patient (Diamond, 1986, p. 243), which in turn facilitates
the therapists ability to employ a language appropriate to the patients operative state of
consciousness (p.244.)


Katalin Varga, Emese Jzsa, va I. Bnyai et al.

Others (Hammond, 1991) also discuss the possibility of going into a trance oneself, and
simply trusting the unconscious to formulate suggestions and conduct hypnotherapy (p.
38.), Enhanced receptivity and empathy are obviously important in experimental settings as
well, and the issue of appropriate language is especially interesting in the experimental
context. The nature of the message exchanged between the hypnotist and subject is always
determined in the hypnotic context (Haley, 1958), but consider, that almost all controlled
experiments employ standardized, verbatim inductions and suggestions. The experimenterhypnotists' ASC may urge them to use a language according to the demands of their own
trance states instead of the standard protocol. The restrictions of the standardized text may
increase the inner tension (dissociation) in the hypnotists, which leads them at a certain point
to break the rule. This way the amount and type of departure from the standardized text and
changes in affective prosody (Gsi-Greguss, Bnyai, Varga, and Horvth, 1992; GsiGreguss, Bnyai and Varga, 1996; Gsi-Greguss, 2002; Gsi-Greguss, Bnyai, Jzsa, SuhaiHodsz and Varga, 2004) may be one of the objective indices of hypnotists trance states.

2.3. Transference on the Part of the Hypnotist

An experimental hypnosis session is a very special situation: two persons, formerly
complete strangers, meet for the first time in their lives, enter an interactional process where
the ways they seat themselves (proxemic), the way they communicate and distribute
information-channels (one with closed eye, other influencing by mere words) is very special,
they must reach a predetermined goal under limited time with special means, and the whole
process is recorded under very detailed observation.
The relationship between hypnotist and subject is most commonly approached by the
process of transference, or archaic involvement (Horvth, Bnyai, Varga, Gsi-Greguss, and
Vg, 1988; Nash, 1991, Nash and Spinler, 1989; Sheehan, 1980). In this intense, sometimes
embarrassing situation it is natural to re-evoke earlier relationship-patterns and find one's way
in the situation by their help. Our result showed that usually an accidental physical
resemblance to some relatives or other important persons in the hypnotists life evokes the
transferential feelings. Our material yielded rich data on this respect:
TRH (H4, S9) As she got relaxed her mouth curved down, and it made her awfully
antipathetic. Her face became so aggressive. It disturbed me! She reminded me of the
secretary of Dr. K. (K: a head of another department).
TRH (H5, S4) She is a kind of woman whose eyes are worth looking into for a long...
long time... yes ... The one whom you snap up into your arms willingly...her body as
well... If... (deep breath and coughing, and turning to other topic).
AAH (H2 S8/1) I like so much these type of persons... this very clever, very
intelligent, and somehow very good type of menI really like...All in all, this Rita
is a really nice girl.
AAH (H6, S2/1) She was a sweet little girl...she stole her way into my heart, really,...I
take a shine to these kind of girls...It was like playing.

Patterns of Interactional Harmony


Wachtels comment on transference is especially relevant here: (transference is) a

particular way of organising new stimulus input, based, but not completely unresponsive to
the actual situation (Wachtel, 1973, p.328, emphasis added).
Brown and Fromm (1986) defines countertransference as a situation, where the
therapists sometimes look at patients through the distorting lenses of the past. They may feel
for and about certain patients, and react to them, as if these patients were important figures
from their own past (Brown and Fromm, 1986, p. 215). These occasions are supposed to be
dangerous for the success of the therapy, even the transfer of the patient to another therapist is
suggested (Lazar and Dempster, 1984; Brown and Fromm, 1986).
In our view, the above examples match this, and other definitions of (counter)
transference: e.g. 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, 1979,
p. 573).
In this case, though, 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, well
controlled situations? What if one of the most important features of the hypnotists'
involvementthat is (counter)transferenceremains uncontrolled, or undetected? (b) As
almost all of our experimental settings showed the signs of some types of
(counter)transferential feelings, one hypothesizes that this phenomenon must be more
frequent in clinical settings as well. If this is true, it is rather a natural phenomenon than an
unwanted side-effect to be minimised. Close analysis of the countertransference reactions in
experimental context may help to differentiate the helpful countertransferenceas a way for
being in tune with the various aspects of the patient's personalityfrom those of
antitherapeutic ones (see Diamond, 1987 about this distinction).
Clearly, 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, 1962) so as to be able to gain the most from the benefits of the functions of the
dissociation (Ludwig, 1983).

By demonstrating that even experimenter hypnotists have rich and important
phenomenological data, we had to develop appropriate methodologies for recording
phenomenological data in interactional approach. We wanted to enrich the research arsenal by
methods that are suitable for both the subjects and for the hypnotists.

3.1. Parallel Experiential Analysis Technique (PEAT)

Sheehan and his colleagues (Sheehan, McConkey and Cross, 1978; Sheehan and
McConkey, 1982; Sheehan, 198283) developed the Experiential Analysis Technique (EAT)


Katalin Varga, Emese Jzsa, va I. Bnyai et al.

for gathering data on hypnotic subjects' phenomenological experiences. 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. In this situation an
independent inquirer listens to the subjects reports (for details of the original procedure see
Sheehan and McConkey, 1982).
Our interactional approach required to extend this procedure to the hypnotist. The new
method, called Parallel Experiential Analysis Technique (PEAT) has been described in
details in Varga, Bnyai and Gsi-Greguss (1994), here we restrict ourselves to the most
important methodological points, and some of the preliminary results that later proved to be
relevant (see Table 1 and Figure 1).

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. Althought we did not compare
this kind of picture systematically to a recording where only the subject is seen, we have the
feeling that the dyadic picture elicit more comments on the partner. Unfortunately, even the
most comprehensive report on EAT (Sheehan and McConkey, 1982) misses to mention who
is (or who are?) seen in the video picture used (subject alone or together with the hypnotist?).
It is better to use two inquirers interviewing the subject and the hypnotist simultaneously
but separately, immediately after the session: in this case both S and H can give fresh and
spontaneous remarks. It would be very tiring for one inquirer to listen to the reports of both S
and H one after the other, and a single inquirer may mediate between the two reports, biasing
the second by losing his/her independence.
The problem arises however, that the difference in the two separate inquirers' style and
personality may result different influences on the reports. 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), but this effect was observed
only in the case of subjects. Nevertheless, it is advisable to work with inquirers who share as
many characteristics (age, gender, hypnotic susceptibility, and so on) as it is possible, in order
to reduce the possibility of such differences seen above.
Parting the Participants of Hypnotic Interaction
After the hypnosis session the hypnotist briefly described the importance of the
registration of subjective experiences, and reasoned that the subject would be interviewed by
an independent person, whom s/he introduced by telling his/her name and affiliation, and
leaved the subject alone in the chamber. The whole parting ceremony of hypnotist and
subject was standardized. When the independent inquirer came in to interview the subject, the
same instruction and procedure was applied as those used by the original EAT method (see
Sheehan and McConkey, 1982).
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.
This parting leads both of them to a situation where they are supposed to give honest and
deep reports on their feelings. Apart from clinical evidence, experimental research (Bnyai,

Patterns of Interactional Harmony


1991) also shows that very strong emotional bonds may develop between hypnotist and
subject, sometimes reaching the deep archaic layers of their personality. Tearing them from
this relationship and asking them to report on the hypnosis session is a problematic point,
even in the original form of EAT (where only the subjects are involved). That is why it is
crucial that before parting, the hypnotist should put trust in the inquirer, and should briefly
explain the scientific importance of the independent way of discussing subjective feelings.
Furthermore this problem is connected to the hypnotizability of the subjects: the higher is
the susceptibility of the S, the stronger is the observable bond to the hypnotist (Nash and
Spinler, 1989): so parting with the hypnotist immediately before the (P)EAT session doesn't
exert equal effect on subjects of different hypnotizability.

The Hypnotist's Report

It is equallyif not moreimportant to make every effort to help the hypnotist too, to
give a detailed report about his/her experiences. In our experiments the PEAT session with
the hypnotist took place in the same or in a very similar experimental chamber, as the
hypnosis session or the PEAT session with the subjects. It is of vital importance to give an
encouraging instruction to the hypnotist as well. 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. In our experiments the hypnotists during
PEAT occasionally turned to very intimate, ego-involved topics, and sometimes the report
was given in a high emotional tone. It may be difficult for the inquirers to handle these
situations: to be empathic, but not deeply involved, and to remain within the strict
experimental conditions determined for them in this method.
Data Analysis
The subjective experiences related by the subjects and by the hypnotist were content
analysed separately. A category system (of about 90 categories) covering the topics and
features of the reports was developed to analyse the experiences. The main groups of
categories were as follows:

attitudes to and preconceptions and/or knowledge about hypnosis;

situational and contextual factors;
signs of alteration of consciousness;
remarks on relational and emotional experiences;
comparison with other states of awareness (waking, sleeping, etc.);
ego-involving experiences;
general evaluation of the state or of process.

One can follow several ways when comparing the independent reports of subject and

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,


Katalin Varga, Emese Jzsa, va I. Bnyai et al.

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, and discrepancies or
concordances can be discovered in the timing of comparable features in the two participants'

1. Original hypnosis interaction, recorded.

2. Reports of hypnotist and subject separately, in the presence of independent inquirers (I1 and I2),
stimulated by the video recordings taken in step 1.
3. Data analysis: comparing the independent reports by viewing it simultaneously on two monitors. The
rater may look for thematic concordances, or judge the degree of harmony between the reports.
Figure 1. Steps of PEAT.

Below three points (A, B, C) will illustrate the interactional nature of PEAT by
demonstrating some connections between the subjective reports of the subject and that of the
A. Thematic concordances:
In the course of analyzing our records, we realized that if we follow the video
recordings of the two reports simultaneouslyfor instance, on two monitorswe
can detect characteristic changes in the degree of harmony between them. In some
parts the hypnotist's and the subject's reports conflicted with each other, but there
were points where the independent reports were in very high concordance. In these
latter cases the two people commented on the events in the same way, they
sometimes used the same expressions or metaphors describing their feelings and
experiences, the color tone of their imagery scenes was the same, and so on. The
agreement between the reports is sometimes striking.
Some verbatim quotations exemplify these concordances:

Patterns of Interactional Harmony


a) Commenting the same part of the session, the subject said:

...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...
Hypnotist: I felt that he would like to go on enjoying this hypnosis.
c) Subject: At this point there was something like sunshine, with a beautiful calm
Hypnotist: At the moment a nice warm feeling spread over my body.
It is important to underline that these points of concordance cannot be attributed
to the observation of obvious behavioral features (e.g., smiling). As in PEAT the
participants of the hypnosis interaction relate their experiences and feelings, and
comment on the events of the hypnotic session completely independent of each other,
it is very interesting to find that these independent reports still match each other. We
postulated that in most of the cases the points of concordance indicate a deep
attunement between the hypnotist and subject, where they have common subjective
feelings and associations, and their reports indicate a very fine harmony of their
experiences. This phenomenon can be considered as another sign or example of
interactional synchrony, apart from those that were described in other levels of the
investigation, e.g. joint movements and posture mirroring in overt behavioral level,
or the common breathing rhythm and parallel myographic activity at the
physiological level (Bnyai Mszros and Cskay, 1982, 1985; Bnyai, 1985;
Bnyai, 1991).
B. According to our analysis of different levels of the hypnosis sessions, 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, while
the hypnotist in the second series remained at a more analytic, cognitive level, using
his cognition instead of his body. These styles were labelled as physical-organic
and analytic-cognitive, respectively.
This analysis was one of the first studies where the various working styles of
hypnotists have been described. Later on a detailed description and
operationalization of hypnosis styles has been published (for detailed description of
these styles see Bnyai, Gsi-Greguss, Vg, Varga and Horvth, 1990; Bnyai,
1991; Bnyai, 1998; Bnyai, 2002; Varga, Bnyai, Jzsa and Gsi-Greguss, 2008).
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, with the amount of the so called common breathing rhythm
and pulsation (r=.53, p<.10): that is, with the time ratio of the matching of breathing
rhythm of the hypnotist and subject during the hypnosis session. This connection was
even stronger with low hypnotizable subjects (r=.96, p<.05).
In the 2nd series, however, the same category in the subjects' reports - referring
to their positive relationship with the hypnotist - was closely connected to those
contents of the hypnotist's reports, which indicate his cognitive style: these were: (1)


Katalin Varga, Emese Jzsa, va I. Bnyai et al.

the amount of interpretation (r=.75, p<.01), (2) the comments on his strategy in
hypnosis (r=.65, p<.05), and (3) the professional statements category (r=.60,
C. 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=.68, p< .02), with the
total number of positive comments of the hypnotist (r=.81, p< .01), and with the
general good feelings of the hypnotist (r=.63, p<.05). In sharp contrast with these
correlations, none of these categories of the hypnotist of 2nd series correlated
significantly with the subjects above mentioned category. So, the intercorrelation of
the participants' subjective experiences shows a very different pattern in the two

3.2. Five-score Version of the Phenomenology of Consciousness Inventory

The Phenomenology of Consciousness Inventory is a paper and pencil test with 53 items,
measuring the subjective alteration of consciousness on 26 dimensions (PCI, Pekala, 1980,
1982, 1991ab; Pekala, Steinberg and Kumar, 1986): Altered Experience (Body image, Time
sense, Perception, Meaning), Positive Affect (Joy, Sexual Excitement, Love), Negative Affect
(Anger, Sadness, Fear), Attention (Direction, Concentration), Imagery (Amount, Vividness),
Self Awareness, Altered Awareness, Arousal, Rationality, Volitional Control, Memory,
Internal Dialogue. PCI is suitable to map phenomenological states by having subjects
complete it in reference to a preceding stimulus condition. The Hungarian version was
validated by Szab (1989; see also Szab, 1993).
As our earlier data proved that experimenter hypnotists free reports contain many details
regarding their own alteration of state of consciousness, PCI seemed to be a good paper and
pencil test to tap this aspect. Especially, as the PCI have been used in wide variety of stimulus
conditions (such as progressive relaxation and deep abdominal breathing (Pekala and Forbes,
1988), out-of-the-body experience (Maitz and Pekala, 1991), drumming and trance postures
(Maurer, Kumar, Pekala, and Woodside, 1997; Woodside, Kumar, and Pekala, 1997), and
firewalking (Pekala and Ersek, 199293) it was just one step to have hypnotists complete the
Phenomenology of Consciousness Inventory as well, to score their own feelings and
experiences, in reference to the preceding hypnotizing period.
But originally PCI has no final score; it gives 26 scores on the above mentioned scales
and subscales. This makes it a bit difficult to use it in relation to other measures. The
difficulty is even grater in the interactional approach, where the scores of both participants are
taken into consideration.
Kumar, Pekala and Cummings (1996) reported a five factor scoring method of PCI,
where only five scores characterize the phenomenological state of a person. 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, Pekala and Cummings, 1996).
Our results are consistent with those of Kumar, Pekala and McCloskey (1999), in that the
factors of dissociative control, positive affect, and attention to internal processes were

Patterns of Interactional Harmony


significantly correlated (p < .001) with the SHSS:C score, even though there were
methodological differences between the two studies. That is, 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), or when the PCI was completed in
reference to the entire scale (as was done in our later study).
The confirmatory factor analysis on the Hungarian data revealed a reasonably good fit for
the factor model found by Kumar, Pekala and Cummings (1996). 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, for further details Varga, Jzsa, Bnyai, Gsi-Greguss and Kumar, 2001).
So, on the basis of these results we included PCI to our research arsenal. Both for
hypnotists and subjects we calculate five scores, as defined below:
1. Dissociative control: Higher factor scores reflect alterations in (a) trance effects
associated with altered state of awareness and altered experiences (body image, time
sense, perception, visual imagery, and meaning) and (b) ego-executive functioning
(Fromm, Brown, Hurt, Oberlander, Boxer and Pfeifer, 1981) and reality orientation
associated with decreases in memory, rationality, volitional control, and internal
dialogue (i.e., the classic suggestion effect, Weitzenhoffer, 1978; Bowers, 1981,
1992). In an earlier study, Spinhoven, Vanderlinden, Ter Kuile and Linssen (1993)
had found two factors, 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, 1975). According to Kumar, Pekala and Cummings
(1996), the dissociated control factor combines Spinhoven et al.s two factors into
one factor.
2. Positive affect: Higher factor scores reflect more joy, more sexual excitement, more
love, altered meaning, altered body image, and altered perception.
3. Negative affect: Higher factor scores reflect more anger, sadness, fear, and arousal,
but low rationality.
4. Visual imagery: Higher factor scores reflect more visual imagery (amount and
5. Attention to internal processes: Higher scores reflect greater alterations in time sense
and perception, greater absorption, inward directed attention, altered state of
awareness, internal dialogue, and low imagery vividness.

3.3. Development, 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, Jzsa, Bnyai and Gsi-Greguss, 2006; see Appendix 1). The most important
characteristic of this measure is its direct focus on the interaction itself, evaluated by the
participants of the interaction themselves.
The main motive for the development of this questionnaire was to get a measure that is:
a) short and simple; b) easily applicable for parallel processing of the data; c) not specific for


Katalin Varga, Emese Jzsa, va I. Bnyai et al.

hypnotic interactions; d) not restricted to experimental hypnosis sessions, but provides

clinically meaningful data as well; e) suitable to characterize the degree and pattern of
harmony between the interacting participants.
DIH lists 50 items: nouns and adjectives that are characteristic of various kinds if dyadic
interactions. The interactants independently fill in the questionnaire indicating how much
each feature characterized their recent interaction on a Likert-type scale, from 1 (not at all) to
5 (completely).
The Hungarian version of DIH was standardized in a sample of 256 subjects (Varga,
Bnyai, Gsi-Greguss, 1999), who were interacting in pairs in a non-hypnotic setting in a so
called mutual Rorschach test situation (for the test see Engelbrecht, Arnold and Eraschky,
1987 and Loveland, Wynne and Singer, 1963). 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. The standardization DIH data of Mutual Rorschach situation
were factor analyzed, using iterated principle factor analysis with varimax rotation. Four
factors were obtained, accounting for 72% of the common variance. On the basis of these
factors, four subscales were created (3 positive and 1 negative), each having good internal
consistency: 1. Intimacy (items like passion, love. Cronbach alpha: 0.85), 2. Communion
(items like understanding, harmony. Cronbach alpha: 0.86), 3. Playfulness (items like
humour, inspiring. Cronbach alpha: 0.81), 4. Tension (items like anxiety, fear. Cronbach
alpha: 0.78). The cumulative explanatory values of these factors are: 42, 58, 66 and 72%
respectively. Appendix 2. shows the data of factoranalysis of DIH.
Of course after standardization we applied DIH to hypnosis sessions as well. At first data
were collected on 232 subjects in standardized individual (E1: Stanford Hypnotic
Susceptibility Scale, Form A, SHSS: A, Weitzenhoffer and Hilgard, 1959) and 110 subjects
in standardized group hypnotic sessions (E2: standardized protocol of Waterloo-Stanford
Group Scale of Hypnotic Susceptibility, Form C, WSGC, Bowers, 1998), where other
measures of hypnosis (e.g. hypnotic susceptibility, PCI) were applied to validate the DIH
subscales on a hypnotic sample. In case of the individual sessions (E1) the measures were
applied for the hypnotists (Hs) as well. The hypnotist (H) and the subject (S) completed the
questionnaires independently.
The four subscales had good internal consistency in this hypnotic sample as well, as their
Cronbach alpha values ranged from 0.77 to 0.92.
The subscales of DIH are not independent from each other (as can be seen in Table 3), as
it was the case in the original standardization sample as well.
Table 3. Correlations of DIH subscales (data of the subjects)



* p < .05; ** p < .01

E1+E2 E1
E1+E2 E1
(N=106) (N=337) (N=231) (N=106) (N=337) (N=231) (N=106) (N=337)
0.69** 0.57**
0.65** 0.62**
-0.28** -0.06

0.53** 0.63** 0.59** 1,00
-0.29** -0.41** -0.31** -0.17** -0.43** -0.25**

Patterns of Interactional Harmony


Table 4. Correlations of the DIH subscales with the other tests in E1









DIH Scores of the hypnotist



DIH Scores of the subject










S scores of the subject; H scores of the hypnotist (* p < .05; ** p < .01).

Table 5. Correlations of the DIH subscales with the other tests in E2



DIH Scores of the subject

Communion Playfulness








S scores of the subject (* p < .05; ** p < .01).

Relationship of DIH with the other Measures of Hypnosis

The correlation coefficients of the subscales of DIH and the other measures (SHSS: A,
WSGC and the 5 factor-based scales of PCI) are presented in Tables 4 and 5.
As it can be seen in Table 4 and 5, SHSS susceptibility scores of subjects have a low to
moderate but significant positive correlation with their Intimacy, Communion and Playfulness
DIH subscales. It means that high level of susceptibility is characterized by an intimate and
playful atmosphere with better communion between H and S. Furthermore the above DIH
scales of hypnotists show higher positive correlation with the SHSS values, 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.
On the basis of their susceptibility scores the subjects were arranged into three groups of
susceptibility range: 04 Low susceptibility, 58 Medium susceptibility, 912 High


Katalin Varga, Emese Jzsa, va I. Bnyai et al.

susceptibility*. As there was no significant interaction of the Experiment and

Susceptibility ranges we report the comparison of Lows, Mediums and Highs on DIH
subscales in a pooled sample of E1+E2.
In the pooled sample, a significant difference appeared in the case of the subjects'
intimacy, communion and playfulness scores (see Table 6) as a function of hypnotic
susceptibility of the subjects, due to the Low hypnotic susceptibles, who gave significantly
lower intimacy communion and playfulness scores than the Medium or High
Table 6. Comparing the means of the DIH subscales of the Low,
Medium and High susceptible subjects
DIH scores of Ss
Tukey Post Hoc test
Post Hoc

Pooled (N=337)
DIH subscale



















2.13 n.s.

* p < .05; ** p < .01

Table 7. The DIH scores of hypnotists and subjects and

their comparison by t-tests (in E1)



E1 (N=227)
















* p < .05; ** p < .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, to get a more suitable range for statistical analysis. That is why we do not
exactly follow the conventional ranges of 04 for Low, 57 for Medium, and 812 for High.

Patterns of Interactional Harmony










DIH score

Average DIH scores of Ss and Hs (E1)

DIH subscales

Figure 2. The DIH scores of hypnotists and subjects on the four subscales. In case of all the subscales
the difference is significant at p < .01.

Phenomenological Data from DIH

On the basis of the 227 hypnotic interactions of E1, the hypnotists and subjects DIH
mean scores were calculated and compared to each other. 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.
As it was seen, the difference between the average scores of the subjects and hypnotists is
significant in case of all the subscales of DIH, but these differences are so small, that the
similarity of subjects and hypnotists average scores in each DIH scale seems to be more
important (see Figure 2.).
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. So these types of experimental
hypnotic sessions are moderately intimate and playful interactions, with high level of felt
communion, and some tensionaccording to the subjective judgments of both H and S.
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),
and in these hypnotic samples as well. The high correlation between the factors and subscales
imply that basically one thing is measured by DIH, i.e., the intimacy subscale. This
strongest factor has the highest explanatory value, but the three other smaller subscales may
contain important information, occasionally showing different relationships with the other
variables than the strongest factor (details are shown later). Subjects of individual sessions
give higher scores on DIH, especially on the communion scale, reflecting the fact that a
dyadic situation is based more on the cooperation of the participants than the group session.
The analysis of the pattern of correlations between PCI (the validating criteria ) and DIH,
we can characterize the relationship between the subjective alteration in consciousness
reported by the participants on PCI, and the way they characterized their interaction 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), which is true both in
the case of subjects and hypnotists. In case of subjects the positive subscales of DIH are


Katalin Varga, Emese Jzsa, va I. Bnyai et al.

moderately connected to the positive affect scale of PCI, but all the other PCI scales are
almost independent from the DIH scores (significant but close to zero correlations). That is
the phenomenological level of subjects (PCI) seems to be almost entirely independent from
the way they evaluate the interaction itself (DIH). On the other hand in case of hypnotists,
their own subjective consciousness alterations represented by PCI H (dissociative control,
positive affect, internal attention) are moderately or highly connected to the way they judged
their interaction with the subjects (DIH). 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, than the state of being hypnotized.
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, quick method which can be
applied for subjects and hypnotists, both in individual and group sessions.


Finally we present two examples to show the special possibilities of interactional
phenomenological analysis. The first will be about the pattern of phenomenological and
relational data in relation of hypnosis stiles (maternal and paternal), the second a twin-study
on the heritability of hypnotic responsibility. In both of these cases phenomenological data,
but only if approached intreactionally, could yield important empirical data, describing
special phenomena that were not appearing in other measures.

4.1. Phenomenology of Hypnosis Styles

During the past decades our laboratory described two characteristic hypnosis styles, the
physical-organic and the analytic-cognitive styles. The most important features of these styles
are summarized in Table 8.
These two basic forms of involvement closely resembled the hypnosis styles described by
Ferenczi (1909/1965), so we gave the same name to them: physical-organic style is now
metaphorically called maternal hypnosis style, which is based on love, while analyticcognitive style as paternal hypnosis style, which is based on fear (Bnyai, 2002). These
names, of course, do not mean (simply) the direct reoccurrence of the appropriate parentinfant relationship patterns; the styles are only resembling them in some respects.
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.

Patterns of Interactional Harmony


Table 8. 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, simultaneous
movement, breathing
Relationship with the

Main characteristics during

phenomenological report

Maternal (physicalorganic) style

Hypnosis is built mainly
on positive emotions
More personal

Paternal (analytic-cognitive)
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, more
personal and emotionally
comforting atmosphere.
The hypnotist is very much
with the hypnotized
person. He/she mainly
wants the hypnotized
subjects desires and ideas
to come true, and
facilitates the independent
initiatives of the
hypnotized person. He/she
places emphasis on the
current condition and
wishes of the subject.
Hypnotists relies on his/her
bodily cues
Deep involvement

Slightly inhibiting the

subjects independent
initiatives and verbal
behavior. The hypnotist leads
and directs the hypnotized
person. He/she mainly wants
to realize his/her own ideas
and intentions, and slightly
limits independent initiatives
of the hypnotized person.
He/she does not place
emphasis on the current
condition and wishes of the
subject. Mentally stimulating
Many professional remarks
Interpreting and analyzing
the hypnotic session

Relationship between Phenomenological Measures and Hypnosis Styles

In our laboratory experiment, each of four hypnotherapists hypnotized 8 young, healthy
volunteer subjects (including two simulators: subjects earlier proven to be extremely low
hypnotizables were used as simulators). The session was semi-standardized: free relaxation
induction followed by free analgesia suggestion was used, analgesia was tested by a
standardized cold pressor test, and then standardized age regression and trance-logic
suggestions were administered; the session was closed by free dehypnosis and a brief inquiry.
The subjective experiences of the participants were screened with PCI and DIH
questionnaires immediately after completing the session (see Table 1 for further details;
Varga, Bnyai, Jzsa and Gsi-Greguss, 2008).


Katalin Varga, Emese Jzsa, va I. Bnyai et al.

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. All indications of name, gender, and hypnotic
susceptibility of the participants were eliminated from the transcripts. To assess the judges
aggregate reliability effective reliability was calculated (Rosenthal and Rosnow, 1991). The
consistency of judgments was also assessed by calculating Cronbachs alpha coefficient
(Cronbach, 1951). Reliability was considered acceptable if both measures were above .60.
Correlations between hypnosis styles and measures of subjective experiences: To
characterize the relationship between the hypnosis styles and the subjective experiences,
intercorrelations were calculated. The results are shown both for the whole sample (N=32
interactions) and for the sample without simulators (N=24 interactions).
The relationships between maternal and paternal scores and DIH scores of hypnotists and
subjects are shown in Figures 3a and 3b.
As it can be seen with half an eyealthough the correlations themselves are moderately
high and because of the low sample size they are not significantthe pattern of the results is
obvious and striking. All of the correlations between maternal score and DIH scales are
positive in every case both for hypnotists and subjects, while they are negative with paternal





Patterns of Interactional Harmony





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 Williamss 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).


Katalin Varga, Emese Jzsa, va I. Bnyai 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 PCIs 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
alterationin 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 scoresverbatim transcripts (!) judged by independent ratersand experience data
the interactants self-reported answers on the questionnairesoriginated in very different
kinds of characteristics of the given interaction.

Patterns of Interactional Harmony





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


Katalin Varga, Emese Jzsa, va I. Bnyai et al.



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


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 situationas 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 Bnyai 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





0.35* -0.04


* p < .05; ** p < .01



0.52** 0.04


Intraclass correlations








0.36* 0.1



DIH Tension





0.58** 0.03

0.55** 0.16



0.40* 0.05



0.32* 0.24









0.31* 0.19

0.34** 0.27


0.34* 0.24










0.45** 0.2



























Patterns of Interactional Harmony


Our laboratory, when replied the work of Morgan (1973), 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). According to our earlier
results hypnotic interactions do differ in the level of concordance/accord between the
subjective reports of the hypnotist and subject. Some hypnotic dyads show high agreement,
and a similar pattern, while others do not match each other in the way they report their
subjective feelings regarding the hypnosis session. We never tested, however, systematically
the effect of kinship on this aspect.
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. Apart from the basic data of hypnotic susceptibility,
well established measures of hypnosis (e.g., DIH, PCI) have been used both with subjects and
with hypnotists (Hs) to test the effect of kinship. Subjects (Ss) (mono- and dyzigotic twins
MZ and DZ, respectivelysiblings and parent-child pairs) have been hypnotized using the
standard protocol of SHSS:A (Weitzenhoffer and Hilgard, 1959). To prevent the relatives
from influencing each other (e.g., by discussing their experiences) they were hypnotized at
the same time in two separate experimental chambers, by two different hypnotists.
Immediately after the hypnosis session the hypnotist and the subject independently completed
the questionnaires (Varga, Bnyai, Gsi-Greguss, Tauszik, n.d., for further details see Table
Here we report only the most peculiar results of our study. The relationship between the
variables will be expressed in intraclass correlations (ICC)1. When the two members of
relatives (e.g. the two persons of a twin pair) will be compared we indicate it by S-S, when
the subject and the hypnotist of the same session will be compared S-H will indicate it (see
Table 9).
As it can be seen all the correlations of hypnotic susceptibility are low, nonsignificant.
Among the ICCs in case of PCI there are significant moderate to high correlations
between the members of MZ twins on dissociative control, positive and negative affect. DZ
twins show moderate significant correlation on the visual imagery scale, siblings on positive
affect and attention to internal processes. Considering the S-H intraclass correlation of PCI
scales we see, that all of the correlations are close to zero, and nonsignificant, except for the
moderate significant correlations on dissociative control, and positive affect in cases of DZ
On the DIH scale, where the interactants evaluate the session itself, a different pattern
appears. In the case of S-S ICCs, MZ twins yield high and highly significant correlations,
with the only exception of playfulness scale. Apart from this all of the correlations are close
to zero, and nonsignificant. The S-H intraclass correlation of DIH scales apart from the
significant moderate correlations between DZ twin members and their hypnotists, all of the
correlations are close to zero, and nonsignificant.

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. There are various ways to calculate ICC, we used the
fromula: ri

within groups.

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


Katalin Varga, Emese Jzsa, va I. Bnyai et al.

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, all the others are either non-significant,
or significant but moderate. This implies that the way relatives of various kinship experience
the phenomenology of hypnosis do not strongly resemble to each other.
As Appendix 3 shows, 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). On the DIH scale, however,
the MZ group gave significantly higher averages than the other groups, with the only
exception of communion, where MZ and DZ groups were similar to each other,
significantly exceeding the other two groups). So, MZ members of our sample gave relatively
higher scores when evaluating the hypnosis interaction (on DIH), but not deviated from the
other groups when their actual phenomenological experiences have been reported (PCI).
It is surprising, that the way interactants evaluate their recent hypnosis interaction on DIH
is very similar in cases of members of MZ twins, but not in cases of any other S-S dyads
(even not in cases of DZ twins)2.
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. The members of MZ twins (but nobody else) correlate highly on DIH scores with
each other (and not with their hypnotists), in spite of the fact that they interacted with two
different hypnotist. They seem to evaluate the session similarly to their co-twins, and not to
the person they were actually interacting. We might suppose that they bring their own
interactional model into the hypnotic situation (Burgoon, Stern and Dillman, 1995).
It is surprising, thought, that the key variable of hypnosis research, hypnotic susceptibility
score does not show the same similarity in cases of MZ twins. As the scores on SHSS:A are
based on behavioral manifestations, this imply that close or similar patterns of subjective
evaluation of the interaction (expressed on DIH) can be connected to different behavioral
scores, and vice-versa: the same behavioral score may hide divergent evaluational patterns.
Behind this pattern of data two types of interactional processes could be hypothesised.
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. 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). In this latter case the
independent hypnotist hypnotizing the members of MZ twins should give similar scores to
each other, as the members of MZ twin evoke similar reactions from them. 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). All of these H-H correlations proved to be close to
zero and nonsignificant (for the details see Appendix 4). So our data seems to support more
the reactive interactional pattern, and not in line with the evocative interaction pattern in
cases of MZ twins.

If we calculate the intraclass correlations only for the subgroup of the same-sex DZ twins, in cases of PCI
subscales only the visual imagery subscale becomes more highly correlated (compared to the total sample of
DZ twins, where we also found a significant but moderate correlation). In cases of DIH subscales, all the
intraclass correlations remains nonsignificant, except for communion, where it becomes significant,
moderately high (r= 0.41 for details see Appendix 5).

Patterns of Interactional Harmony


Unfortunately, our data tell nothing about the question whether this phenomenon is
hypnosis-specific, or MZ twins would give the same concordance with each other while
interacting with two different partners in some non-hypnotic settings (chess, music, sex, etc.)?

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, Bnyai, Gsi-Greguss, 1996, 1997, 1999, 2000; Varga, Jzsa,
Bnyai, Gsi-Greguss and Suhai-Hodsz, 2004; Varga, Jzsa, Bnyai and Gsi-Greguss,
2006; Varga, Bnyai, Jzsa and Gsi-Greguss, 2008). To do so, we had to develop
interactional modifications of well-known subject-centered phenomenological measures
e.g., the Parallel Experiential Analysis Technique (PEAT, Varga, Bnyai and GsiGreguss, 1994, based on EAT of Sheehan and McConkey, 1982); apply for the hypnotist
measures designed for the subject, e.g., the Phenomenology of Consciousness Inventory
(PCI) questionnaire of Pekala, Steinberg and Kumar (1986); or develop special measures to
have the participants evaluate the hypnotic interaction itself, i.e., Dyadic Interactional
Harmony (DIH) (Varga, Jzsa, Bnyai and Gsi-Greguss, 2006).
In the interactional approach, rich and valuable data has been gathered from the
hypnotists. Today we can describe the state and process of hypnotizing much better than
some decades ago. The traditional picture presents the hypnotist as a powerful, magician-like
figure who overwhelms the subject, puts him into trance, and has extraordinary power (see,
e.g., Yapko, 1984). This inevitably leads the therapists to make impossible demands on
themselves to get dramatic results quickly. Having a more realistic, more human picture about
the hypnotist and about the process of hypnotizing seems to be crucial in educating and
training would-be hypnotists. This may prevent the feeling of guilt, self-doubt, self-criticism
and other negative feelings that may lead to burnout. 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. As non-hypnotic therapists also report
spontaneous trance states in which they are especially effective and full of healing powers
(e.g., Rogers, 1979), this possibly works in their case as well.
Especially interesting patterns appeared when we interrelated the phenomenological data
of the subject and that of the hypnotist.
According to our observation, hypnotic interactions do differ in the level of
concordance/accord between the subjective reports of the hypnotist and subject. Some
hypnotic dyads show high agreement and a similar pattern, while others do not match each
other in the way they report their subjective feelings regarding the hypnosis session. In our
view, this can be considered a sign of interactional synchrony at the phenomenological level.
This level is at least as informative as the other indices analyzing the synchronous phenomena
at the behavioral or electrophysiological level (e.g., joint movements and posture mirroring at
the overt behavioral level, or the common breathing rhythm and parallel myographic activity
at the physiological level; for details see Bnyai 1985, 1991, 1998).


Katalin Varga, Emese Jzsa, va I. Bnyai et al.

All of these interactional synchrony indices formed the basis of the description of
hypnosis styles (e.g., paternal and maternal styles, Bnyai, 1991, 1998, 2002ab; Varga,
Gsi-Greguss, and Bnyai, 1999).
The main requirements of a good rapport are selectivity, reciprocity, synchrony
(Bernieri, Gillis, Davis, and Grahe, 1996; Capella 1997; Tickle-Degnen and Rosenthal, 1990).
In the case of hypnotic rapport, it involves sensitivity to each other, a complex emotional
relationship and a special need to be directed (to direct) (Bnyai, 1995). To get to a
relationship of this kind in a strongly controlled standardized hypnosis session, very special
processes must be activated in both partners of the interaction. The influence of working
models seems to be also relevant in this respect. These models are based on early personal
historydescribed by attachment theories (e.g., Bowlby, 1980)and determine the persons
feelings in his adult relationships as well, for instance, when entering a hypnotic interaction.
There is a sharp difference between individuals with, e.g., secure or avoidant attachment
styles (Ainsworth, Blehar, Waters, and Wall, 1978). Many theories of intimacy predict that
some people feel comfortable with closeness and intimacy, and are willing to rely on others
when needed. Others report being very uncomfortable getting close to and depending on
others (see, e.g., Argyle and Dean, 1965 or Patterson, 1976). The explanatory value of these
aspects in the process of interactional adaptation need much further research (Burgoon, Stern,
and Dillman, 1995). The DIH questionnaire is a promising tool to understand better the way
people enter into important human interactions, as it is not specific to hypnosis, and can easily
be applied to any other human interactions.
Hypnosis styles are related to the hypnotists overt behavioral parameterse.g., smiling,
touch, eye contact, words used, calling the subjects by their first name (for more details see
e.g., Bnyai, 2002b). During a hypnosis session these underlying characteristics might
mediate to the subject what kind of hypnosis can he/she expect with the given hypnotist. 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
experiencesprobably at a non-conscious levelin connection with the actual hypnosis.
According to our results, we assume that the development of a given hypnosis style is not
a unidirectional process going from the hypnotist to the subject. It is more probably construed
along constant message-exchanges between subject and hypnotist. Presumably a kind of
typical pattern is formulated in the harmony of their subjective experiences (e.g., regarding
mutuality) develops, if the participants come to an understanding in this style-bargain. If
this bargain remains one-sided, then one of the participants cannot enforce his/her stable or
momentary needs for relationship patterns (Bowlby, 1980), so we will find higher
disharmony in the experiences, and there will be no clear experience-patterns of mutual
The results of our twin study showed that the phenomenologically 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. MZ twinsmost
probably on the basis of reactive interactional patternevaluate the hypnotic interaction very
similarly to each other, possibly by activating early relational patterns. This was not true for
their behavioral responses to hypnosis (SHSS: A), or the phenomenological aspects of the
state (PCI).
These findings can well be interpreted using the concepts of working models and early
interactional patterns, within the sociopsychobiological model of hypnosis. According to our

Patterns of Interactional Harmony


results, the influence of early models may be so strong that MZ twins are not really
disturbed by the actual hypnosis situation. This could be considered a clear example of the
proposal that the hypnotic situation serves as a possibility to activate this early-based model,
proposed by the sociopsychobiological model (Bnyai 1998, 2002ab).
We are far from fully understanding the hypnotic interaction, 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.



Please consider your recent interaction.
Please indicate how much the following features characterized your recent interaction.
Circle the corresponding number
1. meaning: not at all
5. meaning: completely
The numbers in between indicate gradual steps between the two extremes.

2. SYMPATHY.........................




2. COOPERATION...................


4. TENSION..................


4. ANXIETY.............................


3. OPENNESS..............


2. MUTUAL CONFIDENCE 1 - 2 - 3 - 4 - 5



4. CONSTRAINED...................


1. TENDERNESS.........


2. ATTUNEMENT.................... 1 - 2 - 3 - 4 - 5

2. HARMONY..............








3. HUMOUR................


1. LIKING.................................


1. INTIMACY................


2. PATIENCE...........................




4. RELAXED............................






3. PLAYFULNESS..........






1. CORDIAL.............................


1. INTIMATE................





1. EROTICISM/SENSUALITY 1 - 2 - 3 - 4 - 5


1. HAPPINESS.........................


1. WARMTH..................




3. INSPIRING.................



Katalin Varga, Emese Jzsa, va I. Bnyai et al.


SINCERITY............................. 1 - 2 - 3 - 4 - 5 2. MUTUALITY..................



1 - 2 - 3 - 4 - 5 ABANDONED.....................



1 - 2 - 3 - 4 - 5 3. AGITATING....................


1. LOVE..................................
4. FEAR...................................

1 - 2 - 3 - 4 - 5 3,4 EASY-FLOWING.......... 1 - 2 - 3 - 4 - 5
1 - 2 - 3 - 4 - 5 1. PASSION.......................... 1 - 2 - 3 - 4 - 5

3. FREEDOM..........................

1 - 2 - 3 - 4 - 5 DISTANCE..........................



1 - 2 - 3 - 4 - 5 CLOSENESS.......................


Is there any other feature that is not present here, 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.
Intimacy, 2. Communion, 3. Playfulness, 4. Tension). Items without number do not belong to
any subscale, as their factor values were too small.




Cummulative variance
in the data in the factor space

Cronbach alfa

Rotated, sorted factor values (Mutual Rorschach situation)






Patterns of Interactional Harmony

Eigen Value
Note: RELAXED item scores inversely in the Tension scale.




(* p < 0,05; ** p < 0,01)

PCI subscale
Positive affect
Negative affect
Visual Imagery
Attention to


PCI averages of Ss
twins twins
-0.00 0.46 1.14
3.47 3.76 3.28
0.14 -0.41 0.34
2.08 1.89 2.21
0.09 -0.18 -0.12
2.02 1.68 1.38
0.15 0.00 0.18
1.24 1.43 1.47







Tukey Post Hoc test

Post Hoc











MZ = DZ = SB=
MZ = DZ = SB=
MZ = DZ = SB=
MZ = DZ = SB=

Katalin Varga, Emese Jzsa, va I. Bnyai et al.



(* p < 0,05; ** p < 0,01)





Attention to
















Intraclass correlations
Monozygotic twins
Dizygotic twins
Parent-Child pairs










(For the Data of other groups see Table 9 in the text). (* p < 0,05; ** p < 0,01)
twins (N=22)





Attention to






Same-sex dizygotic
twins (N=22)









Patterns of Interactional Harmony


Some charts and tables of this chapter are republished here by the permission of
Contemporary Hypnosis.

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London UK, and by Professor Michael Nash, University of Tennessee, Knoxwille, USA.

In: Hypnosis: Theories, Research and Applications

Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456 2009 Nova Science Publishers, Inc.

Chapter 3



Carlos Lopes-Pires1,3, M. Elena Mendoza2,3,

and Antonio Capafons2

University of Coimbra, Portugal

University of Valencia, Spain
Private practice

In this chapter, we 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, our 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.

Illustrations by Joo Pires.


Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

For years now, there has been an attempt to validate empirically psychological therapies
(Chambless and Ollendick, 2001). This is an initiative of the American Psychological
Association that has been extended internationally (Woody, Weisz, and McLean, 2005).
Despite the advantages of this initiative, some problems arise when these therapies have to be
adjusted to the clinical setting. An obvious problem is the difference found when comparing
the clinical work aimed at research with the private practice. In the first case, all of the
experimental variables are intended to be controlled as much as possible, in a way that all
patients receive the same therapy. On the contrary, in private practice, the approach is that the
therapy is adjusted to take into account the patients individual characteristics so that the
treatment can be more efficient.
These differences are even more noticeable regarding difficult cases or emergencies. In
fact, to the best of our knowledge, there is no empirically validated research devoted to these
kinds of cases. Moreover, the complexity of these cases makes it difficult, if not unfeasible, to
carry out the so-called empirical research. However, as we will explain in the course of this
chapter, these cases are very relevant in private practice. 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. Hence, he has
recently developed some intervention models specific to difficult cases and emergencies
based on the Valencia Model of Waking Hypnosis (VMWH) (Alarcn and Capafons, 2006;
Capafons, 2001; 2004a; 2004b).
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. Also, these
interventions are probably more beneficial than pharmacological treatments, which very often
lead to the development and chronicity of emotional problems. This is because they do not
use a self-regulatory perspective; in other words, medicines do not foster the development of
coping strategies for the patients problems.


One reason that these sorts of cases are unsuitable for evidence-based therapies (EBT), at
least in their first stage, is the existence of some very specific and varied particularities. But,
what are difficult cases and emergencies? Overall, these are cases with the following
1) People who have gone through a number of treatments without receiving significant
benefits, and, consequently, 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;

Applications of Waking Hypnosis to Difficult Cases and Emergencies


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.
Since we are talking about real people with real problems, there will be a wide variety of
characteristics at the starting point. For example, a person who has been suffering from a
panic disorder for many years can also be in shock at the same time. In this way, this person
has simultaneously the above-mentioned five characteristics. Nevertheless, it is worthy to
describe these characteristics separately.
Patients classified in points 1 and 5 are considered difficult cases, whereas those in points
2, 3, and 4 are considered emergencies. This classification does not imply that emergencies
are not difficult, too, but that the former share a common condition that distinguishes them
from the latternamely, emergencies cannot wait weeks or months to obtain the benefits of a
therapeutic approach of whatever kind it may be. These people need immediate relief from
the distress they are suffering.
In the next paragraphs we will describe in detail these characteristics.

1. 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. Often times,
they suffer from iatrogenic problems, above all, caused by pharmacological treatments. These
patients show a variety of characteristics that differs whether they have been taking
treatments including drugs or not. Some of these characteristics are the following: a)
hopelessness, since they were told that the pharmacological approach is the only treatment
and it has failed; b) holding the belief of having structural and functional problems in the
brain (e.g., a problem in the neurotransmitters), in which drugs are the choice treatment; since
in their case drugs have failed, they develop negative expectancies toward a possible
psychological approach; c) problems caused by medicine withdrawal, 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. Obviously, this problem tends to be worsened when there is polymedication.
As a consequence, it is common that patients searching for psychological counseling on
their own initiative establish an ambivalent relationship with that possible help. That is, they
can think of it as their last chance, while at the same time doubt and, sometimes, even resist to
the concretization of that help. In fact, these patients are a professional challenge from a
psychological perspective. Therefore, besides the necessity of correcting beliefs and
expectancies related to the nature of the psychological treatments as well as the psychological
disorders, it is necessary the immediate implementation of psychological means that help
change the patients psychological dynamics.
An important issue to consider is the tendency of psychologists, at least in Europe, to
ignore the problems caused by medications, which are crucial in this kind of patients. First,
because the medication becomes a part of the problem (it generates new symptoms of distress
and disturbance), second, because the patient has already attempted to quit the medication and


Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

has experienced negative consequences, which also reinforces the conviction that the
medication is the only way of feeling a little better1. Moreover, withdrawal symptoms are an
additional target of the intervention in our approach (it may have the same characteristics of
an emergency, but we will discuss it further in point 4).

2. People in Despair
These patients, whether have gone through previous treatments or not, have suffered from
a disorder for many years, or in case the disorder is relatively recent, it has had a strong
impact in patients well-being. From a psychological point of view, patients find themselves
cornered and feel like they had reached a dead end.
Therefore, the cases included in this category are patients suffering from phobias, mood
disorders, affective problems (couple problems), conflicts, etc. All of them show a high
degree of disorientation, anxiety and discourage, overall as a result of a prolonged emotional
suffering. It is important the fact that this state prevents patients from, or makes difficult, the
implementation of an intervention based on an EBT, even though, according to the diagnosis,
it is clear the indication of a particular treatment. In other words, before thinking of
implementing any specific treatment, the therapist have to use a previous procedure in order
to decrease anxiety, improve the mood, or create a minimal emotional stability that allows to
proceed with the intervention.

3. People whose Problem Needs to be Solved or Improved Immediately

This category refers to people who, for instance, suffer severe or chronic insomnia. It
would be the case of a person who has been days or weeks sleeping only in a residual way, or
that since several years ago only sleeps regularly 2 or 3 hours per night. In all these cases, the
sleeping time is perceived as insufficient, which generates disturbance (tiredness, difficulties
with concentration, reasoning, and memory, anxiety, irritability, and discourage, among
others). Also belonging to this category are those cases of sudden situations with severe
consequences, such as a child who in response to a fright quits ingesting solid food.
Therefore, we are referring to cases in which the immediate improvement is needed to avoid
severe or unwanted consequences.
Other cases that can be classified here are those people who are in a situation of strong
suicidal ideation. It is not only that these patients are in despair like in point 2- but above all
that they are in need of finding or at least discover a way out of the situation, a solution to the
suffering they are going through. 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. This is a point of view without any scientific support in
regard to the pharmacological action, and it does not take into account those cases in which

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), authors do not detail this matter further. However, it
is worth pointing out the confusion between relapse and withdrawal that both physicians and psychologists
show very often. It is because of this confusion that patients keep on taking harmful medications that make
their disorders become chronic.

Applications of Waking Hypnosis to Difficult Cases and Emergencies


the medication causes either the induction or exacerbation of the suicidal ideation (Healy,
2004). Additionally, 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, and that
is a goal that may be achieved quickly. In other words, 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.

4. People in Shock
A general characteristic of emergencies is the presence of agitation (mental, motor or
both). It does not allow the establishment of the necessary steps to implement the therapeutic
procedure (e.g. relaxation, exposure, cognitive restructuring) indicated to a given disorder. 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, or
intravenous diazepam) or an intravenous neuroleptic.
Clinical situations considered in this category are people with panic attacks, in sudden
grief2, suffering trauma3, etc. In addition, cases of delirium or cuasi-delirium caused by stress4
can be also included. In the latter, it is evident the existence of a severe agitation and anxiety,
and also it is possible to hear voices, symptom that traditionally has had as a first-choice
treatment the prescription of antipsychotic drugs. According to our experience, it would be
indicated in these cases an efficacious psychological management of these symptoms using
hypnosis. This point even relies on evidence about the phenomenological and epidemiological
nature of these disorders (Barlow, 2002; Bentall, 2007).

5. 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, present major difficulties to actually initiate such treatment. This
is often the case of treatments using techniques such as exposure whether exteroceptive or
interoceptive5. In fact, 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. Therefore, the dropout from the psychological treatment in this
stage is a possibility.
Additionally, people with moderate-severe depression present some important obstacles
at the beginning of the treatment. For instance, how to start behavioral activation with
somebody who feels apathetic, weak, without energy? It is as if the person was overwhelmed
by an immense burden that prevents his/her from cooperating. Hypnosis is a very beneficial
strategy. It helps pre-activate the patient (e.g., active-alert hypnosis procedure), or simply
induces expectancies for change.

The grief can be the consequence of an actual loss of a beloved one, or an affective loss such as a relationship
For instance, in the course of an accident, an assault, a rape, etc.
There has been recognized in the DSM-IV a category called Delirium Disorders.
It is included the exposure in imagination.


Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

Furthermore, people suffering from an obsessive-compulsive disorder can be included in

this group. 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.e., exposure and response prevention). They need a previous emotional
People under medication constitute another group of cases, unfortunately very numerous.
Even though we have already mentioned these cases in point 1, the perspective here is a
different one. Indeed, 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.
This entails the following: 1) the medication has not helped the patient; 2) the psychological
treatment is not compatible with the medication; 3) it would be desirable to discontinue the
medication, however, the patient will suffer from withdrawal symptoms. 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.
Hypnotic techniques appear to be interesting in these cases.


First of all, 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. For one,
when using hypnotic techniques, the psychologist keeps the same frame of mind than when
using any other psychological procedure (since hypnosis is also a psychological procedure).
In other words, the psychologist utilizes hypnotic techniques to modify expectancies,
establish beneficial conditionings, generate favorable conditions to the modification of
competences, and to teach new healthy competences7.
On the other hand, the patient has to have an adequate level of suggestibility, or at least,
to be willing to develop this quality. This means that not everybody can benefit right away of
these procedures. Nevertheless, an interesting fact is that the most of these patients tend to be
very suggestible. It is our view that, to some extent, their problems have been brought about
by the spontaneous use of dysfunctional self-suggestions. In any case, these assumptions and
limitations should be borne in mind so that the approach can be serious from a scientific and
clinical point of view.
From our perspective, there exist several fundamental therapeutic elements to take into
account in the psychological approach of these cases, which, in fact, support our interest in
the VMWH. First of all, it is important the establishment of the perception of safety and
surprise. According to our clinical experience, a positive surprise for the person is therapeutic
on its own, because it helps be open to novelty, change, and perhaps hope. On the other hand,

To be precise, in our opinion based on clinical experience, the VMWH has fewer limitations as the reader will
An important line of research by Kirsch (2007) on the role of expectancies in human behavior, and particularly, in
hypnosis, found that there is no doubt that there is an essential and deliberate utilization of expectancies for
therapeutic purposes.

Applications of Waking Hypnosis to Difficult Cases and Emergencies


the perception of safety allows establishing a therapeutic relationship of trust that will provide
the patient with subsequent therapeutic benefits. Additionally, in the moment of attending an
emergency or approaching a person in a difficult clinical situation, this perception of safety is
essential for achieving emotional stabilization, and creating a soothing effect, as we will
detail further in the presentation of clinical cases.
Another important aspect is regarding to intrinsic characteristics of the VMWH, namely,
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. 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.
The VMWH, based on the socio-cognitive or cognitive-behavioral paradigm of hypnosis,
includes three procedures to establish good rapport: the cognitive-behavioral presentation of
hypnosis, clinical assessment of hypnotic suggestibility, and a didactic metaphor about
hypnosis. Two methods of waking hypnosis are used along with these procedures, namely,
Rapid Self-Hypnosis (RSH) and (hetero) Waking-Alert Hypnosis, being the former the core
of the method (Capafons, 1998b). Even though it is very structured, its sequence is flexible.
The cognitive-behavioral presentation of hypnosis illustrates its association with everyday life
situations. Corrections to the popular misconceptions about hypnosis are provided, 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. Furthermore, this
presentation conceptualizes hypnosis as a means of gaining self-control, which also reduces
any fear of loosing control that the patient may hold.
In this context, the patient is willing and ready to move on to the assessment of
suggestibility, that is conducted without previous hypnotic induction and using classic
hypnosis exercises with a different meaning. The purpose of these exercises is to assess
patients collaboration with, and confidence in, the therapist and their attitudes toward
hypnosis. The exercises are: postural sway, falling back, and hand clasping.
After this, the patients are taught the rapid self-hypnosis method, which once learned, can
be performed very quickly, with eyes open and in a disguised fashion (Figure 1)8. This
induction method is closely linked to the hypnotic suggestibility exercises, namely, falling
backwards and hand clasping, 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,
1998a; 1998b).

As shown in this figure, patients using Rapid Self-hypnosis may be in a public situation and doing other things
while giving themselves the therapeutic suggestions. For instance, in this case, 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, or to be calm in that situation without needing a cigarette. All this would go
unnoticed by other people around him.


Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

Figure 1.

Once the patient has experienced hypnosis, a metaphor is used to convey the following
ideas: hypnosis is not dangerous, it does not imply a lack of effort or perseverance to change
behaviors, and it is an important instrument, albeit only as a helpful agent in the treatment to
be implemented (since hypnosis is an adjunctive to the psychological intervention). 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, see Capafons, Alarcn and Hemmings,
Finally, it is worth mentioning that all these methods of suggestion management has been
described by patients as pleasant, enjoyable, and useful, whereas they keep the efficacy
attributed to other forms of hypnotic suggestion management and have even surpassed other
methods. Likewise, all the procedures included in the VMWH have been empirically
validated (Capafons, 2004a).


As mentioned before, hypnosis is an essential component of the VMWH. According to
the literature, 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. 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.
The first kind of patients corresponds to points 2 and 3 of the classification of cases
mentioned above, that is, people in despair and people who need an immediate improvement,
respectively. 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

Applications of Waking Hypnosis to Difficult Cases and Emergencies


manage anxiety and pain while they go through dressing changes and wound debridement.
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, Middelkoop, Faber and Van Loey, 2007; Patterson, Everett, Burns and Marvin, 1992;
Patterson and Ptacek, 1997; Patterson, Wiechman, Jensen and Sharar, 2006). Additionally,
hypnosis has shown to be efficacious in managing the anxiety and reducing the pain
associated to dressing changes (Frenay, Faymonville, Devlieger, Albert and Vanderkelen,
2001; Patterson, Questad and de Lateur, 1989).
Relative to studies with patients who have to go through surgery, hypnosis has been used
as an adjunct to psychological interventions for reducing anxiety, as an adjunct to
pharmacological analgesia and to teach patients strategies to cope with peri-surgical
procedures. In addition, it has been utilized to reduce the pain medication needed before and
after surgery, the bleeding, and the hospital stay, as well as to facilitate post-operative
recovery (Pinnell and Covino, 2000). There is a great deal of research whose results support
the efficacy of hypnosis in this area (e.g., Blankfield, 1991; Faymonville, Meurisse and
Fissette, 1999; Lang et al., 2000, 2006; Lang et al., 2006). Furthermore, it is important to take
into account the meta-analysis performed by Montgomery, David, Winkel, 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. This was
revealed both in self-report measures and in objective measures, which suggests that hypnosis
used as an adjunctive procedure helped most patients reduce the adverse consequences of
surgical interventions.
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.
Among the studies that have addressed this kind of cases, those conducted on two particular
areas are relevant for the low efficacy of the conservative medical treatments in contrast with
the success of hypnosis.
The first area concerns the incorporation of hypnosis as an adjunct to cognitivebehavioral therapy in the treatment of irritable bowel syndrome (IBS). This disorder leads to
considerable emotional and physical suffering, quality of life impairment, and disability for
many patients. Conventional medical treatments for IBS are unsatisfactory for more than half
of all patients, leaving them with significant chronic symptoms. There are two structured
protocols for the application of hypnosis in the treatment of IBS. One has been developed in
the University of Manchester (UK) (Gonsalkorale, 2006; Whorwell, 2006). The other one is
the North Carolina Protocol, a seven-session hypnosis-treatment, unique because the entire
course of treatment is designed for verbatim delivery. Research has shown that this protocol
benefit more than 80% of patients (Palsson, 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. Gains of intervention include changes in colonic motility and
rectal sensitivity, as well as changes in central processing, psychological effects and
improvement of quality of life, even in patients that do not respond to conventional medical
treatments (Gonsalkorale, Houghton and Whorwell, 2002; Gonsalkorale and Whorwell, 2005;
Whitehead, 2006; Whorwell, 2006).
The second area of study is focused on patients suffering chronic pain caused by
temporomandibular disorders. It is estimated that 23% of patients do not respond to
conservative treatments involving a dental and physical medicine approach (Clark, Lanham

Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons


and Flack, 1988). According to Simon and Lewis study (2000), the use of hypnosis as an
adjunct to cognitive-behavioral treatment in these patients is promising. After the treatment,
patients of this study reported a significant decrease in pain frequency, duration, and intensity,
as well as, in medical use. Likewise, participants showed and increase in daily functioning,
and their treatment gains were maintained for six months after hypnosis treatment (Simon and
Lewis, 2000).
Besides this research, which is focused on cases sharing some of the characteristics of the
cases we consider as difficult or emergencies, to the best of our knowledge, there are no
published studies about the use of hypnosis in the kind of cases we describe in this chapter.
Therefore, it is important to point out that this work is pioneer in two aspects: first, 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), and
whose characteristics make them difficult and in need of a special approach to achieve a
quick improvement; second in the use of the waking version of hypnosis and in particular the
therapeutic procedures of the VMWH adapted to these cases.


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. The approach is supported by three models of intervention (Pires,
2008) intending to respond to the clinical diversity of difficult cases and emergencies. The
models are simply called model 1, 2, and 3. Before further describing each model, it will be
helpful to review the general frame of these models concerning their psychological origins.
First of all, the two aspects already mentioned are very important, namely, safety and
surprise. However, in a strict sense, the establishment of safety and use of surprise are
inherent conditions to any profession in which there is a relationship of help. On the other
hand, 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. In fact,
these two elements can be viewed as essential in the establishment of this approach.
Another aspect that we consider important to explain is the assessment of hypnotic
suggestibility, above all, the possible use of psychometric instruments. In our approach,
whether the cases are difficult and/or emergencies or not, the hypnotic suggestibility is not
assessed, since, according to our clinical experience, there are several limitations or
determining factors that make it not useful9. They are as follows:

Assessment procedures do not predict clinically the therapeutic benefits. Indeed, the
different items used to assess the suggestibility are not related to the clinical and
therapeutic response. Beliefs and attitudes toward hypnosis are more interesting
factors (Capafons, 2001), but they are not relevant in our approach as we will explain
further on.

This opinion has been also advocated by others (for a review on this topic, see Weitzenhoffer, 2000).

Applications of Waking Hypnosis to Difficult Cases and Emergencies


They are very extensive and take time, and consequently they are not suitable for the
kind of clinical situations that we are describing here. In emergencies especially it is
pursued an immediate therapeutic impact.
The assessment procedures can foster a traditional perspective of hypnosis in people
that hold these beliefs, since the exercises can remember familiar scenes of hypnosis
(it is important to take into account that when these items are introduced to patients,
they are also told that their purpose is the assessment of the hypnotic suggestibility).
There is a high risk of spoiling effects that could be used for the patients benefit,
given that the first contact with hypnosis is through the items (which are actually
induction procedures). The surprise factor, that is a very important condition for this
approach, is completely lost. Often times, we have found that patients that responded
very well to the items, at the time of using hypnosis with therapeutic purposes, ended
up resisting or rejecting its use, maybe because their misconceptions about hypnosis.

The main characteristic of our approach is the development of brief procedures taking the
psychological, technical, and philosophical assumptions of the VMWH as a starting point.
The resulting models can be called Very Brief Models. In the following diagram the models
can be compared to each other.
Thus, comparing the two figures the following differences can be easily noticed:



There is not a presentation of hypnosis.

The clinical approach begins with an induction procedure. That is, besides the lack of a
presentation of hypnosis, the clinical assessment of the hypnotic suggestibility is
transformed into a hypnotic induction procedure.
The hypnotic induction is directed in the sense of its maximization in an only session.
That is the reason why the patient is immediately trained in rapid hypnosis.10
As soon as the patient has some experience in the benefits of hypnosis, the presentation
of hypnosis is carried out. This would be what in the VMWH corresponds to the stage
Practice and training suggestions or later. The reason is obvious: when patients have
already felt benefits and have personally experienced what hypnosis is, they are more
receptive and willing to comprehend, accept, and implement the wide range of hypnotic
The didactic metaphor is taken off since this approach aims to be as quick as possible.
However, this does not mean that it can not be used subsequently, after the beginning
(rapid hypnosis)11.

To sum up, the VMWH is adapted to the clinical circumstances and characteristics of
these patients. In table 1 is shown the logic that directs these models, that is, kind of a line of
reasoning for decision-making concerning whether or not using hypnotic techniques.


Notice that in some cases, the approach is directed immediately in terms of self-hypnosis. This will be better
understood when each model be explained.
Except for when in the development of our approach (in subsequent sessions), the format is already set according
to the usual VMWH, after the patients emotional stabilization.


Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

Diagram 1. Comparison of Valencia Model of Waking Hypnosis and Very Brief Model (Taken from
Alarcn & Capafons, 2006).

Applications of Waking Hypnosis to Difficult Cases and Emergencies


The discussion of the first three points is framed in terms of the so-called difficult cases
and emergencies above-mentioned. In point 4 of difficult cases the goal is to know, according
to the clinical history, context, and clinical characteristics, whether the use of hypnosis is
possible. For instance, only counseling could be more feasible and have more benefits.
Relative to the point 4 of emergencies, in may be the case that the person is not in conditions
to pay attention12. Point 5 in both situations consists in the implementation of the approach
through one of the models. The models are explained in the next section.

Model 1
There is not any preparation or mention to hypnotic suggestions. After listening to the
patients complaints, asking ourselves the questions of the table 1, and establishing the
rapport with the patient, we implement the Model 1. This protocol was put forth with the goal
of causing surprise, and the first exercise was selected due to its similarity to tests used in
Table 1. Line of reasoning for decision-making concerning whether or not using
hypnotic techniques
1. Is this a difficult case?
2. Have there been previous treatments? Were these treatments the most adequate?
3. If the treatments were adequate, but they failed, something different should be done,
although taking as a reference the previous treatments. If they were not adequate, the
focus would be a therapeutic adaptation.
4. Conclusion: Is hypnosis a feasible alternative?
5. Procedure (one of the models)
----------------------1. Is this an emergency?
2. Is the suffering unbearable?
3. Is there a strong pressure to get the problem solved immediately?
4. Conclusion: Is the use of hypnosis feasible?
5. 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). The patient is also
asked to fix his/her eyes on a spot and after that to close his/her eyes (Figure 2B). After 5 or
10 seconds the patient will be asked to open again his/her eyes. This position in itself
produces swaying. When the patient has opened his/her eyes s/he is asked the question: what


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, that she had taken for 5 days), which produced her to suffer
from vertigo and to be unable to keep a hardly coherent dialogue. Two days later, after suspending the drug, it
was possible to initiate an approach including hypnosis.


Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

did you feel in your body? Most patients answer that they felt like swaying13. Then, the
protocol goes on with the next exercise: falling back.

Figure 2A.

Figure 2B.


Some people, especially very hypnotizable people, may feel a little dizzy.

Applications of Waking Hypnosis to Difficult Cases and Emergencies


Figure 3.

Figure 4.

Falling Back
The patient remains in the same position and the therapist places him/herself behind the
patient, asking him/her to fall backwards, 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). This exercise is carried
out several times. It is worth noting that this exercise not only pursues to help develop


Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

confidence in the therapist, but also to create a setting of surprise (what are these exercises
for?). After repeating the exercise follows the same one but adding the use of suggestion.

Falling back Using Suggestion

As in Figure 2A, the patient is asked to fix his/her eyes on a spot and to stay put. 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. After that, the therapist says
something like the following: Please, imagine that my hands are powerful magnets that are
attracting you backwards. Attracting youAttracting youAttracting you backwardsMore
and more. (Figure 4). In our approach, it is not so important that the person falls
backwards. 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).
The next exercise used in this Model is a simple exercise of suggestion that appears in
many scales to assess suggestibility, namely, hands attracting to each other.
Hands Attracting to Each other
The patient is asked to stand up, put his/her arms parallel to each other (Figure 5A), and
close his/her eyes, while imagining that his/her hands (separated 15-20cm) are getting closer
to each other, more and more until eventually they touch (Figure 5B). The underlying idea of
this exercise is, once again, the development and increase of the surprise. It is thought that
this exercise leads to an increase of the involvement in a suggestive activity as well as causes
surprise. It also prepares the patient for the next exercise that is actually the one to use in a
therapeutic way: side arm lift (levitation).

Figure 5A.

Applications of Waking Hypnosis to Difficult Cases and Emergencies


Figure 5B.

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, and right after the previous exercise, the therapist says the following:
In this exercise, after asking you to close your eyes, I am going to take your right (or left)
hand by the wrist and push it upwards. I would like you to feel your arm lifting, to feel its
movement. This movement will be repeated several times. It is obvious that this exercise is
intended to be used as a hypnotic induction, by means of creating a movement perceived as
involuntary. In fact, most people quickly experience this involuntary arm movement. 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. Now, pay attention to what is going on the left arm also lets go and begins to
liftand both arms liftliftthey go up until a certain moment comes when they no longer
lift but go down.
At this point, there are several alternatives, depending on the clinical case and the goals
intended to achieve through this intervention. From our point of view, 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,
knowing that statues do not suffer, do not think, do not move, they just observe the world
movement, the pass of the year seasons, the rain, the sun, the clouds, the birds that come and

Obviously, all these exercises can be performed while the patient is sat. This would be the case of either
temporarily or permanently disabled patients. In the falling back exercise, the starting position may be with
the patient sat as close to the edge of his/her wheelchair or the chair as possible, and then proceeding like in
the standing version of the exercise, but substituting the suggestion for feeling that the therapists hands attract
him/her to fall backwards with the suggestion of the same effect but produced by the back of the chair.


Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

the birds that go away. 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. In a second alternative (b)
it can be suggested to the patient to listen to the sound of the road, the cars, the leafs of the
trees, going further every time and very relaxed, calm, and appreciating how big things are
small, and small things are big, depending on the perspective and importance that we give to
Some people do not move their arm (even when the therapist is pushing). These people
tend to do catalepsy, leaving their arm extremely rigid. Others simply leave their arm flaccid,
but do not experience the sensation of involuntariness. Relative to the case of catalepsy, an
alternative to the side arm lift (levitation) can be the suggestion of feeling as being a stone
statue (according to the mentioned scenery).
In regard to the second case, 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. Therefore, an alternative to the side arm lift (levitation) is the
watch pendulum. The wording for the watch pendulum may be as follows: Now, if you pay
close attention, you will notice a very interesting thing: your body is swayingswaying as if
it was a watch pendulumThe pendulum of a very big and antique watch, but the pendulum
is fixed in the baseSwayingSwaying...Insofar as it sways And it continues with those
suggestions thought as the most appropriate for the case.
It is worth pointing out that there are some other possible variants, regarding induction
techniques derived from this initial exercise of arm lift. The first variant consists in
proceeding with the same procedure with the other arm, such as shown in Figure 6A. In this
case the wording may be something like the following: If you wish, in a moment may happen
something very interesting: when I touch you with my finger in your arm (e.g., the left arm),
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.

Figure 6A.

Applications of Waking Hypnosis to Difficult Cases and Emergencies


Figure 6B.

Another variant, this one more complex but also very interesting in terms of the
suggestive-therapeutic possibilities, is shown in Figure 6B. In this case, after the right arm has
lift, 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, arm, hand, and fingers, and you will be able to feel this arm going down until it
touches your body. Your arm will no longer be rigid and hard as if it was a rock). 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, 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, I know you are listening to me and you are going to find this very interesting and
amazing. 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, and because of
that, sometimes we do not know why we do this or that. The learning of better regulating that
unconscious activities will be very important in order to change difficulties, either emotional
or any others. An interesting way of letting these unconscious processes show themselves is
by means of the movement of the left arm. Thus, when I say now, you will be able to feel
some changes in your right arm and hand, 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; you do not know
either... Will it go to your face, to your nose, to one of your ears, to your forehead, to your
hair, to your mouth, to your chin? I do not know, you do not know either... Notice those small
and very subtle movements inside your hand, little by little moving, moving... etc. The
movement involuntariness is reinforced constantly and, at the same time, its relationship with
something pleasant (as your hand and arm raise you feel more confident, calm,
hypnotized). Perhaps, this is the more complex procedure and the most productive, and it
can be used subsequently.
Finally, there are some aspects to emphasize: 1) The patient is ready for rapid hypnosis
through several inductions that will prepare the next stage; 2) At the end, it is explained to the


Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

patient how hypnosis can be incorporated in a therapeutic plan in order to help him/her, and
misconceptions or negative attitudes toward hypnosis are clarified in a conversation.
Everything is ready for preparing the next session.

Model 2
By and large, this model is the most appropriate for emergencies, since it is much more
direct, brief, and incisive. Likewise, it is worth pointing out that, from the start, this second
model uses waking hypnosis and is adapted to a self-hypnosis format. Overall, this model has
two stages and both of them are intended to cause surprise. As mentioned, the final goal is to
deal with the patients emotional agitation and activated state.
The first stage involves, above all, the development of patients absorption in his/her
inner processes that will be the target of the therapists intervention. We use a combination of
several items belonging to the VMWH, in particular, the sensations of heaviness/lightness in
the arms, which subsequently can be associated with other elements leading the patient, in a
gradual way, to understand that his/her emotions are determined by his/her thoughts, in other
words, by his/her mind15. The following paragraphs detail the procedure.
LIGHT/HEAVY ARMS FOR EMOTIONAL EQUIVALENCE. For this exercise the patient is
comfortably sat. The therapist asks the patient to keep his/her eyes open and talk whenever
s/he asks him/her something. However, the patient may choose to keep his/her eyes closed if
s/he feels more comfortable this way. It is explained that the important thing is to let
him/herself go, that is, not to make efforts to produce the sensations that the therapist will
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). Often times, we only realize the presence of
certain sensations when we pay close attention to them. For example, 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. Give that information to your brain and
wait Wait to see what happens and let me know (Pause for some seconds. Most people
tend to report an increase of heaviness or lightness in their hands.) If the patient does not
report anything, the therapist may go on as follows: Most of people notice that one hand turns
a little heavier and the other a little lighter. Please, pay attention to check if something like
that happens to you. It is almost sure that the patient will notice changes. Probably, the hand
and arms will lift (Figure 6B). Moreover, there are alternatives to the heaviness/lightness
sensations, such as hot/cold or simply the immobility of one or both hands.


In our opinion, this is one of the most interesting aspects of the VMWH. 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.

Applications of Waking Hypnosis to Difficult Cases and Emergencies


Figure 7.

The important thing is the occurrence of those alterations, which will be associated
subsequently to wanted emotional aspects, as it is carried out in the VMWH. For example:
Please, now tell your brain that to the extent that your right hand and arm lift, 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.
The second stage may simply consist in keeping this script, deepening above all selfhypnosis, or moving on to another script that can be started in the same session or in the
following one. This decision will depend on the clinical assessment of the patient at that
moment. The other script is the hands attracting each other, that is performed over the
therapists table (Figure 8A), or, alternatively, with the patients hands over his/her thighs
(Figure 8B). It makes no difference, although we recommend for the homework to use the
latter position.
Hands attracting to each other. As is shown in Figure 8A, the patient is sat with his/her
arms over the table in parallel from the elbows. The separation between the hands should be
about 20 cm, not too much since it is more difficult the movement over a surface than, for
example, over the thighs. Additionally, as it can be done with other kind of inductions, if the
hands do not move, different suggestions can be employed (Your hands can not move... they
are immobile more and more immobile, etc.). Actually, the important thing is the rapid
induction of (self) hypnosis, as well as the association of the movement of the hands
approaching to each other (Figure 8B) with a desirable psychological effect. For instance: As
your hands move approaching to each other, you feel more relaxed, safer, calmer
In our clinical practice, this induction procedure is very efficient and pleasant for the
patients. First, because it is very quick, and second because it causes a noticeable surprise
effect, and at the same time a quick stabilizing emotional effect (brought about by the
suggestions given in order to achieve relaxation, serenity, and confidence, among others).


Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

Figure 8A.

Figure 8B.

Model 3
This model is mainly used when the patient has already achieved an adequate emotional
stabilization. Indeed, it is a result of the previous model and, overall, it is developed in terms
of the VMWH, as it was described in the beginning of the chapter. Nevertheless, it can be
more beneficial for the patient to go on working with the approach explained in the Model 2,
but including new clinically and therapeutically relevant aspects. It is worth mentioning that
according to our clinical experience, many emergencies do not need a transition to this
Model, because patients improve or solve their difficulties in a satisfactory level.

Applications of Waking Hypnosis to Difficult Cases and Emergencies


What does the Model 3 consist in? Actually, this Model develops the VMWH in a slower
way, breaking it in stages, and lengthening the hypnotic procedures16. For example, let us
suppose that a patient comes in a situation of panic attack without agoraphobia, and having
been suffering repeatedly from crises in the last days. After a minimal emotional stabilization
is achieved through the Model 2, 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, 2007); 2) The patient is asked to hypnotize him/herself and is trained in
producing alternatively relaxation/calm and anxiety/fear, while giving him/herself
suggestions of safety and confidence. This training will allow the patient to understand two
important theoretical facts of the panic disorder, first, that it is the patient him/herself who,
paradoxically, produces the panic attack; and second, that it is done by increasing his/her
respiratory rate. When the patient is in self-hypnosis, it can be emphasized what happens in
the breathing cycle, that leads him/her to produce an increase in anxiety/fear, namely, there is
an increase of the respiratory rate, along with the obvious reduction of oxygen and increase of
carbon dioxide in blood, which leads to the conditions for the development of the panic attack
(Barlow, 2002).
Specific induction techniques will not be presented for this Model, since they are the
same than for the two previous Modes (above all Model 2), or any other of those included in
the VMWH (Capafons, 2001; Capafons, 2004a; 2004b). The techniques included in the latter
are all aimed to achieve Rapid Self-Hypnosis.
In order to understand and illustrate the clinical applications of these Models, in the next
section we will introduce a variety of clinical cases.

Case A. (Delirious Agitation, Anxiety)
The first case is an emergency. A. is a high school arts teacher who had a position in the
South of Portugal (Algarve) during the past academic year. When he came back home (Center
of Portugal, in a city named Leiria), in July 2007 the event that led him to our office took
place. The patient, a 30-year-old man, was always a person showing a high social anxiety and
obvious interpersonal difficulties. During the past academic year, A. tried to fit in with his
colleagues, what led him to drink and consume marihuana. The latter caused him to start
having some persecutory ideas as well as hearing voices. Perhaps related to this somehow
delirious activity, A. initiated a relationship with one of his colleagues, which he regarded as
a romantic relationship. However, at the end of the academic year, he confirmed that he was
mistaken, and it was only an illusion of his own mind. In this emotional condition he came
back to his family home (his brother and his mother, his father passed away many years ago).
It is A.s mother who contacted us. She was in despair and worried since in the last days
A. had done unpredictable things, such as going to see some friends, giving them the keys of

Clearly, the aim is not using the VMWH as it is established, since that would be going backwards, which is not
possible. However, some of the essential elements of the VMWH can be used working with them in more
detail (thus, according to the assumptions of the VMWH). For example, the therapist may spend more time
explaining and training in the influence that thoughts and interpretations have on what we feel.


Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

his car stating that he was not going to need them anymore, and then being found in the beach
trying to go out of sea. Furthermore, some nights he slept inside his car or outside in the
beach, he used to talk to himself as if there were somebody else, and was very agitated
without being able to sleep. This information given by phone was enough to realize that this
could be a case of psychotic agitation (delirious disorder). A.s mother preferred that we
assess his son first, rather than proceeding directly to his hospitalization in Psychiatry. A. was
received the same day in the evening (A.s mother called at midday).
He appeared to be a very anxious person, agitated, and with difficulties to explain what
happened to him. Even so, it was possible to clarify the events he told us as well as the impact
they had had on him. 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.
The Model 1 was applied with the arm lift procedure. Taking into account that A.
responded very well, the variant of the hand and arm going up to a specific place of the head
was used. Suggestions of calming down, safety, and tranquility were given. The response was
excellent. The patient practiced at home during the following three days and then came back.
At that point, he showed to be calm and ready to use the procedure in self-hypnosis (without
knowing anything about that). He was able to achieve what he called meditation.
A. came back to the office after two weeks and one month and he kept his positive
progress. In these two sessions the work with him was focused on problem solving, including
the hearing voices. He considered being able to proceed on his own in this matter17. Some
months later he contacted us again to improve some interpersonal aspects (related to social
skills), and after several weeks he had gained good results.
Previous to introduce this case in the chapter, we contacted A. again and he confirmed to
be very well18.

Case B. (Traumatic Stress)

This case is an emergency too. B. is a 41 years old male who was referred by a colleague,
after it was verified that he was in a trauma. Five days before, the patient along with four of
his friends (among them there was a cousin of him that he considered as a brother) were
hunting, a hobby all of them had some years ago. In the way back home they were involved in
a serious car accident, as a result of which the patients cousin passed away. One of the things
that most impacted B. was to see part of the brain of his cousin spread on the ground, with his
head opened.
From that day on, B. 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), anxiety, anguish, and sadness. He had
difficulties to concentrate in his job as a business man. Relative to his family his own children
reminded him his cousins children, now without his father, and his own wife reminded him
his cousins wife, now a widow


An interesting aspect is that the patient went on hearing voices, generally neutral or even positive ones. The
patient was able to live with those voices without any problem.
The total therapeutic process (including the first session) took place between July and October, 2007.

Applications of Waking Hypnosis to Difficult Cases and Emergencies


The rationale of the intervention, after talking with the patient about the therapeutic
goals, was, first of all, to reduce his state of high emotional activation. To this end, the
technique of breathing control was used (see Craske and Barlow, 2007). It consists in
breathing in a controlled way during about 15-20 seconds (more than 12 seconds), paying
close attention to the exhaling. The objective is to change the pectoral breathing into a
diaphragmatic breathing. This helps reestablish an adequate balance of brain oxygenation and
helps decrease the symptoms causing anxiety. The patient was trained in this procedure in the
first session, and was asked to repeat it at home several times during the day. He came back
two days later for the next session.
The second session was intended to deal with the link that people tend to do after the
death of a close person, namely, a process of guilt that, as the time passes, fades away. We
proposed B. the use of waking hypnosis to be able to proceed to vanish this process. We
implemented specifically the Model 2, using the second stage (hands attracting each other) to
give temporal distancing suggestions (and in this way, achieving a decrease of negative
emotions): Tell your brain that as your hands approach attracted by each other, you feel
that the accident took place long time ago, long time ago... it did not happen one month ago
nor a year ago... it happened long, long ago... and this is why you feel that your distress,
anxiety, anguish are vanishing and decreasing... Most part of this session was devoted to
implement this procedure, first in hetero-hypnosis and then in self-hypnosis.
The patient felt very relieved and showed to have good ability to use self-hypnosis. There
was another session four days after this one, in which B. was told to practice several times per
day this procedure (at least once in the morning, afternoon, and night). The next sessions were
one and two weeks later respectively. That is, second session four days after the first one;
third session seven days after the second; and fourth session, 14 days after the third session.
It is worth pointing out that this kind of emergencies is, by nature, acute and its treatment
has preventive characteristics. For example, in this case, everything indicated that the patient
would be vulnerable to develop post-traumatic stress. However, since the intervention worked
out successfully, several days after the trauma, that development never reached to an end.
Indeed, an unpublished recent exploratory study conducted by one of the authors (Pires and
Peralta, 2008) suggests that the cognitive involvement subsequent to the exposure to
unpleasant scenes increases drastically the dysphoria, above all depressive feelings,
decreasing the appreciation of neutral or positive scenes. Therefore, by withdrawing the
patient from the cognitive involvement in the traumatic event, as well as allowing him/her to
feel safe, may be very relevant in order to the post-traumatic stress does not develop further.

Case N. (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 treatment lasted 6 months and it revealed to be a very complicated case. The patient not
only was completely limited (he did not go anywhere alone or too far away from his home),
but he also was under much medication (two antidepressants, two benzodiazepines,


Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

propanolol, and a mood stabilizer). For that reason, the first months the intervention was
focused on reducing gradually the medication19.
As it is known, the choice treatment for panic disorder is conducted through the
implementation of exposure variants, such as in vivo exposure (agoraphobic aspects), and
interoceptive exposure (inner/somatic aspect of panic). Even so, many patients are reluctant to
go through such procedures, above all to the interoceptive exposure. This patient was not an
exception to these cases. After a negotiation process with the patient, we agreed to proceed
with gradual in vivo exposure. At this time the patient was no longer taking medication20.
Just as we expected, there were substantial difficulties and resistance. N. admitted to be a
coward: he did not bear to cope with agoraphobic situations. In this context, the use of
hypnosis was put forth as an alternative. The Model 1 was applied and the statue scene was
used to generate in the patient a feeling of distancing regarding the fear, and to suggest
courage by means of some coping scenes of hard adversities in a mountain area. The
important goal here was to elicit his feeling of courage and associate it to the word courage,
in a way that he would be able to use it subsequently during the exposure. Then this situation
was trained in vivo while in waking hypnosis. Therefore, these were the first steps to work
with the exteroceptive exposure.
The procedure was repeated several times, whenever it was necessary to unblock the
agoraphobic coping. Meanwhile, it was possible to initiate interoceptive exposure that the
patient accepted this time.
It is important to emphasize that even though he exposure has been the basis of the
treatment, the use of hypnotic techniques was essential for the effective treatment
implementation. Hypnosis allowed overcoming the patients difficulties to cope with phobic

Case T. (Phobia to Eat)

The patient is an 11 years old male child who quitted eating solid food, taking only
liquids after the death for asphyxia of a neighbor child. The latter21 was alone at home and
tried to swallow a too big amount of food without chewing, and ended up asphyxiating
The patients 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. Due to
they did not obtain any result, they turned to a Psychologist, also without any result. Then
they looked for another Pediatrician who referred the case to us. Meanwhile, several months
had passed. 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 childs health.
As a general rule, in cases involving children a simple approach of the Model 2 has
shown to be useful. Inasmuch as children tend to be very suggestible, the exercise of the
hands attracting to each other is applied without too many details. Additionally, according to

We counted on a physicians collaboration.

Even though from a clinical perspective, the patient did not have at this time any improvement, he considered that
the medication, after all those years, had not solved his problem and had caused him several problems (side
This child had trisomy 21.

Applications of Waking Hypnosis to Difficult Cases and Emergencies


our experience, children like to keep their eyes opened. The intervention in this case was
conducted in several stages that where established in accordance with the goals estimated as
necessary at each moment. First, it was thought helpful to proceed to a sort of oblivion of
the event that brought about the phobic situation, in order to facilitate the ingestion of solid
and harder food in his mouth. During the exercise of hands attracting each other it was
suggested that as his hands approached to each other, the above-mentioned event would turn
distant, more and more distant, further in time until it had completely disappeared. After this
procedure, there was a break to assure that the oblivion was working. 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. The procedure was the same one
with the hands trying to cause sensations of hunger. The suggestions resorted to a detailed
description of the somatic and cognitive signs of hunger, and to the anticipation of the
pleasure of satisfying the hunger, producing salivation. In this stage, the psychologists
intervention (hetero-hypnosis) was alternated with the performance of the child (selfhypnosis). The instruction was: Tell your brain Before terminating, and in order to
prepare for future sessions, it was suggested to T. that the exercise of the hands attracting to
each other would be helpful to make changes in the brain so that the food turned tastier22
Also, T. was told that this training is called self-hypnosis.
After finishing hypnosis, the patient said that he had a stomachache that felt like...
hunger. He ate in a natural way, to his mother astonishment, as if he had never had such a
problem. The following sessions took place every other day during a week in which we went
to his house at dinner time. T. stayed alone with us while his parents went to the living room.
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. Right after this, the mentioned
exercise to turn food tastier was utilized. T. was told the following: Very well, now you are
in self-hypnosis and are going to eat until you do not feel like eating more. You will be able to
move, to watch TV, to drink water, etc. You will remain alone. When you are finished, call
me. See you later.
Two weeks later we went to the patients house again to observe his progresses and
reinforce the procedure. Everything was going well. In the next few months a follow-up by
phone was performed. More than three years has passed and there has not come up any

Case C. (Depression, Pharmacological Iatrogeny)

This case is framed in what we consider as difficult cases. Indeed, in our clinical
practice a kind of case very common is chronic depression. To be precise, they are depressed
patients who initiated a pharmacological treatment many years ago, and with the passing of
the years, not only do not improve the initial clinical situation, but also present clear
symptoms of emotional, cognitive, and behavioral deterioration, most of all as a result of the
own treatment iatrogeny. As a rule, they are people without motivation and hopeless, with

This procedure was necessary to avoid the contradiction created by doing something with the goal that he eats,
whereas it has been suggested oblivion Subsequently, his mother confirmed that when she asked him the
reason to do that exercise, he replied: it is for improving my appetite. The food I ate before was not so tasty.


Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

severe difficulties in their jobs (they are on sick leave many times or retired). Despite all this,
they are not able to leave the medication since those times they have tried, they go through
strong withdrawal syndrome and their physicians reject such a possibility. In this way, the
situation becomes very complicated and the first objective is the relief of the side effects of
the medication. This may take a more or less long period of time. During this time, a detailed
intervention is carried out. That is, education, restructuring of the psychological components
essentials for a comprehensive and in-depth psychological treatment. From our approach,
hypnotic techniques can be useful in different points. Let us proceed explaining these points
with this illustrative case. The patient is a 41 years old woman who has been depressed for
nearly 6 years. She is married and has two children. She has many difficulties in her job as a
lawyer, since she has reasoning and memory problems and repeated work absences. She is on
psychiatric pharmacological treatment since the start of the problem, namely, an antipsychotic
(risperidone), two antidepressants (fluoxetine and fluvoxamine), and two benzodiazepines
(alprazolam and triazolam). This prescription is the most recent from a very long list.
Building of a context of hope. It consists in creating positive and favorable expectancies
toward this new process of help23. We turn to the Model 1. After proceeding as it was
described above, we can pass to the following scenario: Now, you can be in any place. Do
you like going to the beach in a summers evening where there are few people and the sea is
very calm? If so, imagine yourself walking by the seashore, walking on the wet sand. You
know that the sand is wet because you are walking barefoot. Turn to face the sea. Today the
sea is very calm and smooth. The seagulls fly along with the air current. In the background,
some ships hardly move on the horizon. You are happy and satisfied. Actually, a few months
have passed since your health improved and you feel better. Smile Smile while looking at
the sea and the seagulls, while thinking that all the efforts are really worthy. At the beginning
everything seemed to be impossible, but then, little by little you overcame all the difficulties.
You have become a better person. Take a deep breath notice the smell of the sea You are
satisfied Now, you know that, in life, there are good things and not as good things, and the
latter are difficulties, obstacles that can be overcome.
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. In this case hypnosis was also used to cope with withdrawal
symptoms that the patient reported to be the most distressful, that is, pain and anxiety. This
procedure had to be repeated inasmuch as all the medications dosage reduction had effects of
withdrawal of variable intensity.
The period in which the withdrawal of the medication took place lasted about two
months. Just before the complete withdrawal the patient was ready and felt like starting with
behavioral activation. Actually, there were few things left to do after this. The same rationale
was applied and usual elements of cognitive-behavioral therapy for depression were used,
such as behavioral activation and correction of dysfunctional cognitions, and benefitting from


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. In this case, it is important to take into account the pathological
role of the own medication in the patients current state, trying to know in details the relationship between the
drugs and the complaints. For example, 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

Applications of Waking Hypnosis to Difficult Cases and Emergencies


a self-help book wrote by the first author (Pires, 2004), which helped the patient to follow the
psychologists indications.


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. Due to their
nature, these cases represent a major challenge for professionals. As we have pointed out, the
application of hypnotic techniques and procedures may be an important instrument to help
these patients. Notwithstanding, the aim is not to apply techniques on their own without the
support of a planned psychological intervention. On the contrary, according to our point of
view, hypnotic techniques are, above all, psychological procedures based on psychological
variables and fitting into a set of therapeutic procedures that psychologists can use.
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. Therefore, it allows an easier approach
in which there is no need for giving explanations to the patient24. In point of fact, hypnotic
techniques can be integrated easily in the intervention and, overall, patients are not afraid of
losing control over themselves or being in a trance state. In the case of the VMWH, there are
some additional advantages: It is standardized in a protocol of procedures established in
stages, and these stages are so clear and simple that its use becomes very appealing for those
using it in their clinical work.
It was from the clinical experience with the model that its application to difficult cases
and emergencies arose. In these kind of cases, the VMWH cannot be used as it was initially
put forth and described, but it is still possible to apply and adjust its principles and its
philosophy, in a way that some appealing and elegant intervention models can be obtained
and offered to those patients in need of help. The resulting models are specific versions of the
VMWH for very specific cases.
From a clinical/therapeutic point of view, what are the most interesting aspects of the
models described in this chapter that could be emphasized? Most of all, their parsimony and
simplicity are very important. The intervention is focused directly on the clinical aspects
using hypnotic procedures that are simple, interesting, and, oftentimes, surprising for the
patients. Another characteristic is that the models are quick. The VMWH itself is quick, but
the variants presented here are even faster in responding to the demands of these kinds of
cases. Likewise, our view is that this rapidity is an element of the surprise itself. On the
whole, 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,
motivation, hope, courage, etc.).
Another interesting aspect is the easy integration of the logic of these models in a
cognitive-behavioral psychological approach. It allows, for one, 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, at least for the patients, could appear as mysterious (such as the idea of
trance); on the other hand, it allows the patients to integrate more easily what they are


Carlos Lopes-Pires, M. Elena Mendoza and Antonio Capafons

learning from a self-regulatory or a self-control point of view. Likewise, this is also one of the
essential aspects of the VMWH.
Obviously, the cases described here are only illustrative, since these models can be
applied to the majority of psychological disorders encountered in the clinical practice.
Together with the therapeutic arsenal that psychological therapies represent nowadays,
hypnotic techniques and, in particular, those characterizing waking hypnosis according to the
Valencia Model, constitute another instrument that can be very useful to help patients.
Empirical evidence supporting these models is recently increasing, along with the evidence
coming from clinical practice (Ludea and Pires, in press). We consider that the
dissemination of these techniques, more modern and psychologically integrated, will
constitute in future a relevant research field and an important set of clinical interventions
(Agostinho, in press).

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In: Hypnosis: Theories, Research and Applications

Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456 2009 Nova Science Publishers, Inc.

Chapter 4


Renzo Balugani1,* and Giuseppe Ducci2,

Societ Italiana di Ipnosi, Via Tagliamento 25, 00198 Rome, Italy

Societ Italiana di Ipnosi, Via Tagliamento 25, 00198 Rome, Italy

Neuroscience, in particular thanks to imaging techniques, now makes it possible to
express the embodied, sensorimotor nature of many cognitive domains including 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.

In recent years, 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. In a previous contribution we reviewed the implications of mirror neuron functions in

Contact: renzo.balugani@libero.it
Contact: g.ducci@tin.it


Renzo Balugani and Giuseppe Ducci

the practice of psychotherapy (Balugani, 2008; Balugani and Ducci, 2007). These neurons,
rather than simply monitoring action execution, also fire during the observation of the same
action performed by someone else. The embodied simulation (Gallese, 2007) is the postulated
mechanism of resonance emerging from their functioning: this preconscious, automatic
mechanism would also allow many fundamental abilities of the mind, such as the imitative
learning, the comprehension of fine actions performed by another and the inference of the
purposes of such actions, as well as the agents intentions (Iacoboni, Molnar-Szakacs,
Gallese, Buccino, Mazziotta and Rizzolatti, 2005).
A central role of mirror neurons has also been postulated in the ability to create an inner
representation of the others mind state (including perceptual, affective and emotional
features), the ability commonly addressed as theory of mind. Thanks to the encoding of the
observed experience in the observers physiological parameters, this automatic and
preconscious process would predispose the adult human being to empathy (Gallese et al.,
2004; Gallese, 2007): in the authors hypothesis, through the process of internally simulating
the other persons goals, one comes to infer and represent the others mental state as well as
anticipate the actions these intentional mind states are likely to cause. This involves mentally
inducing the internal subjective states of the other in ourselves by imitation, identification or,
lately, through neural resonance evoked by the automatic activation of our brains mirror
neuron system during the observation of the other persons behaviour (Gallese et al., 2004;
Gallese, 2007).
This radical view - a mirror system allowing action understanding by mean of an inner
simulation mechanism - has been recently criticised by research from other fields of study
(Fonagy, Gergely, & Target, 2007). Firstly, 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 dont have motor
schemes (Kamerawi, Kato, Kanda, Ishiguro and Hiraki, 2005; Luo and Baillargeon, 2005;
Wagner and Carey, 2005). Secondarily, by using neuro-imaging techniques with very
accurate experimental designs, other researchers have found a wider activation pattern, rather
than solely localized to the mirror neuron system: the activation involves brain areas, such as
the above-mentioned superior temporal sulcus (STS), the temporo-parietal junction (TPJ) and
the anterior fronto-median cortex), which have no mirror properties and which are typically
involved in mentalisation and belief attribution tasks (Grezes, Frith and Passingham, 2004;
Saxe and Kanwisher, 2003; Saxe and Wexler, 2005). 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, in
contrast to the radical shared representation model of selfother understanding, the motor
systemincludes representations of other agents as qualitatively different from the self
(Schtz-Bosbach, Mancini, Aglioti and Haggard, 2006).
Even considering the criticisms raised against the hypothesis of a unique, sensory-motor
mechanism able to manage the attribution of meaning to human experience, we are not prone
to abandon the importance given to embodied processes. As we described in a previous work
(Balugani, 2008; Balugani and Ducci, 2007), there are other features of brain function that
highlight the existence of such a mechanism, mental imagery being one of these. The ability
to autonomously activate representations of fine-graded, 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, mental imagery is

Language, Metaphor and Neuroscience


deliberated, conscious and controlled. In spite of that, 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,
2001). 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, an embodied
simulation process is implicated.
Similar characteristics are traceable in another cardinal cognitive domain: language. In
the present work, we would like to analyse concept formation, categorization and reasoning
and their correlations with embodied mechanisms. After that, we would like to discuss some
important implications in the psychotherapeutic process in general, and in hypnotic therapy in
particular. As we pointed out previously (Balugani, 2008; Balugani and Ducci, 2007), we
consider hypnosis embodied in nature per se. 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.


A vast, 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, 2005; Gallese, 2003). They begin with a firm critique of the classical theories of
language, for which concepts were conceived as abstract, amodal, and arbitrary, made up of
symbols and having the properties of productivity and compositionality, among others. In
Fodors theory (see Fodor, 1975), the purported amodal (or supra-modal) nature of concepts
would be implemented in putative brain structures, endowed with characteristics and rules
totally independent from those governing the input/output modules. Cognitive linguistics, in
contrast, ascribes the inferential structure of concepts to the web-like structure of the brain as
well as its organisation in functional clusters. The human brain can generate and use concepts
owing to the previous experiences of interaction with the phenomenic world, and to the
development of perceptual and motor processes in charge of regulating these interactions.
From this position, the theory of the grandmother cell is refuted: a neuron codifying for the
grandmother meaning, the loss of which would cause the loss of its semantic counterpart,
doesnt exist. Contrarily, concepts are embedded in a web of connections, with the functional
clusters governing the sensory motor experience (Lakoff and Johnson, 1998) at the most basic
level. At least, in this regard, concepts are primarily embodied.
Accordingly, language is inherently multimodal in this sense: it uses many modalities
linked together, i.e., sight, hearing, touch, motor actions, and so on. Language exploits the
pre-existing multimodal character of the sensory-motor system. If this is true, it follows that
there is no single module for language1. But let us look in detail at the arguments regarding
the categorisation and concept formation.

In the words of Gallese and Lakoff, It is important to distinguish multimodality from what has been called
supramodality. 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, & Lakoff, 2005).


Renzo Balugani and Giuseppe Ducci

The classic theory of categorisation assumed that categories formed a hierarchybottom

to topand that there was nothing special about those categories in the middle. This view
was challenged by the research by Rosch and her co-workers, who found that in the
hierarchies continuum, such as vehiclecarsports car, the one in the middle is special:
Rosch called it the basic-level category (Rosch, 1973; 1978). One can get a mental image
of a car but not of a vehicle in general: we have motor programmes for interacting with cars,
but not with vehicles in general (a bicycle requires very different motor skills of those
involved in the driving of an articulated lorry)2. The basic level is the highest level at which
this is true. Moreover, words for basic-level categories tend to be recognisable via gestalt
perception, learned earlier, to be shorter (e.g., car vs. vehicle), to be more frequent, to be
remembered more easily, and so on. Rosch observed that the basic level is the level at which
we interact optimally in the world with our bodies. The consequence is that categorisation is
embodiedgiven by our interactions, not just by objective properties of objects in the world,
as a long philosophical tradition had assumed. 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, both part of the same, more general
feline). He just didnt have the time to transmit his genes to the descendants!
This way, it is easier to consider the actual brain organisation as a consequence of our
evolutionary history, which is the way in which our brain and the brains of our evolutionary
ancestors have been shaped by bodily interactions in the world.
It is now simpler to hypothesize a body-based comprehension: according to Gallese and
Lakoff, understanding requires simulation, as they argue about the concept of grasp. A
growing body of neurophysiological evidence confirms that it is true for concrete concepts,
such as physical actions and physical objects.
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 (Brocas area), those sectors of the premotor cortex where the
actions described are motorically coded, as well as the inferior parietal lobule, the
intraparietal sulcus, and the posterior middle temporal gyrus. These data provide direct
evidence that listening to sentences that describe actions engages the visuomotor circuits,
which subserve action execution and observation.
Two research studies, one (Hauk, Johnsrude and Pulvermuller, 2004) using fMRI and one
(Buccino et al., 2005) using motor-evoked potentials (MEP) and transcranial magnetic
stimulation (TMS), pointed out that processing verbally-presented actions (related to mouth,
hand and foot) activates the specific motor system involved. This is coherent with the
hypothesis that concept understanding involves sensory-motor mechanisms (the embodied
simulation postulated by Gallese). In particular, the results obtained with TMS and MEP
recordings show that when the response to the behavioural task is given with the hand,
reaction times are slower during listening to hand-action-related sentences (Buccino et al.,
2005), indicating a facilitation due to a sub-threshold activation.

Furthermore, what is true for the basic level category is also applicable for the more particular ones: with few
variants, the drive programmes of a sports car and a runabout are the same.

Language, Metaphor and Neuroscience


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, Buccino, Lange, McNamara and Binfofski, 2007).
Nowadays, any traditional theory that claims that concrete concepts are modality-neutral
and disembodied encounters great difficulties. The modality-neutral structure is just not
needed, and if it exists, it would be a useless duplication, contravening Occams argument.
On the contrary, these results taken together give us a confirmation of the thesis of
embodied semantics. It holds that conceptual representations accessed during linguistic
processing are, in part, equivalent to the sensory-motor representations required for the
enactment of the concepts described (Aziz-Zadeh, Wilson, Rizzolatti and Iacoboni, 2006).


As everyone knows, human language and thought dont operate just on concrete
concepts: many facts of interest can appear to the consciousness without any impact on our
sensory filters. Abstract concepts such as feelings, moral values and spiritual ideals, before
being something the human being is prone to live and die for, are daily matters to deal with;
furthermore, we make daily efforts to share them with others. 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, talk about them and regulate their behaviours by virtue of them.
How can the human brain build a stable representation of the concepts of freedom,
morality and causality, 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 such a flexible way that allows it to cope with a permanently changing reality?
By a dodge. Every natural language, in the course of cultural evolution, has selected a
rich repertoire of metaphors used as equivalences. In order to catch and manipulate an
abstract concept, its principal characteristics are compared to those of another concrete, wellknown concept that will work as a prototype. As it is customary to interact with the latter, so
will it be with the former. The cognitive linguistic calls these metaphors conceptual: the
abstract concept requiring explanation (the explanandum) is mapped on an image-schemata
(the explanans), which is a neural representation whose origin lies in the experiential,
sensory-motor domain.
In such a way, the knowledge accumulated during the sensory-motor interactions with the
physical worldreal sensations and actions with real objectsare projected by analogy to
the explanandum, allowing a fictitiousabstractly and no more concretelybut effective
interaction with it. Following Lakoff (1987), metaphor is not just a matter of rhetoric, but a
way we think, through a systematic projection from a source domain to a target one. In Lakoff
and Johnsons words: Metaphor is pervasive in everyday life, not just in language but in
thought and action. Our ordinary conceptual system, in terms of which we both think and act,
is fundamentally metaphorical in nature (Lakoff and Johnson, 1980).
Lets look at an example: How do we reason and talk about the concept of time? Through
a limited number of metaphors, time is moving objects being one of these. 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.g., time and its


Renzo Balugani and Giuseppe Ducci

discrete moments) on the image-schema of the source domain (moving objects). This way,
any discrete future moment is intended as a concrete object moving from a perceptual-like
horizon toward a fixed observer, the speed of its movement being the same as that of the time
flow. Another frequent metaphor is the seemingly different one of time is a fix field which
the observer moves on. In this case, the observer moves along a field punctuated of discrete
objects representing the discrete moments: Think about the expressions Well arrive at the
date without finishing the job or Id like to come back to my childhood time. Time is seen
here as a fix background where the observer can move forward (future) or backward (past).
Lakoff and Johnson (1998, 1999) give us a full, rich description of the primary imageschemas we use everyday in thought and in language, often in a preconscious, automatic way.
Some of the prominent primary schemas are the following:
Intimacy is closeness (e.g., We have a close relationship).
Difficulties are burdens (e.g., Shes weighed down by responsibilities).
Affection is warmth (e.g., They greeted me warmly).
Importance is big (e.g., Tomorrow is a big day).
More is up (e.g., Prices are high).
Similarity is closeness (e.g., Those colors arent the same, but theyre close).
Organization is physical structure (e.g., How do pieces of the theory fit together?).
Help is support (e.g., Support your local charities).
Time is motion (e.g., Time flies).
States are locations (e.g., Im close to being in a depression).
Change is motion (e.g., My car has gone from bad to worse).
Purposes are destinations (e.g., Hell be successful, but isnt there yet).
Causes are physical forces (e.g., They push the bill through Congress).
Knowing is seeing (e.g., I see what you mean).
Understanding is grasping (e.g., Ive never been able to grasp transfinite numbers).
A key note: Because they originate in the kinaesthetic possibilities that our body has to
interact with the physical world, the most basic of these schemas are limited in number.
Anyway, the use we make of them in understanding and talking about abstract concepts such as love, causality and time - is ubiquitous in our everyday lives.
When the source domain is suitably basic, such as when it deals with human kinaesthetic
experience or knowledge of the properties of physical objects, then we are no longer just
talking about metaphor, but rather about a system for the embodiment of human cognition.
This step is very close to the concept of embodied simulation (Gallese, 2004). Embodiment is
sometimes also referred to as semantic or symbol grounding, by which is meant a process for
assigning meaning to an arbitrary symbol. The image-schemas consist of basic level
kinaesthetic programmes (Johnson, 1987), the kinds of sensorimotor experiences that begin at
the earliest age and involve the most central objects and actions in our lives. Basic-level is
meant in the tradition of Rosch, as that level of interaction with the external environment at
which people function most effectively and accurately. This basic level is characterized by
gestalt perception (the whole is more than its parts), mental imagery, and motor movements
and our proprioceptive perception of those movements.
As everyone can note, in natural language we use a number of conceptual metaphors
larger than that permitted by the primary mappings listed above. A compound or complex

Language, Metaphor and Neuroscience


metaphor is a self-consistent metaphorical complex composed of more than one primitive.

Complex metaphors are created by blending primary metaphors and thereby fitting together
small metaphorical pieces into larger metaphorical wholes. For instance, consider the
following three primitive metaphors: persisting is remaining erect, structure is physical
structure, and interrelated is interwoven. These three primitives can be combined in
different ways to give rise to compound metaphors that have traditionally been seen as
conceptual metaphors. But the combination of these primitives allows for metaphorical
concepts without gaps. Thus, 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, etc., without any
mappings such as theories need windows.
Given the complexity which compound metaphors can reach, 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, sensory-motor ones. On
the base of connectionist models (Narayanan, 1999), Lakoff offers the hypothesis that the
most abstract concepts, such as metaphoric ones and those belonging to grammar in any
natural language, are coded in secondary areas, not directly involved in the action/perception
information processing (Gallese and Lakoff, 2005).
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. Lets now see how cognitive neuroscience help
us to understand the way our brain process metaphors.
Linguistic analysis as well as psychological studies indicate an embodiment of metaphor.
Human brain creates, manages and talks about conceptual metaphors through the very same
parameters emerged during the development of sensory-motor skills. 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. Gibbs and co-workers give us a convicting
description of the physical momentum / representational momentum matching, on which are
built a number of daily used metaphors, as in the expressions: I was bowled over by that
idea; I got carried away by what I was doing; You had better stop the argument now
before it picks up too much momentum and we cant stop it, and so on (Gibbs, Costa Limab
and Francozo, 2004).
Seitz (2005) accurately reviewed some major strand of scientific evidence (evolutionary,
developmental, 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. These basic metaphoric equivalences operates
largely outside of conscious awareness, and include perceptual-perceptual, movementmovement, cross-modal (synesthetic), and perceptual-affective relations demonstrated to be
uniquely mapped onto brain networks (Seitz, 2005). In accordance with Gallese and Lakoff
(2005) and Gibbs and colleagues (2004), moreover, he posits that linkages belonging to a
complex, secondary metaphor is a self-consistent amalgam of more than one primitive,
partially losing the involvement of sensory-motor areas.
Indirect evidence of the link between metaphorical generation and manipulation skills
and the embodied simulation system is given by the neuropsychology of patients suffering


Renzo Balugani and Giuseppe Ducci

from autism: they can not make any use of metaphorical images, being their language strictly
literal. The evidence relies in their recently recognised deficit of such fronto-parietal circuitry
having mirror properties (Oberman, Hubbard, McCleery, Altschuler, Ramachandran, &
Pineda, 2005).

Some authors found enlightening implications of the mirror system in elucidating
hypnotic induction, 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, at the root of the
implicit acquisition of new, adaptive skills (Rossi and Rossi, 2006).
Moreover, from our point of view, hypnotic psychotherapy is a very advantageous one by
virtue of its embodied nature, as well as its possibility to directly modify the basic
computational level of the patient, the sensory-motor one (Balugani, 2008; Balugani and
Ducci, 2007).
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.
Neuropsychophysiologic theory of hypnosis postulates that during this altered state of
consciousness the aware, logic, controlling role of left hemisphere (LH) is reduced, in favour
of RH holistic, analogical processes (Gruzelier, 1998; 2006).
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. The comprehension of new, unconventional metaphors is processed in the
Wernicke homologue area, in the posterior superior temporal sulcus (STS), in the inferior
frontal gyrus (IFG) of the RH; in contrast, the processing of semantically correlated concepts
inside salient and conventional verbal expressions relies in the LH functioning. Moreover, the
results support previous researches indicating that during word recognition, the RH activates
a broader range of related meanings than the LH, including novel, nonsalient meanings
(Mashal, Faust and Hendler, 2005; Faust and Mashal, 2007). These data suggest a close,
functional link between metaphors and hypnosis.
In every linguistic transaction we can make two kind of use of metaphors: the first and
more obvious is the rhetoric one, in which a metaphorical image is explicitly sorted out by the
speaker in order to pict out a nonliteral meaning. For example, a patient feeling having not
enough resources to fly up in his/her existential journey could say I have loosen my wings,
we could refer to an impulsive patient by saying He doesnt let the grass grow under his
feet, and so on.
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, having recourse to the experiential repertoire about our previous interactions with the

Language, Metaphor and Neuroscience


physical world. In the utterance anger urged me to react that way, a patient could select a
particular case of the conceptual metaphor emotions are forces, by which showing the
impotence and passivity he/she felt.
While the first kind of metaphors is conscious and arbitrary (often a matter of eloquence),
the second one is pre-reflexive, unaware and largely universal for the speakers a specific
idiom. Even universal, some variant can be more frequent in specific conditions, such as in
mutually segregated cultural contexts.3 Psychotherapeutic relationship is not an exception,
conceptual metaphors being real organizational principles allowing the building and sharing
of shared narrations between therapist and patient (Casonato, 1994).
Rapport is the name given to the intense cognitive, emotional, and behavioural
attunement existing between patient and hypnotist: thanks to this attunement, the both
become more and more mutually responsive. Among the most frequent techniques used to
empower rapport, as described in any Ericksonian psychotherapy handbook, pacing implies
the acceptance and utilization by the therapist of the spontaneous characteristics of a patients
language (Bandler and Grinder, 1975; 1976; 1977). The same use of predicates (nouns
describing action or events, verbs and their modifiers) allows the therapist to tailor a finer
graded intervention following the patients existential point of view (Gordon and MeyersAnderson, 1984). Pacing facilitates rapport in the fact that the therapist is in the patients
(linguistic) shoes. In agreement with the primary embodied nature of language (as discussed
above), 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,
Gilligan and Zeig, 1991; Zeig, 1984; Zeig, 1982; Gilligan, 1982). If the patient says I cant
catch the meaning, I cant see any association between my problem and your solution we
first categorise him/her as visually/kinaesthetically inclined; then we can think about the
specific use of the conceptual metaphors grasping is understanding, seeing is knowing:
not just as a technical imperative, but in order to encode his/her very specific
phenomenological horizon in his/her own sensory-motor parameters. Using the same
metaphors will allow us to better attune with him/her. A second argument in favour of
including the metaphoric expressions in our hypnotic diagnosis, is the known existence of
variants in their use among different psychopathological conditions. In fact, 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, 2004).
When the excited patient says Events run over me or The present rapidly runs away,
he/she uses the metaphor in a particular way: the observer is oriented toward the future, and
time runs away in a fast, elusive way. On the other hand, depressed patients who say When I
realize that time goes on, its already gone, I live in an eternal present, or I cant go on
mean that they are turned to the past, time has stopped its flow, and their movement toward
future events is impossible.
If we are able to catch these detailed minimal cues we will better attune, empathize and
understand our patients phenomenological experience.
Once a good rapport is built and every useful detail is recorded in our hypnotic diagnosis,
we have to meet another principle of Ericksonian therapy: utilization. It means that we have

See a French work discussing the conceptual metaphor body as container, and its variants in fields as clinical
psychopathology, Freudian and Ericksonian psychotherapy, and poetry (Santarpia, Blanchet, Cavallo and
Raynaud, 2006)


Renzo Balugani and Giuseppe Ducci

to start our intervention from the frame given by that patient, from the lenses he/she uses to
look at the reality, in order to allow him/her to build new narratives, new associations, new
evocations (Casilli and Ducci, 2002). It is absolutely necessary that utilization include the
metaphorical repertoire of the patient, both the rhetoric and the conceptual ones. Utilization
will mean using that repertoire in a strategic way, contemporarily making him/her feel
accepted and authentically understood: at the same time, we then tell a story, a metaphor or an
anecdote using his/her very same idiom but also promoting the therapeutic change.
Casula argues that metaphor allows therapists to send messages resulting from a
combination of scientific reasoning and therapeutic intuition (2005). In fact, 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. First of all, the
embodied parameters of patient and therapist (Balugani and Ducci, 2007; Balugani, 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, Blanchet, Venturini, Cavall and Raynaud, 2006).
Taking into account a hypnotic diagnosis that includes all of the communicative aspects
(beyond the cognitive and the behavioural ones usually considered), 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, grounding its root in his/her sensory-motor
Following Haley, analogical and metaphoric techniques are particularly effective with
resistant subjects, based on the fact that they cannot resist a suggestion that they are unaware
of receiving (Haley, 1973): in order to raise the effectiveness of our intervention, then, we
will enrich a metaphor of such sensory-motor features belonging to the real action involved as
if it were real. If a ruminating patient complains about the difficulty of making a decision and
says I cant come to the point, our purpose will be to virtually imagine walking toward a
well-described point in a field of grass, getting over any obstacle.
Our language will be as concrete, clear and easy as possible: such is the language used by
the right hemisphere (Gruzelier, 1998). For the same reason, 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.
The following is the case of Franco, a young patient who has discovered he is HIV
positive only five months ago. The illness is being managed well and he doesnt need to take
medication. But his partner is trying to leave him, denying that the reason is the risk of
infection. Franco is very depressed, and the actual situation reactivates old feelings of being
inadequate and a loser. During the therapy, the hypnotist suggests, as a personal experience,
to give attention to some little and usual experiences, 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, or the sweet sound of little waves on a beach and the smell of the sea in a night lighted
by the moon, or the smell of the wet ground after a summer rain, and how all these usual
experiences come together to bring about the comfortable feeling of being alive. The
repetition of these suggestions, at the same time, evokes the strength and the stability during
the time (in the past, in the present and, above all, in the future) of the cottonwood, of the
beach, and of the ground, giving the opportunity for the subject to identify himself in these
features. It wouldnt 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

Language, Metaphor and Neuroscience


intended to bring about the desired representation in a way that is mostly outside of the field
of consciousness and intentionality.
In this regard, there are numerous works indicating lists of therapeutic metaphors
(Barker, 1987; Casula, 2004). Often, nevertheless, the easiest way to find a good one is to
accurately listen to our patients.
This is the case of Gianluca, whose feelings of emptiness and demotivation to meet the
challenges of everyday life are described, in his words, as being barren, dried, with not
energy enough inside of me. The therapist, identifying these details as a part of the metaphor
interior life as soil, directs the patient to watch the field and the aqueduct in charge of
carrying the water; then, 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. Once
found, 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. Back to the soil, look at the slow but inexorable impregnation as the ground
becomes soaked and fertile. 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, confident
Another delicious example of the Ericksonian approach is offered by Roffman, as a part
of an insightful article explaning how metaphor works in psychotherapy. He depicts the case
of a nine-year-old child suffering from encopresis (Roffman, 2008). When the excited boy
narrates in detail his uncle operating with excavators and bulldozers, the therapist follows
him, transforming that casual description in an effective therapeutic metaphor, asking him
what these machines do with the dirt they pick up.

They dump it into the dumptrucks.

Then what happens?
The dumptrucks take it to the place, the dump or whatever, and drop it off.
They dump it?
Yeah, what else should they do with it?
Quite right. But how do they know where to dump it and when?
They just know. Theyre not stupid.
You mean they know where to dump it. They dont just dump it wherever
or whenever? They do it in the right place at the right time?
Of course, what do you think?

We would like to conclude with a consideration evoked by the nature of Batesonians

syllogism in grass (grass dies, men die, men are grass), as discussed in Roffman (2008). In
metaphors as well as in psychotherapy, we operate in a domain where associations are right if
and when they work: consistence or logical are often question of no importance.
This is why a humble attitude is cardinal among therapists: they offer, dont force. 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.


Renzo Balugani and Giuseppe Ducci

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Balugani R., & Ducci G. (2007). Ipnosi e neuroscienze. Neuroni specchio, simulazione ed
immaginazione allopera nellazione terapeutica. Ipnosi, 1: 5-18.
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In: Hypnosis: Theories, Research and Applications

Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456 2009 Nova Science Publishers, Inc.

Chapter 5


Udi Bonshtein
Child & Family Guidance Unit, Western Galilee Hospital, Nahariya, Israel
and The psychotherapy study program, Zefat, Israel

The main aim of the present paper 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 paper 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 paper 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.

It could be interesting to look backward,

Where things had begun

Psychoanalysis and Hypnosis
Psychoanalysis was born out of hypnosis. Sigmund Freud, the Viennese physician who
founded Psychoanalysis, arrived on a fellowship at Jean Martin Charcot's hospital,


Udi Bonshtein

Salpetrie`re, in late 1885. Freud had previously acquired an interest in hypnosis as a medical
student, and engaged in some clinical applications. He had originally intended to study
neuropathology in Paris, but because of his personal bonding with Charcot (the mentor he
called his great teacher; Freud, 1914/1957, p. 13), his special interest soon shifted to the
psychopathology of hysteria. His meeting with Josef Breuer, a prominent Viennese physician
who was 14 years Freuds senior, led to their co-authored essay, "Studies in hysteria" (Breuer
and Freud, 1895), which is generally considered as the formation point of psychoanalysis,
although it was actually a book about hypnosis. Let us take now a careful look at that time.
The development of psychoanalysis since Breuer and Freud's pioneering work reveals
three main split offs. Two of them are externals - the split between psychoanalysis and brain
science and the split between psychoanalysis and hypnosis. The third was an internal split
(actually, many splits) within psychoanalysis; dividing it into many divisions and schools. We
can begin our journey by reviewing each of those splits.

Psychoanalysis Splits off from Brain Science

I believe that Freud consciously chose to move away from neurology and found a new
discipline. He abandoned brain research in favor of the subjective point of view establishing
psychoanalysis. Due to the lack of effective research methods at that time, he chose a
different method of learning about human subjectivity. Freud saw this split as temporary,
until science would be able to investigate the mind. Another reason for Freud's choice to
found a new discipline was the sociopolitical atmosphere in Vienna. As a Jew who spoke
about sexuality as the main inner motivator of children and adults he was isolated from the
mainstream of psychiatry. He worked on his own at first, gradually winning over colleagues
(Gay, 1988).

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. He preferred to do
this by using free associations. One can ask if lying on a couch and offering free associations
is not a variation of hypnosis. One can ask the same thing about transference, since
transference emerges very powerfully during hypnosis.
Freud was not sure about his qualifications as a hypnotist, which was another reason for
abandoning this method in favor of psychoanalysis. This is surprising, since Freud seems to
have been a creative therapist who was very successful in hypnotizing his hysteria patients.
As I see it, Freud never abandoned hypnosis, but only its authoritative style, replacing it with
a more permissive form of hypnosis, which he called psychoanalysis.
Despite his announced abandonment of hypnosis as a clinical technique in 1896, Freud
maintained an interest it throughout his career (Gravitz, 1991; Gravitz & Gerton, 1984).
Hypnosis was both mysterious and personally unsettling for him.
In fact, hypnosis and psychoanalysis have more similarities then differences.
Psychoanalysis is saturated with suggestive processes, including free-association, therapeutic
setting (lying on the couch, therapist's tone of voice, routine of time) and suggestivity of

The Relational (Intersubjective) Approach to Hypnosis


psychoanalytic theories (Bonshtein, 2003). Moreover, the theory and practice of hypnosis
developed in parallel with psychoanalysis, using psychoanalytic conceptualizations such as
transference, objection, defense mechanisms and the like, which are important to every
hypnotists' training and daily work.
This split, like the previous one, served the developmental and consolidation of
psychoanalysis as an independent discipline. Freud owed a great debt to the hypnotherapists
of his time, mainly Charcot and Janet.
Pierre Janet was a pioneering French psychiatrist and philosopher in the field of
dissociation and traumatic memory. 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, and he coined the
words dissociation and subconscious. He studied under Charcot and managed Charcot's
Psychological Laboratory while Freud was there. Despite the similarities of some of his ideas
to those of Freud (some consider him the true founder of psychoanalysis, as he preceded
Sigmund Freud in some ways), 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, but this is not the place to discuss this issue.
In essence, according to Freud, the hypnotic subject played a passive dependent role. In
1890 he compared hypnosis to the relationship between parent and child (Freud, 1890/1953).
It was, he said, these attributes that facilitated the subject's acceptance of the therapist's
suggestions. He further maintained that hypnosis is a manifestation of libidinal regression in
which the patient undergoes temporal regression to an infantile dependent relationship (Freud,
1905/1953). For Freud (1921/1922), then, the effects of hypnosis derived from the
overarching construct that they were basically transferential phenomenon. Transference . . .
can give you the key to an understanding of hypnotic suggestion (Freud, 1910/ 1957, p. 51).

Splits within Psychoanalysis

The many splits within psychoanalysis occurred because different practitioners defined
the borders of the field differently. These splits served a necessary developmental function.
Even in the Bible, in Genesis creation occurs trough separation (or splits): God divided the
light from the darkness, the upper waters from the lowers waters, the day from the night, men
from women and the like.
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, 1997).
During the past 15 years, there has been a vast change in psychoanalysis. It takes the
form of a broad movement away from classical psychoanalytic theorizing grounded in Freud's
drive theory, toward models of mind and development grounded in object relations. In
clinical practice, there has been a corresponding movement away from the classical principles
of neutrality, abstinence and anonymity toward an interactive vision of the analytic situation
that places the analytic relationship, with its powerful, reciprocal affective currents, in the
While the goal of psychoanalysis in Freud's day was rational understanding and control
(secondary processes) over fantasy-driven, conflictual impulses (primary processes), the goal
of psychoanalysis in our day is most often described as the establishment of a richer, more


Udi Bonshtein

authentic sense of identity (Mitchell, 1993). What the patient needs, according to Mitchell, is
not clarification or insight so much as a sustained experience of being seen, personally
engaged, and, basically, valued and cared about. What today's analysis provides is the
opportunity to freely discover and playfully explore one's own subjectivity, one's own

And now, in your pace

Easily, safety and softly
You can come to here and now
Healing the Splits
Psychoanalysis and brain science are meeting again those days. We can see the subjective
and objective points of view join together in the inter-disciplinary field called neuropsychoanalysis. Brain researchers uses psychoanalytic concepts to investigate human
subjectivity, and psychotherapists uses empirical findings to advance theoretical and clinical
The split between hypnosis and psychoanalysis has not healed yet, but it is beginning to
do so. Over the years, psychoanalysts have become more antagonistic towards hypnosis, but
hypnotists have become more favorably disposed to psychoanalysis. In fact, the essential
developmental pathways of psychoanalysis are reflected in the theory hypnosis and its clinical
implications. The professional hypnosis literature contains many interpersonal and
intersubjective considerations, of "hard" psychoanalytic concepts are used (as in the HypnoAnalytic approach). Present psychoanalytic objectives seems to fit in with modern approaches
to hypnosis.
The healing of the rift in psychoanalysis was achieved by adopting a meta-theoretical
point of view, which combines interpersonal and intrapersonal psychologies. In fact, this is
happening right now. Theory is no longer a truth on its own, but more like an organizer of
human experience, allowing us to make more flexible use of it.
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. More detailed information on this topic can be found
in Balugani (2008) and Jamieson (2007). Here I focus on one of the new and most promising
discovery of recent years: mirror neurons.
A mirror neuron is a neuron which "mirrors" the behavior of another animal or human,
by firing both when the animal (or human) itself acts and when it observes the same action
performed by another.
These neurons were first discovered by Giacomo Rizzolatti and his research team in Italy
in the early 1990s, while investigating primate motor cortex (see Rizzolatti et al., 1996;
Rizzolati & Craighero, 2004).
In the human brain, mirror neurons have been found in the premotor cortex and the
inferior parietal cortex. Some scientists believe that mirror neurons might be very important
in imitation and language acquisition. It is generally accepted that no single neuron can be
responsible for any phenomenon. Rather, a whole network of neurons (neuronal assembly) is
activated when an action is observed. These neurons may be important for understanding the

The Relational (Intersubjective) Approach to Hypnosis


actions of other people, and contribute to our Theory of Mind (ToM) skills. The term "theory
of mind" refers to the ability to represent mental states of others or one self, including their
beliefs, feelings, intentions or knowledge, and account for their behavior. Some preliminary
evidence connects ToM and hypnosis demonstrating that the same brain regions and modules
are involved in both (Bonshtein, in preparation).
Rossi and Rossi (2006) proposed that mirror neurons may function as an interface
mediating among the observing consciousness, the gene expression/protein synthesis cycle,
and brain plasticity in therapeutic hypnosis and psychosomatic medicine.
Linking absorption, empathic, introspective, and reflective functions to hypnosis leads us
closer to the relational perspective on hypnosis. Hypnosis, in this view, is a process involving
two active partners, like the theoretic assumption in the psychoanalytic relational field. We
begin with a short review of the relational approach and then examine its implications for


Adopting a relational (intersubjective) perspective in psychoanalysis means giving up
what Stolorow and Atwood (1992) call the myth of the isolated mind. Intersubjectivity is
the sharing of subjective states by two or more individuals. It is very close to my view of
hypnosis as a shared subjective state and to Winnicott's potential space, which I consider in
more detail in below.
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. Relationalists argue that
personality emerges out of the matrix of early formative relationships with parents and other
While in traditional psychoanalytic thought (such as Freudian theory) human beings are
motivated by sexual and aggressive drives, relationalists argue that the primary motivation of
the psyche is to be in relationships with others. As a consequence early relationships, usually
with primary caregivers, shape one's expectations about the way in which one's needs are met.

Figure 1. A dwarf saxophone player or a female face?

Therefore, motivation is determined by the systemic interaction of a person with his or
her relational world. Individuals attempt to re-create these early learned relationships in
ongoing relationships that may have little or nothing in common with those early


Udi Bonshtein

relationships. 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. This re-creation is called enactment.
For relational analysts, psychotherapy works best when the therapist focuses on
establishing a healing relationship with the patient, in addition to focusing on facilitating
insight. They believe that this helps the patient break out of the repetitive patterns of relating
to others that maintain psychopathology. In the treatment room there are two subjects, the
patient and the therapist, each of whom bring his unconscious to the situation, with mutual
(but not symmetric) relations. The therapist's subjectivity and specific encounter with the
patient's subjectivity is crucial in that view. In the post-modern age there is no place for one
and only one truth (e.g., the unconscious drive that is seen by the therapist as is hiding from
the patient's consciousness). Truth is relational and context-dependent, as demonstrated in
figure 1: One can see a dwarf saxophone player or a female face at any time. Both are
The primary significance of those theories is that the therapist's subjectivity is important
as a diagnostic or theraputic tool. Some basic concepts that can be used in relational hypnosis
are projective identification, containment, attunement, enactment, transitional space and selfdisclosure.
Projective Identification
Melanie Klein (1946), who first introduced the term, considered it as an intrapsychic
phenomenon, while her followers (especially Bion) considered it as an interpersonal
phenomenon. Projective identification is defined as a phenomenon in which a person projects
a part of himself into another object (not onto it, as occurs in projection) in such a way that
his behavior towards those onto whom he projects part of himself evokes the thoughts,
feelings or behaviors projected. Consequently, projective identification brings about a change
in the psychic reality of the receiver of the projection. 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. This is a process that generally happens outside the awareness of both persons
What is projected is most often an intolerable, painful, or dangerous idea or belief about
the self that the projecting person cannot accept. 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. Yet it is also thought to be the basis from which more mature
psychological processes like empathy and intuition are formed, and have a communicative
In psychoanalytic theory, the term "container" is associated with the development of the
concept of projective identification. When a part of the self is projected into an object, the
object then becomes a container that holds what has been projected into it.
In the mother-infant relationship, the infant projects into the mother parts of the self that
are intolerable and suffused with anxiety. The mother constitutes a container for the projected
parts of the infant. She contains what is projected. The affective and mental condition of a
mother capable of taking in what has been projected and remaining with it is called 'reverie'.
In the therapeutic situation the therapist serves as a container. With the development of
the intersubjective approach in psychoanalysis (Berman, 1997), the can no longer be

The Relational (Intersubjective) Approach to Hypnosis


considered empty. The reactions of the therapist to the patient in many cases are not merely
the result of the patients projective identification, but rather a mixture of projected parts of
the patient with denied and split-off parts of the therapist.
Affect Attunement is Stern's (1985) conceptualization of a sharing or alignment of
internal states in the domain of intersubjective relatedness. For Stern, the subjective sense of
self is something that arises about of a kind of mutual, wordless experience that he describes
as attunement based on his observational work.
Attunement differs from empathy in that attunement occurs largely outside of awareness
and almost automatically, while aspects of empathy require conscious cognitive mediation.
Both empathy and attunement share emotional resonance, but attunement takes emotional
resonance and recasts it into another form of expression, sometimes even another sensory
modality. It is a distinct form of affective transaction in its own right.
Enactment has become a central concept in psychoanalytic understanding of the therapy
process. Relational psychotherapists argue that the primary motivation of the psyche is to be
in relationships with others. Early relationships, usually with primary caregivers, shape one's
expectations about the way in which one's needs are met. Individuals attempt to recreate these
early learned relationships in ongoing relationships that may have little or nothing to do with
those early relationships. 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.
Transitional Space
The concept of ransitional space is a condensation of Winnicott's ideas of potential space
and transitional phenomena (Winnicott, 1971). Potential space is the overlapping space
between two individuals, neither subject nor object but some of both. In this space we find
transitional objects and transitional phenomena. Hypnosis, for many reasons (as Winnicott
himself thought about psychoanalysis), is a transitional phenomenon which occurs in
transitional space.
Self Disclosure
Self-disclosure is the act of revealing more about ourselves to others: what we feel, think,
imagine, dream, and the like. In psychotherapy the patient is the one who reveals his or her
inner life. Freud, for example, insists that the psychoanalyst must be neutral and anonymous,
but actually discloses himself to his patients to a great extent. In relational psychoanalysis,
however, self-disclosure serves as a useful therapeutic tool, although still a very controversial


Udi Bonshtein


Empirically, the intersubjective school is inspired by research on infants non-verbal
communication, which in turn inspired research on the hypnotize-hypnotist dyad. Such
research has been conducted by Eva Banyai and her collegous at their laboratory in Budapest.
Traditional approaches focused either on the hypnotist or on the subject's hypnotic states.
Historically, the hypnosis literature has concentrated either on the skill of the hypnotist (such
as Mesmer or, more recently, Erickson) or on the hypnotizability of the subject (such as
Charcot and the authors of the modern hypnotic susceptibility scales). Since researches
focused on either the hypnotist or the subject, they attributed hypnotic effects to only one of
them ("one- person hypnosis"). Banyai (1998) described this split as reflected in the fact that
clinicians using hypnosis as a therapeutic tool tend to follow the mesmeric tradition,
emphasizing the hypnotists' skilled and sometimes even virtuoso technical manoeuvres
(Barber, 1980; Haley, 1963; Van Dyck, 1982; etc.). Experimental investigation, in contrast,
has focused almost exclusively on changes occurring within the hypnotized person. Owing to
the important recognition that hypnotic responsiveness as measured by standardized scales is a stable personality trait, compelling data have been accumulated on the differences in
people's susceptibility to hypnosis (Hilgard, 1986).
From the relational point of view there is no need to limit ourselves by focusing attention
on either the hypnotist or the subject (i.e, on only one of the individuals participating in
hypnosis). Rather, we can consider hypnosis an interpersonal process ("two-person hypnosis",
involving a paradigms shift equivalent to the main shift in psychoanalysis, mentioned earlier).
From this point of view the two participants affect each other consciously and unconsciously,
and sensitive hypnotists can gain an advantage by paying attention to their inner mental life
during hypnosis. Livnay calls this the hypnotist trance (Livnay, 1995, 1996).
Sandor Ferenczi (1909), who considers hypnosis in an interactional framework,
hypothesized a distinction between 'maternal' and 'paternal' hypnosis. Banyai (1998) further
identified two different working styles of hypnotists: one a physical-organic style
characterized by proximity, warmth and being very personal with the subject, which she
likened to Ferenczi's (1909) description of a maternal hypnotist, as opposed to a analyticalcognitive style, characterized by distance and reason, which she likened to Ferenczi's
description of a paternal hypnotist.
Case vignette 1:
Ruth is a 30-year old hi-tech worker, married, with one child. She came to therapy due to
a severe case of trichotillomania (compulsive hair pulling). As in the case of anxiety disorders
(some consider anxiety management difficulties as the basis of trichotillomania), in the first
stage of therapy I am more authoritative, didactic and serve as an information supplier, as is
Ferenczi's description of paternal hypnosis. In this initial stage Ruth needed to feel that she
had someone to lean on. When I became more permissive and acceptive she regressed back to
her starting point, giving up all her accomplishments. Since she had already had some
ineffective treatments in past, I listened very carefully to what she "said", understanding that
my paternal stance had been a response to her archaic needs at that phase. I used that stage to
gave her "homework", an exercises, according to the integrative hypnotic-CBT model
(Bonshtein et al., 2005), which led to complete cessation of her habit. At the next stage I
became more flexible, accepting and "maternal", and started to deal with more affective

The Relational (Intersubjective) Approach to Hypnosis


In addition to the paternal and maternal styles, Banyai (2002) described two more styles
of hypnosis: sibling style and lover-like style.
In the sibling style hypnosis is based mainly on equality. The hypnotist almost wishes to
participate in the realization of the desires and ideas of the hypnotized subject, and accepts
this person's independent initiatives. The hypnotist places emphasis on togetherness. The
atmosphere is an intimate one.
In the lover-like style hypnosis is built mainly on erotic attraction. The feelings and
emotions aroused by the hypnotized person are most important for the hypnotist. It is almost
indifferent to the hypnotist if the hypnotized subjects desires and ideas are realized or not, or
if the hypnotized person has independent initiatives. The hypnotist emphasizes his/her own
Banyai and her colleagues (1985, 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,
their relationship and their actual physiological, behavioral and subjective experiential
changes during the mutual interaction between them. These findings accord with the mirror
neuron hypothesis described above.
The interaction synchrony appears either in overt movements (e.g. joint movements of
the limbs when the subject enacts motor suggestions) and postures (e.g., posture mirroring),
or in covert processes (e.g. breathing and electromyographic activity). These phenomena are
usually involuntary and outside of awareness. When hypnosis is sufficiently deep, a swaying
motion of the hypnotist's body has been observed in synchrony with the subject's breathing.
This phenomenon has been called "joint rhythmic movements".
Such mutual regulatory functions can be found in parent-infant interactions (e.g., Stern,
1985; Brazelton et al., 1974). There is evidence that in both animals and humans social
emotions and interactions are accompanied by marked neurophysiological and hormonal
changes (Reite & Field, 1985). Field states, "Attachment might . . . be viewed as a
relationship that develops between two or more organisms as their behavioral and
physiological systems become attuned to each other. Each partner provides meaningful
stimulation for the other and has a modulating influence on the other's arousal level" (1985, p.
Different styles of hypnosis may help meet the subject's various needs, and, in the case of
a patient, they may correct different regulatory deficiencies.
Banyai and colleagues' findings indicate that these styles are not as stable as they seemed
first. Hypnotists who usually use a maternal style may sometimes show signs that do not fit
into this style. The same is true for paternal hypnotists (Gosi-Greguss et al., 1993).
Case vignette 2:
Some years ago, during an experiential intersubjective workshop under my guidance, one
of the participants began to share a personal experience. I became attuned, in a trance state,
absorbing unbearable feelings from her and the rest of the group (which also experienced
trance a state). My emotional experience was very powerful; all the periphery of my
perception field became blurry. I felt pain and sadness. My mind generated a variety of
images, which I tried to integrate into communicative a domain. My experience crystallized
into a song lyrics and music. Since music has great affective and emotional qualities and can
be used as a projective and expressive vehicle (or, in Winnicott's term, "potential space"), I
played the song to the group at the end of the sharing, calling it a gift from me to the speaker.


Udi Bonshtein
The effect was amazing. The group was silent. People cried, indicating a powerful emotional
experience and leading us to more effective work.

While transference is the redirection of a client's feelings from a significant person to a
therapist, countertransference is the redirection of a therapist's feelings toward a client, or
more generally, a therapist's emotional entanglement with a client. I have coined the word
"countertranceference" to describe the hypnotist's trance and subjective experience during
hypnosis. 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, yet
caution about the complexities and dangers of sharing them with the patient.
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, 1983, 1984, 1987,
1988). He mentioned the hypnotherapist's need to gather up the courage to experience and
tolerate the patient's unconscious affects and images within himself, including pain and
uncertainty, while remaining strong and stable enough to support and direct the healing
Case vignette 3:
Jean is a 16 year-old girl whom I met while she was hospitalized. She was an attractive
girl, with a complex clinical picture, including dissociative conditions and suspected psychotic
states. I will describe one aspect of her treatment, with the aim of demonstrating a productive
use of countertransference, although some people might consider it controversial.
During a session in which she minimized her difficulties, 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,
someone who can really see you. After some silence she replied, "Suppose you were a student
who is really care about his grades, and suppose your grandfather is dying, Ok? What would
you do if you got a zero on an exam?"
I thought about it, allowing myself to become absorbed in my memories of having an ill
sibling, keeping my own needs away in fronts of a "real" pain of somebody else. I said: "I am
not proud of it, but I am assuming that I was not telling about my sadness to anybody". "Why
you are saying you are not proud of it?" she said, and (probably due to projective
identification) I felt a sudden sadness, with tears in my eyes. This authentic response of mine
opened the door for Jean to progress considerably in therapy.

There is a great debate about self-disclosure and sharing the therapist's

countertransference with the patient. Several writers have proposed the careful use of
disclosure and sharing of countertransferential feelings with the patient (e.g. Epstein &
Feiner, 1979; Gorkin, 1987; Wollstein, 1988). Here too, Ferenczi preceded his time with an
open approach including disclosing the therapist's feelings and attitudes to the patient, going
as far as free-associating to one's unconscious motives after making a countertransferentially
based error in therapy (Gorkin, 1987).
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.

The Relational (Intersubjective) Approach to Hypnosis


When is Sharing and Self-disclosure Appropriate?

While many clinicians gain great advantages from sharing and self-disclosure, questions
have been raised about when they are appropriate. The main issues include patient's level of
personality organization and who needs the self-disclosure (patient or therapist).
Although disclosure of countertransference has occasionally been used with very
disturbed patients (Racker, 1953; Searles, 1979), Diamond (1983) has cautioned against using
it with patients with a poor level of organization. On the other hand, patients with poor
personality organization can have serious difficulties accepting the therapist's subjectivity,
and many find the therapist's self-disclosure insulting or even a destructive attack on their
own subjectivity. On the other hand, some patients can be eager for role reversal, thriving
whenever there is real, intimate sharing. Livnay (1995) found that patients with severe
personality disorders are those who are most likely to put him into a trance state. These states
very often bring him into contact with a more mothering style, in Banyai's terms (1992).
The second issue is whether self-disclosure serves the patient or the therapist. Whenever
a therapist considers sharing or disclosing, this must be done with the patient's needs in mind.
Many authors have cautioned about therapists' improper use of sharing or disclosure for their
own narcissistic, aggressive or dependency needs. This caution must be weighed against overintellectualization and the loss of the benefits of spontaneity. Self-disclosure must be based on
a high level of maturity and self-awareness on the therapist's part, including constantly
checking the basis of one's motivation for speaking and acting. Diamond (1983) stressed the
need for the therapist to have reached a high level of integration. Being in supervision or
therapy is recommended for enhancing awareness of the therapist's own motives and
unconscious wishes and needs.
Case vignette 4:
Sara, a 40-year-old woman, suffered from severe social anxiety. She functioned at a very
low level, trying hard to go out and work in her profession as a kindergarten art teacher. She
had been previously diagnosed as having a low-borderline personality organization level.
During the initial moments of the session she "got lost", having difficulty in focusing: "It
takes so much timeI dont know from where to beginI am talking about just one activity I
need to, and I have 30 more to make ready!" she terrified stated. "How can I work for just 45
minutes?" she keeps asking herself, helplessly.
At the first stage I gave her a preliminary suggestion about focus and limit time
investment at work, using a story and self-discloser material. Pacing and leading her through
my tone of voice, slowly lowered her stress level. Her muscles seemed to be a little more
relaxed and she smiled at me. In those moments I felt like a mother calming a distressed baby,
by being attuned to her inner rhythms (which in turn gave me the opportunity to free-associate
the story I told her). After containing her fears, I tried to serve as an organizer for her, by
asking a title to the first encounter she was making. I asked for more titles. If she connects
those titles between them, can she see her activity develop until a clear picture?
"I feel as if you opened a curtain for me" she says gratefully.
At this point I induced relaxation indirectly, playfully, encouraging her to use her
imagination. After some productive work, I began to feel her twisting and fighting and myself
as despairing, losing, and giving up my hurt rate increased and I felt a great amount of
It was clear to me that my feelings were actually her feelings, so I "digest" them for her,
distancing them by telling her about another person I knew who felt very distressed when


Udi Bonshtein
giving his lectures, and the way he used the imagery of the audience in their underwear, using
an amusing illusion to dispel his fear.
After some more organizing work, I gave her positive and reinforcing suggestions,
reframing the work she already done as very successful, as well as the intended work (future

Hypnosis can be seen as a two person phenomenon - two people who create each other
continually and mutually. The view of hypnosis as a context-dependent, interpersonal
phenomenon is based on well-known theoretical models, such as social role-playing or sociocognitive theory (Kirch, 1991; Spanos, 1991; Wagstaff, 1991). Today's evidence from
neuroscience and experimental hypnosis support the hypothesis of unconscious attunement
and rhythmic resonance between hypnotists and their patients.
Skilled hypnotherapists can use their mental states (such as images, mentalrepresentations, dreams, feelings and thoughts) as therapeutic and/or diagnostic tools. One of
the interesting directions for further investigation is the curative aspects of attunement,
empathy and precise affective recognition of the patient. The trance state, as a Winnicottian
potential space, is a very powerful therapeutic tool, reminiscent of reminds the initial
affective atmosphere between mother and child (as Freud himself claimed, see Freud, 1890). I
can take a risk hypothesize that the infant's brain is equipped with mirror-neurons and great
hypnotic susceptibility, which make it possible for him/her to respond easily to mother's
rocking, voice, presence or touch, with unlimited amounts of trust.

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In: Hypnosis: Theories, Research and Applications

Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456 2009 Nova Science Publishers, Inc.

Chapter 6


Graham A. Jamieson
University of New England, Australia
In memory of my mother, Agnes Fraser Jamieson

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
persons 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


Graham A. Jamieson
understand the unique contributions of absorption and hypnosis in effective practices of

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. 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.
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. Meanwhile, 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.
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).
The one notable exception to these null findings was the biographical interview work,
focusing on the construct of imaginative involvement, conducted by Josephine Hilgard and
her associates (Hilgard, 1974). At the same time Tellegen and Atkinson (1974) reported the
development of a paper and pencil personality scale which correlated significantly with
hypnotic susceptibility. 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. 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. They described absorption as a state
of, total attention involving a full commitment of available perceptual, motoric, imaginative
and ideational resources to a unified representation of the attentional object (Tellegen &
Atkinson, 1974, p. 274).


Influenced by this lead, 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. The Supervisory Attentional System (SAS) model of Norman and
Shallice (1986) elegantly summarises key elements of the thinking which guided these
efforts. According to this model the selection of routine responses is the outcome of an
automatic and unconscious competition amongst fixed action schemata (neural networks

Hypnosis, Absorption and the Neurobiology of Self-Regulation


mapping specific inputs to specific outputs), for access to various response systems. This
process, called contention scheduling is implemented predominantly in posterior cortical
regions. However flexible, 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. 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. Task set representations are stored in anterior cortical
regions, thus the source of top-down attentional control is activity in elements of a far frontal
attentional network.
These researchers therefore searched for evidence of activity within the anterior cortical
networks believed to implement top-down attentional control, which would distinguish high
from low hypnotically susceptible individuals particularly during hypnosis, or when
responding to specific suggestions such as hypnotic analgesia. 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.g., Ishii et al., 1999). 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.g., Ray, 1997). In addition increased prefrontal cortical activation reported in PET studies
of hypnotic analgesia suggestion, a phenomenon which some have considered to be a
paradigm case for the role of focused attentional control in the production of hypnotic
responses, have been interpreted as further support for this view (e.g., Crawford et al., 2000).
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, otherwise known as the classic suggestion effect
(Weitzenhoffer, 1953). On the Norman and Shallice account a volitional response is a
paradigm case of attentional control implemented by the SAS. Therefore, Woody and Bowers
argued, if the experience of non volition in hypnosis is veridical it must be accompanied by a
reduction, if not loss, of SAS control and a shift toward contention scheduling. At the level of
cortical dynamics this corresponds to a weakening of the influence of prefrontal task set
representations on more posterior cortical processing. 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
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. 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. The Stroop task (Stroop,
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, 2000). In the Stroop task participants view color-name stimuli presented in an
actual color, which may be congruent (e.g., the color-name red presented in red) or
incongruent (e.g., the color-name red printed in green) with the color-name. Participants
must respond to either the color-word or the actual color. The Stroop effect is evidenced by
slower reaction times (and typically a greater error rate) when responding to incongruent than


Graham A. Jamieson

congruent stimuli. 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. 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, respectively).
When these are congruent there is little response conflict. 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. However, 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, Cohen and
Carter, 2004). A similar logic is employed in many Stroop type tasks subsequently developed
in the experimental literature.
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.e.,
incongruent, color naming) trials. Sheehan, 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). Kaiser et al. (1997) found
higher errors in hypnotized participants with higher hypnotic susceptibility using a Stroop
type task. Nordby, Hugdhal, Jasiukaitis and Spiegel (1999) also reported greater Stroop errors
in hypnotized high susceptibles. Jamieson and Sheehan (2004) employed a classic version of
the Stroop task in a very large sample, 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). 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.
However Sheehan et al. (1988) found that, distinct from the effect of hypnosis per se,
with specific suggestions hypnotized high susceptibles were better able to control Stroop
induced response conflict than were lows. Recently Raz, Shapiro, Fan and Posner (2002)
found that high susceptibles were able to eliminate the Stroop effect by means of specific
hypnotic suggestions. Subsequently Raz, Kirsch, 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. Thus it appears that, in response to suggestion, there are effects in hypnosis which
suggest enhanced control of conflicting or distracting competition for attentional resources.
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, 1993) during the hypnosis condition, particularly by those higher
in hypnotic susceptibility. Gruzelier (e.g., 1998) has consistently interpreted these findings as
evidence for a decrease in frontal cortical activation brought about by hypnosis.
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. In
this case focused attention becomes a prerequisite for subsequent frontal inhibition. Egner and

Hypnosis, Absorption and the Neurobiology of Self-Regulation


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. 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. 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, when it appears in hypnosis, 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, 2004).


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. 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. 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, Aston-Jones and Gilzenrat, 2004; Miller and
Cohen, 2000). 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. However activation in these task set representations is
dynamically modulated by feedback about the level of conflict between competing response
tendencies. Specifically response conflict is monitored by the dorsal Anterior Cingulate
Cortex (dACC), a deep midline anterior cortical structure. 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, Cohen and Carter,
Using this model MacDonald, Cohen, 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. 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. Two different contrasts were performed. The first
contrast was performed for the post instruction interval and was between the color naming
instruction and the color-word naming instruction. This represented a contrast between high
and low control demand conditions respectively and revealed significant activation in the left
dorsolateral prefrontal cortex. The second contrast was made in the post stimulus period and
was between incongruent (high response conflict) and congruent (low response conflict)


Graham A. Jamieson

stimulus events respectively. In this case conflict related activation occurred exclusively in
the dACC.
The conflict-monitoring model functionally and anatomically fractionates monitoring and
control functions and clearly specifies the relationship expected between them. 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.
Egner, Jamieson and Gruzelier (2005) adopted a strategy similar to that used by
MacDonald et al. (2000) in order to identify the specific mechanism of the dissociation in
attentional control believed to occur in hypnosis. 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. Similarly to MacDonald et al. (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). However when activity levels were examined in conflict related regions
of interest a classic interaction effect was found between hypnotic susceptibility and hypnotic
condition. 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. 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. 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. 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 this study Egner et al. (2005) sought to directly assess functional connectivity between
cortical regions through EEG coherence. 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. 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, 2007) declined between recording sites reflecting activity in dACC and left
IFG (electrodes Fz and F3 respectively) for high susceptibles in the hypnotized condition. No
such breakdown in cortical functional connectivity was observed for low susceptibles or for
the homologous right hemisphere connection between Fz and F4. A similar breakdown in
EEG gamma band coherence was found by Trippe, Weiss and Miltner (2004) between motor
cortex and frontal cortical sites in hypnotized high susceptibles experiencing hypnotic
analgesia. 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. 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,
Williams, Haenschel and Gruzelier (2002) who found that the correlation between ACC

Hypnosis, Absorption and the Neurobiology of Self-Regulation


sourced gamma and subjective pain experience broke down for higher susceptible individuals
in the hypnosis condition.
An often overlooked finding from EEG research on cognitive control in hypnosis comes
from the work of Kaiser et al. (1997) who examined averaged event related potentials
(ERPs) to error responses on their Stroop type task (see discussion of their behavioral results
above). These error related ERPs 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, 2004). Kaiser et al. (1997) found that a later
positive component the error related positivity or Pe, 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., 2001), is diminished in
high susceptibles in hypnosis. However an earlier negative going component of the brains
response to errors, the error related negativity or Ne, was not affected. In our most recent data
on this topic, gathered in conjunction with Croft, Cleary, Hammond and Findlay, 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. Although significant we are currently extending our
sample prior to a journal submission.
If correct this suggests two things. Firstly the finding of an increased Ne independently
supports the finding of Egner et al. (2005) that hypnotized highs showed greater conflict
related activation in dACC while performing the Stroop task. Both sets of results were
produced from a Stroop paradigm, one utilized fMRI the other EEG, one studied correct
responses the other error responses. 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, 2002). Note that due to the timing of its peak,
approximately 100 milliseconds post error response, the Ne cannot be generated by feedback
from the actual error response itself. 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. (2005) that is increased dACC
responsiveness to the detection of response-conflict in hypnotized high susceptibles.
Secondly, 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. 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, Luu and Posner,
2000). 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. Consistent with the findings of Egner et al. (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.


Graham A. Jamieson


Over the last fifteen years the new discipline of cognitive neuroscience, which combines
the new imaging technologies with the EEG, the rigorous experimental paradigms of
cognitive psychology and the mathematical modeling of connectionism, has grown and
flourished principally focusing on the issue of cognitive control. While there remains deep
disagreement and controversy rapid progress has been made which no truly contemporary
hypnosis researcher should ignore. For many traditional cognitive paradigms key components
of the circuitry of cognitive control have been mapped along with their dynamic functional
connectivity. Whist this circuitry is far from identical for disparate tasks there are common
identifiable themes (sketched above) involving a dynamic interplay between dACC
monitoring, prefrontal task set representations and top-down control of more posterior
perceptual and motor control functions. Within this same time period the work described
above has shown that, at least in part, important aspects of the change in mental organization
which occurs in hypnosis can also be understood within this emerging theoretical framework,
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. 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.
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. 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 controlconditions. However just as ubiquitous, but much less commented on, was a
consistent deactivation of several other brain regions (including the rACC) in the same
experimental contrasts. 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). 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. These distinct functional networks are mutually inhibitory;
implementation of one excludes implementation of the other. The dorsal and rostral divisions
of the ACC are critical nodes in each network. 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., 2000).
I have argued above that hypnosis is closely associated with a specific type of disruption
to one of these principal networks. 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. Data from PET studies of hypnosis conducted by Faymonville et al. (2003) and
by Rainville et al. (2002) may provide initial evidence of this wider possibility. Faymonville
et al., (2003) conducted an investigation of the functional connectivity of a dACC region in

Hypnosis, Absorption and the Neurobiology of Self-Regulation


which activity co-varied with the analgesic effects of hypnotic suggestions to relive a positive
affective experience. They conducted a Psychophysiological Interaction (PPI) analysis which
found regulatory interactions with key nodes of the resting state network, including rACC
and regions of the posterior cingulate cortex and parietal association areas. Rainville et al.
(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. They also reported a network which featured rACC, posterior cingulate and
parietal association cortex. 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. 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, and what are more widely known as trance states, in psychophysiological (as
distinct from cognitive) self-regulation (see also Woody and Szechtman, 2007). A recent
series of neuroimaging studies conducted by Critchley and colleagues (Critchley et al., 2003;
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. Activation in each network is mutually inhibitory and the dorsal and
rostral ACC play a fundamental role in each. 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.
Growing evidence for two functionally distinct, mutually inhibitory networks of
cognitive, affective and somatic self-regulation bring us full circle to a psychobiological
construct with deep roots in hypnosis research, that of absorption (Ott, Reuter, Hennig and
Vaitl, 2005). Absorption has been found to play a critical role in the success of different
psychological strategies for somatic self-regulation. Qualls and Sheehan (1981) attempted to
understand the factors underlying the success (and failure) of biofeedback training. 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. 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. 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. When instructed to adopt this approach low absorption
individuals failed to lower (and actually raised) their level of muscular tension. 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.
These findings led Tellegen (1981) away from his earlier account of absorption as
strongly focused attention to a fundamental redefinition of the trait. Tellegen (1981) described
experience as being organized around two discrete and mutually exclusive mental sets, the
instrumental-mental-set and the experiential-mental-set. He (Tellegen, 1981, p.222) describes
the instrumental set as a state of readiness to engage in active, realistic, voluntary and
effortful planning, decision making and goal directed behavior. A description which is
immediately recognizable as active cognitive control implemented by the dACC, lateral PFC


Graham A. Jamieson

and posterior cortical networks described by cognitive neuroscience and known to be

disrupted in high susceptibles during hypnosis.
By contrast, Tellegen described the experiential set as a state of receptivity or openness
to experiencing whatever events, 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, 1981, p. 222). He further emphasized the role of affective
processes in the experiential-mental-set. Tellegen then conceptualized absorption as a
predisposition, when circumstances permit, to set aside an instrumental set and adopt instead
an experiential mental set. That is, from a contemporary cognitive-affective-social
neuroscience perspective, he described absorption as the predisposition and ability to inhibit
or disrupt one of two major patterns of neural functional connectivity, experience and selfregulatory organization and to adopt the other, a very different mode of organization with its
own characteristic patterns of functional connectivity, experience and self-regulatory

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, map and explain (Sheehan and McConkey, 1982). The mutual
engagement between cognitive neuroscience and hypnosis research as outlined here has
already proven most fruitful in this regard. However, the principal social role of hypnosis has
always been and remains the self-regulation of psychological, psychophysiological and
related somatic states. Therefore, the study of hypnosis must not only include but also extend
beyond the purely psychological level of analysis. For example, recent studies have
demonstrated the important role of hypnosis and hypnotic susceptibility in the self-regulation
of stress-related endothelial dysfunction (Jambrik et al., 2005), ventricular arrhythmia
(Taggart et al., 2005) and other elements of heart rate variability (Diamond, Davis and Howe,
2008). If continued vigor is shown by researchers and supported by funding bodies, the future
collaboration of hypnosis with systems-level neuroscience research holds the great promise of
uncovering the full nature of these underlying psychological, central and peripheral systems
of self-regulation.

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Reviewed by Professor Adrian P. Burgess, Department of Psychology, Aston University,
Birmingham UK, and by Dr Nick Cooper, University of Essex, Colchester, UK.

In: Hypnosis: Theories, Research and Applications

Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456 2009 Nova Science Publishers, Inc.

Chapter 7


Felipe A. Tallabs G*
The Free Institute of Science, os Revueltas 2748, Col Alta Vista Sur, Monterrey,

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 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.

Keywords: Hypnosis, Mass Anxiety Hysteria, Mass Motor Hysteria, Empathy, Mirror

Email: felipetallabs@msn.com


Felipe A. Tallabs G

Collective psychogenic illness has been reported since the Middle Ages, and such
accounts have continued to appear all the way up to our time. Many forms of behavior had
been described, ranging from general anxiety symptoms like dizziness, fainting, headaches,
hyperventilation, nausea, palpitation, anxiety, abdominal pain, etc. (Bebbington et al., 1980;
Colligan and Murphy, 1979; Small and Nicholi, 1982; Small and Borus, 1983; Watson and
Bausher, 1983) to more specific symptoms like seizures, agitation terror (Acherman and Lee,
1978), running, laughing and twitching, reciting poetry (Dhadphale and Shaikh, 1983),
trances, hallucinations, peudoparesis, anesthesia (Lee and Acherman, 1980; McEvedy and
Beard, 1970), agitation, possession (Teoh and Yeoh, 1973), just to name a few.
There exists no satisfactory definition of mass hysteria. A wide variety of crazes, panic
and abnormal group beliefs have been labeled as mass hysteria. However, these epidemics,
while definitely of a pathological order are certainly psychosocial phenomena rather than
manifestation of individual mental Illness. A detailed assessment of modern mass hysteria
symptoms suggests that two broad groups may be identified. The first consists of episodes
featuring some or all the symptoms of acute anxiety. The second group consists of episodes
involving symptoms more recognizable as hysterical in nature, demonstrating alterations in
motor function, such as pseudo seizures, pseudo paresis and all sorts of pseudoneurological
phenomena. However there are cases in which both sets of phenomena are present, anxiety
and pseudoneurological (Ali Gombe et al., 1996).
It has been argued that in cases where anxiety-like symptoms (mass anxiety hysteria) are
predominant, there was almost no history of previous prolonged stress or tension, which is
always present in the cases where hysteria symptoms are predominant (Wessely, 1987). But
whatever the form of the specific case, there is always a mythical belief on a source that
causes the phenomena, could be a mysterious gas (Wong et al., 1982), an insect plague
(Bartholomew, 1994), even demons (Huxley, 1952) or any other belief.
The difference is that in Mass Anxiety Hysteria (MAH), the belief is created at the same
time that the first symptoms appear in the case 0 or first subject, whereas in Mass Motor
Hysteria (MMH) there is a previous belief in the cause. It is relevant also that MAH lasts only
for hours whilst MMH can last from weeks to years. Interesting to note is the fact that this
time difference is similar to the difference found between hypnotic paralysis and conversion
paralysis. (This will be explained further in section 3.)
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., 1965; Tan, 1963; Teoh et al., 1975; Colligan et al., 1982; Kerchkoff and Back, 1965;
Stahl and Lebedun, 1974; Ikeda, 1966) whilst MAH seems to be the result of momentary
suggestibility triggered by a situation where attention is focalized (contracted) into a
perceived danger, which in turn raises the level of anxiety.
Regarding the nature of the perceived danger, 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, 1987). This inability to comprehend the nature of the
stressor mentioned by Wessely is the cause of the cultural interpretation of the stressor into a

The Neurophysiology of Hypnosis in Mass Psychogenic Illness


comprehensible, culturally manufactured danger. This particular danger provides the features
of the condition itself (symptoms).
The unitary approach to group behavior started with LeBon (1895) who saw crowd
behavior as more than the sum of single behaviors. He suggested the existence of a
complexity in crowd psychology that provoked emergent behaviors observable only in
groups. It has been proposed that group reality replaces external reality, and such isolations
prevents adequate verification of perceived threats (Festinger, 1950; Gruenberg, 1957).
Theories of mass hysteria spreading mechanisms have also involved the analogy between
the spread of mass hysteria and the spread of an infectious disease. According to Penrose
(1952) also Back (1971), those who accepted the fantasy idea will succumb to the epidemic,
those who reject it will be resistant, and those who ignore it will be immune.
Theoretical models of group behavior have been designed to be applied to all forms of
group behavior. It is this universality that prevents such models from becoming complete
explanations, specifically when observing the difference of spread that occurs in MAH and
MMH. In Mass Anxiety Hysteria, transmission of the outbreak is commonly along a line of
sight, those who do not witness the outbreak are never affected.
The spread of Mass Motor Hysteria however, depends upon social interaction occurring
between the initial case preceding the outbreak and the rest of the group. If a belief is to be
propagated and sustained over a prolonged period of time, it must be relevant to the group
and all involved in the epidemics should be able to identify with the initial case or subject 0s
This is only possible if the subject 0 has high status in the group. In experimental settings,
subjects with high prestige were found to be the most effective models of contagion
(Bartholomew and Wessely, 2002). What is evident is that in MMH, social networks facilitate
the spread of the symptoms.


In 1924 some of Ivan Pavlovs dogs accidentally became trapped in their cages when the
Nerva River flooded St Petersburg. The water entered Pavlovs laboratory and reached nearly
to the top of the cages containing the dogs. Towards the end, when they were swimming
around the very tops of their cages, they were dramatically rescued by a laboratory attendant
who brought the dogs out under the water to safety. All the dogs had met the frightening
experience with initial fear and excitement. But after their rescue, some were in a state of
severe inhibition, stupor and collapse. The strain on the nervous system had been so intense
that the fearful excitement aroused had resulted in a final emotional collapse.
Pavlov was most excited when he found that in all those dogs which had experienced the
collapse, all the recently implanted conditioned reflexes had been abolished. it was as if the
recently printed brain-slate had been suddenly wiped clean. Pavlov was able to imprint on
them new patterns of behavior (Sargant, 1974). One of Pavlovs most important findings
(Pavlov, 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. He called this state rupture in higher nervous activity. After the onset of
this rupture a state of transmarginal inhibition is set.


Felipe A. Tallabs G

According to Pavlov, this state of brain activity is similar to that seen in human hysteria.
This can cause a great increase in suggestibility. The individual suddenly takes notice of
events and influences around him to which he would normally have paid little or no attention.
In this hypnoid state of brain activity, people become open to the uncritical adoption of
thoughts and behavior patterns present in their environment, which normally would not have
influenced them emotionally or intellectually. The individual becomes susceptible to
influences in the environment to which he was formerly immune.
Evidence of the relationship between severe traumatic events and development of
dissociative symptomatology is considerable (Spiegel, 1984, 1988; Frankel, 1990; Marmar et
al., 1994; Koopman et al., 1995) However little empirical evidence existed that could relate
hypnotic susceptibility to conversion (Frischolz et al., 1992) until Roelofs et al. (2002)
provided hard evidence of this by comparing several conversion patients with control subjects
on measures of hypnotic susceptibility, cognitive dissociation and somatoform dissociation.
Conversion patients were significantly more responsive to hypnotic suggestion than
controls; however this important result awaits independent replication.
Hypnosis can be explained as a controlled and structured dissociation (Kaplan, 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, 1990). Absorption is a state of highly focused attention with a total involvement in a
single dimension of experience, like perception, memory or ideation (Tellegen and Atkinson,
1974; Spiegel, 1992). This focalization excludes other experiences that should normally be
present in conscious awareness. Janet (1907) described this as a retraction in the field of
This retraction requires the relegation of material to the periphery of consciousness where
it no longer impinges on awareness. This aspect of hypnosis is considered a dissociation of
content (Spiegel, 1990; Butler et al., 1996). Suggestibility is an increased responsiveness to
environmental cues (real or perceived) and is a main characteristic of hypnosis, and is thought
to result from the heightened focal awareness through absorption.
A person under instructions of hypnosis is fully absorbed in only one or two aspects of
awareness, and therefore is less likely to critically judge or evaluate the meaning of the
experience (Spiegel, 1992). The narrowing of attention results in a diminution of higher
order critical capacities; therefore a proneness to be influenced by suggestion develops.


Empathy defined as the ability to perceive accurately another persons feelings, is a
fundamental part of the social fabric of emotion, providing a bridge between one persons
feelings and those of another. The notion that empathy between two people is related to a
state of shared physiology is not new, however most of the literature generated by the study
of empathy is taken from a single person perspective, and although it has generated
physiological measurements (Di Mascio et al, 1955; Malmo et al, 1957; Kaplan and Bloom,
1960), they came from either the observing person or the observed one, but never both of

The Neurophysiology of Hypnosis in Mass Psychogenic Illness


Physiology has always been perceived as something private. However, the essence of
empathy is interpersonal, and during the experiencing of empathy, the physiological response
of an individual can be understood in terms of basic social processes (Cacioppo and Petty,
1983) and even the physiological response of two people can evidence a considerable
relatedness and linkage (Levenson and Ruef, 1992). This is evidence that observing the
emotional display of another person can result in similar emotional displays, as well as
autonomic arousal on the part of the observer (Dimberg, 1982; Lanzetta and Englis, 1989;
McHugo et al, 1985; Vaughan and Lanzetta, 1980).
We can then reformulate the definition of empathy as: The ability to detect emotional
information, and thus physiological information transmitted by another persons behavior.
From this definition we can also define a level of empathy as: The level of accuracy to
perceive and reproduce another persons physiological state related to emotions.
As I mention in the introduction, most Mass Psychogenic Illness studies consider that the
symptoms begin spreading from high status students (Bartholomew and Wessely, 2002). This
is evidence of the direct relationship between empathy and MPI. High status students provoke
higher levels of empathy in their schoolmates. However lets describe a possible scenario in
order to clarify the role of empathy in a real life scenario of MPI epidemics. Consider the
following scenario of an MPI epidemic, specifically a Mass Anxiety Hysteria fast spreading
There is a belief in an urban area Middle school that a nearby industrial complex releases
fumes into the air that might be toxic. A high status student is under stress because of an
impending math test the following day. Stress and lack of proper sleep cause the student to
feel sick, developing dizziness and nausea. He finally throws up in front of the class and
complains of difficulty breathing. Earlier that morning the stench of the nearby factory fumes
had reached the school, the teacher nervously comments to her class that the students
condition must be a result of the morning fumes. The observation of the sick students
behavior provides to the class a confirmation that the teachers belief might be a reality. At
the same time empathy gives them a physiological model of the first case or student 0
feelings, thus the cognitive experience and the physiological experience are now coupled, at
this moment the stress rises (the class was already under stress because of the future test). If
the level of empathy with the student 0 is high enough, then the reality of that person becomes
consensual reality. In this moment, where single reality becomes consensual reality the
mechanism of hypnosis is fundamental.
As mentioned earlier, suggestibility is defined as the suspension of critical contextual
evaluation, and can only be possible when attention is focalized, such focalization can be
produced by the continuous perception of certain danger (real or not). In the previous scenario
it was a possible toxic gas threat, however such absorption of attention was also catalyzed
by an unavoidable future of a mathematics test, which caused an above normal level of stress.
Once absorption of attention is present, the physiological response caused by an empathic
observation of the student 0, triggers a suspension of critical contextual evaluation, thus, a
state of suggestibility develops. Orne (1959) defined suggestibility as an increased
responsiveness to social (environmental) cues, real or perceived. That is exactly what happens
during MPI. However the role of empathy in MPI is still a theoretical formulation since no
studies to date have thoroughly assessed it. Nevertheless, it seems feasible that the
physiological response triggered by empathy, must be a fundamental element for the
development of suggestibility during MPI epidemics.

Felipe A. Tallabs G



All forms of Mass Psychogenic Illness may be considered an interaction between the
individual and its social group. However, the nature of this interaction differs between MAH
and MMH. This difference provides different characteristics to the onset of both conditions.
See Table 1. Based upon Wessely (1987).
Table 1.
Initial case
Preexisting tension

Acute anxiety
Rarely identified
Hours(may be repeated)
Rapid, line of sight
Under 18

Changes in motor function

Usually identified
Weeks to years
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
I speculated elsewhere (Tallabs, 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. Such enhancement could certainly obstruct effective
functioning of the cognitive subdivisions which are suddenly disregarded by this pathological
feedback circuit, leading to a dysfunctional processing of motor behaviors (among others)
that finally provokes the onset of the symptoms of conversion paralysis.
Also during MAH, there are similarities with hypnotic-induced conditions like induced
anesthesia; however, there is no stress during hypnotically induced conditions, which seems
to be fundamental in MAH. As I have mentioned earlier there is no evidence of a previous
stressing environment in MAH cases, however, there is stress in the beginning of the event,
which triggers the onset of the symptoms. Stress seems to be fundamental for the
suggestibility state to develop during MAH. Another fundamental difference between MAH
and induced conditions is precisely the fact that MAH is environmentally shaped rather than
induced. Nevertheless, 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. Most of such cases were mild, involving few students, but very
repetitive. These results evidence the fact that certain personality traits in teachers might
induce episodes of MAH. Teachers that experience episodes of MAH regularly complained of
being unable to control the discipline in their classrooms. This led to the Insecure Teacher
Inducer Hypothesis.
According to this hypothesis, a factor related to behaviors of insecurity in the teacher
during a stressful situation, must be leading to the induction of the onset of the symptoms.

The Neurophysiology of Hypnosis in Mass Psychogenic Illness


When a teacher complains about the discipline in his/her classroom, the teacher is failing as a
leader, leaving a void of an adult figure in the classroom. A teacher should be most of all a
problem solver for the children. This sort of teacher is not really in control of the childrens
behavior, and this can be expressed not only in words but in facial and body expressions.
Once children feel the insecurity of the adult figure, many students may experience a sense of
indefensibility. This stress is different to that of repressive environments so common during
MMH. This is a stress of being unprotected, a feeling that anything might happen, a state of
Such state of unsafeness is an excellent condition to produce suggestibility. If you add to
this, a teachers 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. So
according to this hypothesis, MAH onset might benefit from an indirect inducer person. This
would mean that MAH could be in certain occasions an induced condition, like induced
pseudoneurological syndromes in experimental conditions.


At the end of the last century, a group of Italian neuroscientists headed by Giacomo
Rizzolati and Luciano Fadiga made a transcendental discovery for the neurosciences. They
discovered a system of neurons that behave like a mirror (Rizzolati et al, 1988), this mirror
neurons were found to represent observed actions, as if made by subjects watching the action.
They refer to these behaviors as resonance behaviors.
In this type of behavior, 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, not more complex types of resonance). The most typical example of resonance
behavior is found in the imitative behavior observed in different species of animals. A
thoroughly studied example is displayed by shore birds when alarmed. Typically one or a few
birds start wing flapping, then others repeat the action and eventually the entire flock begins
flight (Thorpe W H, 1953; Tinbergen N, 1953). This contagious behavior does not require
necessarily an understanding of the action, 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, et al., 1999).
Resonance behaviors appear to be present in humans also. In infants, for example, they
play a fundamental role in establishing communication with adults. An example of this is the
capacity of young children to imitate mouth and manual gestures (Meltzoff and Moore,
1977). 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.
These sorts of behaviors can also be observed in adult humans. Actions that seem to be
related to some degree of empathy can be contagious; smiling produces a tendency to respond
with smiling, laughing is well known to be contagious. The most usual response to the sight
of someone yawning is to yawn. For all these actions there is no need to postulate a
comprehension of the observed actions, such actions simply releases in the observers the seen
action. The term response facilitation was proposed to describe this kind of behavior
(Byrne, 1995). I believe that this response facilitation is just an element of the mechanism
of empathy. This type of response provides an adaptational advantage to the individual


Felipe A. Tallabs G

inserted in a society, just like the contagious wing flapping (escape) mechanism to a bird
flock. However, the behaviors observed during MMH epidemics are far from being a regular
occurrence of human societies. So how do the behaviors observed during MMH come to be
In 2001 it was discovered that there was a modulation of spinal excitability during
observation of actions in humans. This modulation, however, was opposite to that occurring
when the recorded muscles were actually executing the observed action (Lemon et al., 1995)
such modulation replicated the observed movements (Fadiga et al., 1995) but in an inverted
mirror fashion, thus it was speculated as a mechanism to prevent the overt replica of an
observed action (Baldissera et al., 2001).
In contrast with the behaviors previously mentioned: laughing, smiling and yawning,
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, the behaviors
observed in MMH are limb related and thus must be dependent on a mechanism to overcome
such inhibition. This would mean that during MMH, such inhibition can be overriden, and
behaviors become quite involuntary, like a yawning infection.
Now, lets look at the mechanism that facilitates the overriding of the inhibition. It is
logical to speculate that the inverted mirror spinal inhibition is originated in the motor
cortex, otherwise, it would not be easily overridden; because of the psychological stress
present in MMH, it could not be the case if it was a purely spinal condition. My hypothesis is
that such inhibition is the result of hypnotic-like suggestion. It is known that the Orbitofrontal
Cortex (OFC) of the brain controls adequate responses to environmental stimuli (Kolb and
Whishaw, 1998; Damasio, 1999). OFC is also implicated in action, emotion and motor
inhibition of spontaneous movements (Kaada, 1969; Ludens et al., 1995). Suggestibility, as
mentioned in the introduction, is an increased responsiveness to environmental cues, which is
a main characteristic of hypnosis. I have speculated elsewhere (Tallabs, 2005) that OFC is an
area that is responsible for suggestibility; nevertheless, further research is required to
dilucidate the exact range of its functional characteristics. It is then hypothesizable that OFC
is in charge of this spinal inhibitory modulation. So it makes sense to speculate that during
suggestibility, the OFC could override any inhibition in order to correspond to the irregular
level of empathy required by the situation during MMH. 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.

There are two different neuropsychological mechanisms that correspond to Mass Anxiety
Hysteria and Mass Motor Hysteria, and although they are closely related, they also differ in
fundamental aspects. But whatever the differences, these models are only a variation of the
same phenomenon, which is the neurophysiology of hypnosis.
In MAH, a belief is introduced by a third party, i.e. a teacher; the reality of such belief is
confirmed by empathic observation of a defined symptomatology, and if the level of empathy
with the first case is high enough, then, one persons reality becomes consensual (group)
reality, thus, attention is focalized in the condition of the first person to become sick. This

The Neurophysiology of Hypnosis in Mass Psychogenic Illness


triggers a suspension of critical evaluation, in other words, a suggestion. We can speculate

that such group suggestion is the cause of the communicated symptomatology.
During MMH, there is a long history of a stressful environment in the group, most of the
time related to a repressive environment within the group, i.e. a strict school discipline.
Similar to MAH, there is an empathic response to a first case; however, there is not any
environmental suggestion present. Stress focalizes attention in the empathic response to the
observed behavior. 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. This allows the corresponding mirror system to exert a direct influence in motor
areas otherwise blocked to its influence.
What is definitely behind both variations of Mass Psychogenic Illness is the engagement
of frontal brain cortex areas, specifically the Anterior Cingulate Cortex (ACC) and the
Orbitofrontal Cortex (OFC). ACC has been found to be selective of attentional demands
(Posner et al., 1988; Pardo et al., 1990) and it is in charge of attention focalization. OFC as
mentioned earlier is in charge of suspension of critical evaluation as well as motor inhibition.
These two areas are fundamental elements for the mechanism of hypnosis.
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, however, the mechanism observed in MAH although similar to hypnotic paralysis,
does not involve motor behavior. Extensive research on the neural correlates of MAH will
have to be undertaken.

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Teoh J, Yeoh K (1973) Cultural conflict and transition: epidemic hysteria and social sanction.
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Reviewed by: Prof Anarbol Lopez, Center for Applied Psychology
Address: Espinoza 854 Pte, Monterrey N.L. Mxico.

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


Philip D. Shenefelt
Department of Dermatology and Cutaneous Surgery
University of South Florida, Tampa, Florida, USA

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.


Philip D. Shenefelt

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 persons 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)
Family life
South Korea
United Kingdom
United States
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


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
Lichen simplex chronicus
Neurotic excoriations
Alopecia areata
Warts, multiple & spreading
Lichen planus
Dyshidrotic hand dermatitis
Atopic dermatitis
Factitial dermatosis
Traumatic dermatitis
Dermatitis not otherwise specified
Acne vulgaris
Telogen effluvium
Nummular dermatitis
Seborrheic dermatitis
Herpes simplex / zoster
Pyoderma / bacterial infection
Nail dystrophy
Warts, single / multiple
Contact dermatitis
Fungal infections
Basal cell carcinoma

% Triggered

Modified from Shenefelt: Arch Dermatol 2000; 136: 393-399, Table 1, p. 394

d-2 wk
2 wk
d-2 wk
d-2 wk
2-3 wk
d-2 wk
2-3 wk
2-3 wk
2-3 wk
d-2 wk


Philip D. Shenefelt

The central nervous system (CNS) also mediates hormone release through the
hypothalamus with its actions on the pituitary and other endocrine glands. Skin and hair are
influenced by thyroid and sex hormones. Melanocytes are stimulated by melanocytestimulating hormone to produce more melanin. Stress hormones influence the immune
system, affecting inflammatory processes in the skin. Many inflammatory skin diseases such
as acne, alopecia areata, aphthous stomatitis, atopic dermatitis, herpes simplex recurrences,
lichen planus, rosacea, psoriasis, seborrheic dermatitis, telogen effluvium, vitiligo, and others
are exacerbated by excessive stress (Zane 2003). The interactions of the CNS and the immune
system were well reviewed by Kiecolt-Glaser et al (Kiecolt-Glaser, McGuire, Robles et al
Habits (CNS conditioned responses) can be influenced by stress and determine skin
exposure to environmental hazards such as ultraviolet light, chemicals, physical injury, and
temperature extremes. Manipulation of normal or diseased skin can result in excoriations
(damage from scratching), lichenification (thickening in response to rubbing), factitial
(intentional) trauma, aggravation of existing skin conditions, and subsequent dyspigmentation
or scarring.
Conversely, the appearance of the skin and hair can have a significant impact on self
image (in the CNS) and social interactions, leading to stress. Skin diseases also can affect self
image, social interactions, and behavior. Chronic skin disorders such as acne, alopecia areata,
atopic dermatitis, or psoriasis can induce or aggravate depression in susceptible individuals
(Gupta and Gupta 2003). Reducing acute and especially chronic stress through
nonpharmacologic methods can help calm inflammatory skin disorders and rebalance the
immune response. The stress reducing techniques can be divided into primarily physical and
primarily mental (Smith 2005). See Table 3.
Table 3. Deep Relaxation Categories of Methods
Primarily Physical
Progressive muscle relaxation
Yoga stretching
Biofeedbackrequires equipment
Primarily Mental
Autogenic suggestion---a special sequence of self-hypnosis
Hypnosis and self-hypnosis
Imagery and relaxing self-talk
Concentrativeone simple stimulus or mantra
Mindfulness---quiet observation with detachment

Relaxation, Meditation, and Hypnosis for Skin Disorders and Procedures


Breath relaxation has been practiced for centuries. It has been an aspect of some yoga
traditions and has been used in the Lamaze method of natural childbirth. The basic method is
to focus on the breath and to intentionally slow and deepen breathing, shifting from more
shallow and rapid chest centered breathing to deeper and slower diaphragmatic abdominal
breathing. Breath relaxation can induce trance. It is more commonly used to induce
meditative trance but also can be used as a hypnotic induction. The resulting calming effect
can improve the psychosomatic aspects of skin disorders.
Progressive muscular relaxation was developed by Edmund Jacobson (1929). He showed
using biofeedback instrumentation that excess muscular tension was present in many
psychosomatic disorders. Intentionally tensing and then relaxing the muscles decreased
emotional distress and the resulting calmness and relaxation reduced psychosomatic
symptoms. The basic method is to be in a seated or recumbent position and start at the hands,
head, or toes with intentional muscle tensing followed by relaxation. The adjacent body part
muscles are then tensed and relaxed, followed by those of the next adjacent body area until all
areas of the body have been covered. Progressive muscular relaxation can be used by itself for
treatment and prophylaxis of psychosomatic components of skin disorders. It may induce a
hypnotic or meditative trance and is one of the methods of hypnotic trance induction. The
relaxation should be maintained for 5 to 25 minutes for optimal benefit. The sitting position is
preferred if the patient desires to realert after the progressive muscular relaxation, while the
recumbent position is preferred if the patient desires to drift off to sleep for a nap or at
Biofeedback of muscle tension via EMG can enhance teaching of relaxation. Biofeedback
assisted relaxation can have a positive effect on inflammatory and emotionally triggered skin
conditions such as acne, atopic dermatitis, dyshidrotic dermatitis (Koldys and Meyer 1979),
hyperhidrosis (Duller and Gentry 1980), lichen planus, neurodermatitis, psoriasis (Benoit and
Harrell 1980) and urticaria. The most common mechanism is through influencing
immunoreactivity (Tausk 1998). Patients who have low hypnotic ability may be especially
suitable for this type of relaxation training utilizing EMG biofeedback.

Various forms of meditation have been used since antiquity. They are an efficient and
effective means of reducing stress. 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, image, sound, word, or mantra and mindfulness meditation where the focus is on
emotional nonattachment but broad awareness of many objects, sounds, other sensations, or
thoughts. Both may involve entering a trance. The concentrative trance reduces external
awareness, while the mindfulness trance maintains external awareness while remaining
calmly centered. There are parallels of concentrative meditation to internally focused
hypnotic trance and of mindfulness meditation to alert awake hypnotic trance.
The western paradigm for healing tends to look at the how of disease, examining the
subsystems involved and the means to repair and cure or control the problem with a short


Philip D. Shenefelt

term focus, while the eastern paradigm for healing tends to look at the what of disease,
examining the systems and supersystems involved and the means to restore or rebalance the
system with a long term focus (Otani 2003). Hypnosis arose in the western cultural milieu
while meditation arose in the eastern cultural milieu. They both use the trance phenomena but
with different conceptual approaches and different types of emphasis.
One form of generic concentrative meditation was introduced by Herbert Benson (1975)
to induce what he termed the relaxation response. It involves sitting in a quiet place, closing
your eyes, letting your muscles loosen and relax, starting at your feet and working upward
(progressive muscular relaxation trance induction), breathing evenly through your nose and
becoming aware of the breath (breath relaxation trance induction). With each exhalation, say
the word one to yourself (concentrative mantra meditation trance induction). Maintain a
passive attitude. Let any distracting thoughts or sensations drift away ignored like clouds in
the sky. Maintain the concentrative meditation for 10 to 15 minutes. When you finish, remain
sitting quietly for a few minutes, first with your eyes closed, then with your eyes open. The
health benefits of the relaxation response have been extensive researched with positive results
in areas such as cardiovascular health.
Mindfulness meditation has also been used extensively for stress reduction. Originally
associated with Buddhism and in particular Zen, it has been adapted for medical use. Jon
Kabat-Zinn (1991, 1994) has been a major proponent of this methodology, employing
mindfulness mediation and hatha yoga. He developed the Mindfulness-Based Stress
Reduction program. The 8 week course had weekly 2 hour classes where techniques of
breath, awareness of body sensations, 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, moment to moment
awareness, attention monitoring, and acceptance. 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, those listening to mindfulness
meditation tapes and those who were controls. 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.

Hypnosis is a tool with many useful dermatologic applications, including stress
reduction. It involves guiding the patient into a trance state for a specific purpose such as
relaxation, pain or pruritus reduction, or habit modification. Hypnosis may improve or clear
numerous skin disorders. Examples include acne excorie, alopecia areata, atopic dermatitis,
congenital ichthyosiform erythroderma, dyshidrotic dermatitis, erythromelalgia, furuncles,
glossodynia, herpes simplex, hyperhidrosis, ichthyosis vulgaris, lichen planus,
neurodermatitis, nummular dermatitis, post-herpetic neuralgia, pruritus, psoriasis, rosacea,
trichotillomania, urticaria, verruca vulgaris, and vitiligo (Shenefelt 2000). Hypnosis can also
reduce stress, anxiety and pain associated with dermatologic procedures. See Table 4.
We all experience spontaneous mild trances daily while absorbed in watching television
or a movie, reading a book or magazine, or other focused activity. After appropriate training,

Relaxation, Meditation, and Hypnosis for Skin Disorders and Procedures


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. We may induce the trance
state using guided imagery, relaxation, deep breathing, meditation techniques, self-hypnosis,
or hypnosis induction techniques.
Table 4. Skin disorders reported responsive to hypnosis.
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 excorie
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, deepening, maintenance, and termination of the

trance state for a specific purpose. Trance has been used since antiquity to assist the healing
process. The purpose of medical hypnotherapy is to reduce suffering, to promote healing, or
to help the person alter a destructive behavior. Some people are more highly hypnotizable,
others less so, but most can obtain some benefit from hypnosis. 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). One biological factor
that has been associated with degree of hypnotizability is the catechol-o-methyl-transferase
gene. At position 148 in this enzyme, gene coding for the amino acid valine on both alleles


Philip D. 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. Heterozygous coding for valine
and methionine is associated with medium to high hypnotizability (Lichtenberg, BachnerMelman R, Gritsenko et al, 2000).
Hypnosis can hasten the resolution of some skin diseases, including verruca vulgaris
(warts). Hypnosis may also help to reduce stress, skin pain, pruritus, or psychosomatic
aspects of skin diseases. Suggestion without formal trance induction may be sufficient in
some cases. Bloch (1927) and Sulzberger (1934) used suggestion to treat verrucae
The precise definition of hypnosis is still somewhat controversial. Marmer (1959) defined
hypnosis as a psychophysiological tetrad of altered consciousness consisting of narrowed
awareness, restricted and focused attentiveness, selective wakefulness, and heightened
suggestibility. Further discussions of the definitions of hypnosis are available in Crasilneck
and Hall (1985) or Barabasz andWatkins (2005). There are many myths about hypnosis that
distort, overrate, or underrate the true capabilities of hypnosis. 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. Quantitative EEG findings by Freeman et al (Freeman, Barabasz, Barabasz et
all 2000) in a study of hypnosis versus distraction effects on cold pressor pain showed
significantly greater high theta (5.5-7.5 Hz) activity for high hypnotizables (based on Stanford
Hypnotic Susceptibility Scale, Form C, or SHSS:C scores ) compared with low hypnotizables
at parietal and occipital sites during hypnosis and also during waking relaxation. PET
subtraction studies by Faymonville et al (Faymonville, Laurys, Degueldre et al 2000)
demonstrated specific areas of the cerebral cortex with higher bloodflow during hypnosis and
others with lower bloodflow, presumably related to cerebral activity. In their study, pain
reduction mediated by hypnosis localized to the mid anterior cingulate cortex.
The mechanisms by which hypnosis produces improvement in symptoms and in skin
lesions are not fully understood. Hypnosis can help regulate bloodflow and other autonomic
functions not usually under conscious control. Stress reduction through the relaxation
response that accompanies hypnosis alters the neurohormonal systems that in turn regulate
many body functions. (Tausk 1998)
For skin disorders, hypnosis may be used to help control stress exacerbated harmful
habits such as scratching. It can also be used to provide immediate and long term analgesia,
reduce symptoms such as pruritus, improve recovery from surgery, and facilitate the mindbody connection to promote healing.
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). Koblenzer (1987) also mentions some of the uses of hypnosis in common
dermatologic problems. Grossbart and Sherman (1992) include hypnosis as recommended
therapy for a number of skin conditions in an excellent resource book for patients. Skin
disorders that have responded to hypnotherapy are discussed below.

Relaxation, Meditation, and Hypnosis for Skin Disorders and Procedures


Hypnosis can be used to reduce stress and psychological or behavioral impediments to
healing. Hypnosis facilitates supportive therapies (ego-strengthening), direct suggestion,
symptom substitution, and hypnoanalysis (Scott 1960; Scott 1963; Scott 1964; Hartland
1969). See Table 5. Mentioning hypnosis to patients will allow the practitioner to gauge the
patient's receptiveness to this treatment modality. The time needed to screen patients, educate
them about realistic expectations for results from hypnosis, and actually perform the
hypnotherapy are similar to or less than those for screening, preparing, and educating patients
about cutaneous surgery and then actually performing the surgery. 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.
Table 5. Hypnotic trance sequence during medical hypnotherapy.
Trance induction
Rapid- -Eyeroll
Slow- -Progressive relaxation or other method
Trance deepening
Trance work (one or more)
Ego strengthening
Direct suggestion
Indirect suggestion
Relaxation for procedures
Trance termination
Some advantages of medical hypnotherapy for skin diseases include nontoxicity, costeffectiveness, ability to obtain a response where other treatment modalities have failed, and
ability of patients to self-treat and gain a sense of control when taught self-hypnosis
reinforced by using audiotapes or mp3s. Disadvantages include the practitioner training
required, the low hypnotizability of some patients, 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. Patient selection is an
important aspect of successful medical hypnotherapy. With proper selection of disease
process, patient, and provider, hypnosis can decrease suffering and morbidity from skin
disorders with minimal side effects.
Induction of the hypnotic state in adults is achieved by methods that focus attention,
soothe, and/or produce monotony or confusion (Crasilneck and Hall 1985; Barabasz and
Watkins 2005). The hypnotic state may be induced in children by having the child makebelieve that he or she is watching television, a movie, or a play or by using some other
distractive process that employs the imagination (Olness 1986).
Supportive (ego-strengthening) therapies include positive suggestions and posthypnotic
suggestions for self-worth and effectiveness. Reinforcement can be achieved by recording an

Philip D. Shenefelt


audiocassette tape or mp3 that the patient can use subsequently for repeated self-hypnosis.
The strengthened ego is better able to deal with psychological elements that inhibit healing.
Direct suggestion during hypnosis may be used to decrease stress, skin discomfort from
pain, pruritus, burning sensations, anxiety, and insomnia. 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. In highly hypnotizable individuals, direct
suggestion may produce sufficiently deep anesthesia to permit cutaneous surgery. Direct
suggestion can also reduce compulsive acts of skin scratching or picking, nail biting or
manipulating, and hair pulling or twisting (Scott 1960). Autonomic responses in
hyperhidrosis, blushing, and some forms of urticaria can also be controlled by direct
suggestion. Verrucae can be induced to resolve using direct suggestion (see below).
Symptom substitution replaces a negative habit pattern with a more constructive one
(Scott 1960). For example, another physical activity, such as grasping something and holding
it so tightly for a half minute that it almost hurts, can be substituted for scratching. Other
activities that can be substituted for scratching include athletics, artwork, verbal expression of
feelings, or meditation.
Hypnoanalysis may help patients with skin disorders unresponsive to other simpler
approaches. Using hypnoanalysis, results may also occur much more quickly than with
standard psychoanalysis (Scott 1960). The C.O.M.P.A.S.S. method of identifying seven
trigger or exacerbating psychosomatic root causes is slightly modified from the method well
described in Ewin and Eimer (2006). See 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. 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).
Table 6. C.O.M.P.A.S.S. method of hypnoanalysis for root causes

Organ language
Past experiences
Active identification
Self punishment


Until recently, reports of the effectiveness of hypnosis on specific dermatologic
conditions were mostly based on one or a few uncontrolled cases. Since the validity of such
findings await further confirmation, "may" is used below to qualify recommendations that are
based on weak evidence. The trend toward more controlled trials has produced more reliable

Relaxation, Meditation, and Hypnosis for Skin Disorders and Procedures


information (Kaschel, Revenstorf and Wrz 1991), although randomized controlled trial
results are still not available for most skin disorders. The list of responsive skin conditions
below is not all-inclusive.
Posthypnotic suggestion was successful in reducing or stopping the picking associated
with acne excorie in two reported cases (Hollander 1959). 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. I have had similar success in one case (Shenefelt 2004). Hypnosis
may be an appropriate treatment for the picking habit aspect of acne excorie in conjunction
with standard treatments for the acne itself.
In a small clinical trial of medical hypnotherapy with five patients having extensive
alopecia areata, only one patient showed significant increase in hair growth. Although three
patients had only slight increase in hair growth and one had no change, hypnosis did improve
stress and psychological parameters in these five patients (Harrison PV, Stepanek 1991). In a
larger clinical trial (Willemsen, Vanderlinden, Deconinck et al 2006), all 21 patients with
severe alopecia areata had improvement of anxiety and depression with hypnotherapy. Nine
patients had total regrowth of scalp hair, and another 3 patients had better than 75 percent
regrowth. Hypnosis may be appropriate as a complementary supportive treatment for the
psychological impact of having alopecia areata, and may sometimes have an effect on the
condition itself.
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 plays a significant role in
the exacerbation of atopic dermatitis. In a nonrandomized controlled clinical trial. Stewart and
Thomas (1995) treated 18 adults with extensive atopic dermatitis who had been resistant to
conventional treatment with hypnotherapy that included relaxation, stress management, direct
suggestion for non-scratching behavior, direct suggestion for skin comfort and coolness, ego
strengthening, posthypnotic suggestions, and instruction in self-hypnosis. The results were
statistically significant (p < 0.01) for reduction in itch, scratching, sleep disturbance, and
tension. Patient use of topical corticosteroid decreased by 40% at 4 weeks, 50% at 8 weeks,
and 60% at 16 weeks. For atopic dermatitis, hypnosis can be a very useful complementary
therapy that can decrease the needed amount of other treatments.
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).
Similar though less spectacular results were confirmed with two sisters aged eight and six
(Wink 1961), with a 20 year old woman (Schneck 1966), and with 34 year old father and his
four year old son (Kidd 1966). Based on these case reports, hypnosis may be potentially very
useful as a complementary therapy in addition to emollients.
Reduction in severity of dyshidrotic dermatitis has been reported with using hypnosis as a
complementary treatment (Tobia 1982). Stress is a known common trigger factor for
dyshydrotic dermatitis, to the point where some individuals can use the flaring of their
dyshidrotic dermatitis as a barometer of their stress levels.
There is one case report of successful treatment of erythromelalgia in an 18 year old
woman using hypnosis alone followed by self-hypnosis (Chakravarty, Pharoah, Scott et al
1992). Permanent resolution occurred.
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.
Hypnosis and self-hypnosis with imagined sensations of warmth, cold, tingling, and


Philip D. Shenefelt

heaviness brought about dramatic improvement over 5 weeks with full resolution of the
recurrent furuncles (Jabush 1969). The patient also improved substantially from a mental
standpoint. Conventional antibiotic therapy is the first line of treatment for furuncles, but in
unusually resistant cases with significant psychosomatic overlay, complementary use of
hypnosis may help to end the chronic susceptibility to recurrent infection.
Oral pain such as glossodynia may respond well to hypnosis as a primary treatment if
there is a significant psychological component (Golan 1997). With organic disease, hypnosis
may give temporary relief from pain.
Discomfort relief from herpes simplex is similar to that for postherpetic neuralgia (see
below). A reduction in the frequency of recurrences of herpes simplex following hypnosis has
also been reported (Bertolino 1983). In cases with an apparent emotional stress trigger factor,
hypnotic suggestion may be useful as a complementary therapy for reducing the frequency of
Hypnosis or autogenic training may be useful as adjunctive therapy for hyperhidrosis
(Hlzle 1994). Stress is a common trigger or exacerbator of hyperhidrosis.
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, winter, and spring (Schneck 1954).
Pruritus and lesions of lichen planus may be reduced in selected cases using hypnosis
(Scott 1960; Tobia 1982). Stress is a definite exacerbating factor in lichen planus.
Some cases of neurodermatitis have resolved and stayed resolved with up to 4 years of
followup using hypnosis as an alternative therapy (Kline 1953; Sacerdote 1965; Collison
1972; Lehman 1978). Stress is a major factor in increasing scratching or picking in these
Reduction of pruritus and resolution of lesions of nummular dermatitis has been reported
with use of hypnotic suggestion (Scott 1960; Tobia 1982).
Pain from herpes zoster and post-herpetic neuralgia can be reduced by hypnosis (Scott
1960; Tobia 1982). Hypnosis may be useful as a complementary therapy for postherpetic
Hypnosis may modify and lessen the intensity of pruritus (Scott 1960). A man with
chronic myelogenous leukemia had intractable pruritus that was much improved with
hypnotic suggestion (Ament and Milgram 1967). Itching typically increases with stress.
Stress is a common exacerbating factor in psoriasis. Hypnosis and suggestion have been
demonstrated to have a positive effect on psoriasis (Kantor 1990; Winchell and Watts 1988;
Zachariae, Oster, Bjerring et al 1996). A 75 percent clearing of psoriasis was reported in one
case using a hypnotic sensory-imagery technique (Kline 1954). 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). Another case of severe psoriasis of 20 years duration resolved fully with a
hypnoanalytic technique (Waxman 1973). 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. Hypnosis can be quite useful as a complementary therapy
for resistant psoriasis, especially if there is a significant emotional factor in the triggering of
the psoriasis.
The vascular blush component of rosacea has been reported to improve in selected cases

Relaxation, Meditation, and Hypnosis for Skin Disorders and Procedures


of resistant rosacea where hypnosis has been added as complementary therapy (Scott 1960;
Tobia 1982). Stress can increase blushing.
Several reports of successful adjunctive treatment of trichotillomania have been
published (Galski 1981; Rowen 1981; Barabasz 1987). Stress is an exacerbating factor.
Hypnosis may be a useful complementary therapy for trichotillomania.
Two cases of urticaria responded to hypnotic suggestion in one study. Stress was a trigger
factor. 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). In 15 patients with chronic
urticaria of 7.8 years average duration, hypnosis with relaxation therapy resulted within 14
months in 6 patients being cleared and another 8 patients improved, with decreased
medication requirements reported by 80 percent of the subjects (Shertzer and Lookingbill
1987). Hypnosis may be useful as complementary or even alternative therapy for selected
cases of chronic urticaria.
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; Ullman 1959; Dudek 1967; Sheehan 1978) and failed to be
confirmed in a few studies (Clarke 1965; Stankler 1967). 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, Hall and Olness 1998). Many reports
confirm the efficacy of hypnosis in treating warts (McDowell 1949; Ullman and Dudek 1960;
Vickers 1961; Surman, Gottlieb and Hackett 1972; Ewin 1974; Clawson and Swade 1975;
Tasini and Hackett 1977; Johnson and Barber 1978; Dreaper 1978; Straatmeyer and Rhodes
1983; Morris 1985; Spanos, Stenstrom and Johnston 1988; Noll 1988; Spanos, Williams and
Gwynn 1990; Ewin 1992; Noll 1994). 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. 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, while none of the control group had
improvement (Surman, Gottlieb, and Hackett 1973). Hypnosis has been proved to be helpful
as a complementary or alternative therapy for warts.
Vitiligo has improved using hypnotic suggestion as complementary therapy (Scott 1960;
Tobia 1982), but it is unclear whether the recovery was simply spontaneous. Hypnosis may be
appropriate as a complementary supportive treatment for the psychological impact of having


Hypnosis can reduce stress, anxiety, needle phobia, and pain during cutaneous surgery, as
well as reducing postoperative discomfort. Fick et al (Fick, Lang, 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. A


Philip D. Shenefelt

standardized protocol and script was used to guide patients into a state of self-hypnotic
relaxation. All 56 patients developed an imaginary scenario. The imagery they chose was
highly individualistic. They concluded that average patients can engage in imagery, but topics
chosen are highly individualistic, making prerecorded tapes or provider directed imagery
likely to be less effective than self-directed imagery. I have used this technique with good
success in dermatology patients (Shenefelt 2003).
Lang et al (Lang, Benotsch, Fick et al, 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),
structured attention, and self-hypnotic relaxation. Pain increased linearly with time in the
standard and the attention group, but remained flat in the hypnosis group. Anxiety decreased
over time in all three groups, but more so with hypnosis. Drug use was significantly higher in
the standard group than in the structured attention and self-hypnosis groups. The
hemodynamic stability was significantly higher in the hypnosis group than in the attention
and standard groups. Procedure times were significantly shorter in the hypnosis group than in
the standard group, with the attention group intermediate. 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, making
the latter considerably more cost-effective.
A meta-analysis of hypnotically induced analgesia found that hypnosis has been
demonstrated to relieve pain in patients with headache, burn injury, heart disease, cancer,
dental problems, eczema, and chronic back problems (Montgomery, DuHamel, and Redd
2000). For most purposes light and medium trance is sufficient, but deep trance is required for
hypnotic anesthesia for surgery (Barabasz and Watkins 2005). Pain reduction mediated by
hypnosis localized to the mid anterior cingulate cortex in a study (Faymonville, Laureys,
Degueldre et al 2000) using a positron emission tomography (PET).
For hypnosis to be of benefit, patients must be mentally intact, not psychotic nor
intoxicated; motivated, not resistant, 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. However, for self-guided imagery a moderate or high
degree of hypnotizability is not critical to success. Letting the patient choose his or her own
self-guided imagery allows most individuals to reach a state of relaxation during procedures.

Ament P, Milgram H. Effects of suggestion on pruritus with cutaneous lesions in chronic
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Klin Hypn 1991; 7:65-82.
Kidd CB. Congenital ichthyosiform erythroderma treated by hypnosis. Br J Dermatol 1966;
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Kline M. Delimited hypnotherapy: the acceptance of resistance in the treatment of a long
standing neurodermatitis with a sensory-imagery technique. Int J Clin Exp Hypn 1953;
Kline MV. Psoriasis and hypnotherapy: a case report. Int J Clin Exp Hypn 1954; 2:318-322.
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Lang EV, Rosen MP. Cost analysis of adjunct hypnosis with sedation during outpatient
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Clin Hypn 1978; 21:48-51.
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In: Hypnosis: Theories, Research and Applications

Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456 2009 Nova Science Publishers, Inc.

Chapter 9


Fabrice Kwiatkowski1, Nancy Uhrhammer2, Yves-Jean Bignon2
and Alain Blanchet3

Bio-statistics unit, Centre Jean Perrin and University Paris-8 (Saint-Denis), France
Laboratory of Molecular Oncology, Centre Jean Perrin, Clermont-Ferrand, France
Department of Psychology, University Paris-8 (Saint-Denis), France

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 endpoints, we suggest that well-trained hypnotists participate, preferably practitioners trained
in psychology. These trials should explore various dimensions of the patients 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

A version of this book was also published as a chapter in Progress in Circadian Rhythm Research, edited by AnneLaure Lglise, published by Nova Science Publishers, Inc. It was submitted for appropriate modifications in an
effort to encourage wider dissemination of research.


Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon et al.

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.

Thanks to Milton Ericksons considerable work during the 20th century, hypnosis is
currently viewed as an acceptable practice by western medicine [Pirotta, 2000; Gray, 2002].
Of course, this does not mean it is considered a standard medical treatment: hypnosis does not
work in the way that chemical drugs do. However, neuroscience is advancing so rapidly
that we may be at a turning point in our understanding of brain function, and may soon
understand why hypnosis appears to be so efficient in comparison to other psychosocial
interventions1. For example, the discovery that memories are not recorded once forever, but
may evolve each time they are evoked, sheds new light on the rebuilding of the past, as
illustrated by Erickson in the February man [1989].
Hypnotism today cannot be rejected as mesmerism was in the 19th century when many
physicians were involved in this practice, with often surprising and reproducible results
[Mheust, 1999; Quinn SO, 2007]. 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
Last but not least, methodology in psychosocial sciences has made tremendous progress,
and the hard science approach using statistics and objective outcomes can now be applied
to measure the efficiency of any intervention, even when the underlying mechanisms are
unknown. This makes it possible to compare the impact of different psychological approaches
on particular psychopathologies. The subjective nature of psychological interventions and
objectives, however, make it difficult to bring this science fully into the realm of hard
science. There may in fact be no difference between a real psychological change and belief in
that change.
One of the best ways to show the impact of psychosocial intervention is to test it on
somatic disease. Investigators do not need to know the mechanisms by which the
interventions work, nor what happens in the patients minds. Focusing on measurable
symptoms is an appropriate strategy to study the effect of a psychosocial intervention like
hypnosis. Indeed, biology is a convenient context to measure changes, and to evaluate
protocols regardless of content. The patient + hypnotist couple can be treated as a blackbox by the researcher, and its influence on biology can easily be studied. Traditional clinical
research methods, including standard prospective randomized trials, can be used. This
approach, with statistical analysis of the data and sample numbers appropriate to measure the
expected variability of the parameters, brings hypnosis into the realm of standard scientific
investigation. This first step, if the results are positive, may eventually be followed by an
analysis of what occurs in the black-box, using specific tools, protocols, trials, and experts.
Many authors have conducted serious investigations at the frontier of psychology and
medicine, especially in the domain of cancer, where physicians facing major treatment

The contrary is also true: it is very likely that hypnosis will help neurosciences to understand brain functionning.

Hypnosis and Cancer: A Dead-End Story?


difficulties may be more open-minded to look for resources out of their usual domain of
competence. This article will focus on these experiments.
The medical literature on hypnosis these past decades, and notably that concerning cancer
(Medline or CancerLit index), shows a slowdown of research in this area through the 1980s
and 1990s, followed by a resurgence in the new century (Fig 1, blue columns). A flatter but
similar trend appears with the more specialized PsychInfo index (Fig 1, violet columns).

Number of articles


Medline - CancerLit


Trials (not review)












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. Last column counts the number of articles from Medline where the
publication type is trial but excludes reviews. Most articles found in PsychInfo are also referenced in
Medline, except for book chapters that appear only in PsychInfo.

Special attention should be paid to prospective randomized trials: when they respect the
methodological guidelines of evidence-based medicine, they are considered the most reliable
type of proof [Guyatt, 1992; Cook, 1995]. Since 1980, new trials have been published at an
average of almost one per year (right columns in Fig.1), representing 8 % of the literature on
the topic hypnosis and cancer. The other 92 % includes case reports, hypnosis
management, expert opinions and reviews. Very often the content of these latter [Wild, 2004;
Rajasekaran, 2005; Tsao, 2005; Ladas, 2006; Rogovick, 2007] either analyze children and
adults separately or consider only one population. In this chapter, since biological, clinical
and psychosocial factors are evoked, we propose a different approach and to successively

Research investigating the effect of hypnosis on clinical or biological parameters.

Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon et al.


Research into the impact of hypnosis on the patients well-being, including quality of
life, anxiety and depression, pain management and the prevention of treatment side
Technical aspects of research on hypnosis with the following main topics :

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, and what target the
hypnosis sessions should address
Beyond biological parameters, what to measure when hypnosis is used in a trial.


Results of trials including hypnosis
Impact on overall survival
As in many prospective trials in cancer, the main clinical end-point is overall survival2.
This is the parameter of choice, since the patients are followed all during their disease and
long after, even if they are in remission. 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, and any lost patients are
equally distributed in the different arms of the trial.

In phase III trials, overall survival is preferred to disease-free survival, since the latter
may not coincide with overall survival and thus cannot be considered a surrogate end-point.
For example, 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, recurrence is no longer synonymous with death from cancer; therefore,
overall survival has almost been the sole clinical factor tested in studies of psychosocial
interventions in cancer.
Prospective trials on psychosocial interventions are scarce. This is even truer for those
that use hypnosis. The first reference of a trial using hypnosis as a complementary treatment
for cancer concerned overall survival [Newton, 1983]. Unfortunately, its design was
inappropriate: it was not a randomized trial, and the statistical analysis separated patients
receiving a minimum of ten 1-hour hypnosis sessions within 3 months, from patients who
received less that ten but at least three sessions. 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,

Overall survival is the interval between a starting point (date of disease diagnosis, first treatment) and the date
of death or last follow-up. Statistical methods (Kaplan-Meier, actuarial) are used to analyse these intervals.

Hypnosis and Cancer: A Dead-End Story?


and this selection may account for the difference in survival. In spite of these flaws, this trial
launched a long series of prospective research on psychosocial interventions.
Aside from Newtons trial, only one study testing hypnosis as the main psychological
intervention in cancer patients (Hodgkins and non Hodgkins lymphoma) has been published
[Walker, 2000]. This second trial was also not randomized, and the slightly significant results
in favor of hypnosis have to be questioned. The impact of hypnosis alone on the survival of
cancer patients is thus a question that has not been yet tested with appropriate methodology.
Spiegels well-known article in the Lancet involved a moderate number of patients (n =
86), 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,
1989]. In the intervention group, self-hypnosis was taught for pain control, and patients were
encouraged to discuss strategies for coping with cancer, but were not led to believe that
participation would affect the course of their lives. This came to be known as supportiveexpressive group therapy [Goodwin, 2005].
To date, hypnosis has mostly been used in association with other educational and/or
supportive interventions (mainly group therapy), and only as a supplementary method to help
patients handle pain or anxiety. Spiegel [1989, 2000] initiated this kind of protocol, and
several prospective trials using hypnosis in cancer patients follow the same model. Although
these studies did not use standard hypnosis, but instead taught patients how to practice selfhypnosis, for this chapter we will consider the results of these trials as representative of
hypnosis impact. Even so, just four prospective trials can be selected from the literature (Fig.
2). All four studies concern metastatic breast cancer patients, and use the same psychosocial
protocol established by Spiegel.


Spiegel (1989)
Goodwin (2001)
Kissane (2007)
Spiegel (2007)



n = 86


n = 235

n = 227


n = 122


Total n = 670

Cox hazard ratios

Figure 2: Impact on survival of self-hypnosis as a auxiliary treatment (hazard ratios are represented by the
circles, 95% confidence intervals are drawn with horizontal lines). (which one is the imagery study?)

At the end of the 20th century, it has become obvious that the early enthousiasm could not
be sustained by the results. More recent publications confirm the failure of psychosocial

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. Odds-ratio (OR) applies to case-control studies, and differs from RR in the way it is
calculated: if the occurrence of the sign or the disease is less than 20 %, these figures are comparable. Hazardratio (HR) is similar to RR except it applies to survival, it integrates the survival delay and is calculated using
Cox's regression model.

Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon et al.


intervention including self-hypnosis to significantly improve survival [Spiegel, 2007;

Kissane, 2007].
The conclusion of this brief review of trials using hypnosis does not differ from
Smedslunds meta-analysis of psychosocial interventions [Smedslund, 2004] where the
authors found no significant advantage of these interventions on overall survival of cancer
patients. But two remarks should be noted :

hypnosis was not the main psychological lever in the supportive-expressive

group therapy, but a minor one and it consisted in self-hypnosis.
An interesting finding of Smedslunds meta-analysis is that individual treatments
seemed to have a stronger impact on survival than group treatments. The hazard
ratio associated with a subset of three trials testing individual interventions was
0.55 [0.43, 0.70] while the global estimate of the impact of the complementary
subset (i.e. nine group treatments) was 0.97 [0.73, 1.27]. This means that
individual management seemed to reduce the risk of death by half.

Thus a first global conclusion: hypnosis as the main psychological treatment has never
been tested against survival in cancer patients with appropriate prospective methodology.
Many types of psychosocial interventions have been investigated, but not hypnosis.
Moreover, going along with Smedslung suggestions, it is likely that individual sessions of
hypnosis will do much better than group training.

Impact on the response to chemotherapy

Most of the time, the response to treatment is correlated to overall survival. Recently, a
prospective trial in England tested a technique similar to hypnosis to enhance the response to
neoadjuvant chemotherapy in breast cancer [Walker, 1998]. This idea is attractive, since for
most types of cancer, data on treatment response is usually obtained routinely, and also
because it is obtained more quickly than overall survival data. The psychological intervention
consisted of relaxation training and guided imagery. Before the first cycle of chemotherapy,
patients were taught progressive muscular relaxation and cue-controlled relaxation
[Hutchings, 1980]. 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. Patients kept a diary in order to evaluate their daily practice duration. Ninety six
patients were accrued, 48 in each arm. After completion of chemotherapy, no significant
difference in pathological or clinical responses was found, although a weak association in the
relaxation arm was found between the rating of imagery vividness and clinical tumor
regression. A lack of statistical power may have been responsible for the non significance of
the main outcomes, and a larger trial may show a positive response. The main interest of this
study is the originality of the protocol, focusing on the response to treatment.
Impact on immunity
Although many authors underline the importance of immune functions in the evolution of
cancer [Kiecolt-Glaser, 1999; Temoshok, 2002; Kwiatkowski, 2007a], very few trials include
end-points concerning immunity. There may be at least two reasons for this dearth of

Hypnosis and Cancer: A Dead-End Story?



the main reason is that initial expectations were too high (especially after
Spiegels positive results), and a significant gain in survival was naturally
Second, immunity is a very large and intricate set of biological processes that
interfere with the whole metabolism. It appears difficult to choose the relevant
parameters for cancer: number of natural killer (NK)-cells, their cytotoxic
potential, cytokines (IL-2, IL-6, IL-15), hormones (melatonin, cortisol, leptin)
that inhibit or activate NK activity, or other nonspecific markers of activation of
cellular immunity, such as E2-microglobulin [Sabbioni, 2000] ? Immunity is a
chain of biological processes, and as a chain, it has the strength of its weakest
link. Testing immunity in a trial on hypnosis therefore needs to include the
measure of a large set of biological parameters (Kwiatkowski, 2007b). The
disadvantage of increasing the number of factors studied is the risk of falsepositive conclusions (i.e. the risk of finding a parameter significant when only
chance is at work). The Bonferroni correction for multiple testing can be used to
counter this effect [Bland, 1995], but it dramatically increases the population size
necessary to reach sufficient statistical power, and as a consequence may make
the trial unfeasible because of the associated costs.

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. 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, 1990].
The first trial using hypnosis-like approaches used a longitudinal design where patients
were their own controls [Bakke et al., 2002]. This kind of design causes problems, since it is
impossible to guarantee that the parameters followed through time change due to the
psychological intervention or to some other uncontrolled cause. 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. Nevertheless, the study is interesting.
For 25 stage I-II breast cancer patients, NK cell count and cytotoxicity were measured at base
line, at 8 weeks and at 3 months. Hypnotic guided imagery followed the methods of Simonton
[1980]. Each patient received 8 individual weekly imagery training sessions and were
encouraged to practice 3 times a week. They also received relaxation training based on the
Jacobson method [Jacobson, 1938].
The NK lymphocyte fraction increased with improvements in mood on different
subscales of the POMS questionnaire: confusion (p = 0.004), tension (p = 0.017), anger (p =
0.015) and depression (p = 0.013). NK counts rose significantly after 8 weeks (p = 0.03) but
this response was not sustained at the 3-month follow-up. No change in NK cytotoxicity was
Lengacher et al. [2008] recently performed a second pilot study using the same pretestposttest kind of design, but with a control arm. As in Bakke et al, breast cancer at stages 0 to
2 was targeted, while 28 patients were included (14 per arm) and relaxation with guided
imagery was employed as the psychological intervention. The immunological parameter
measured was IL-2-activated NK cell activity in blood samples obtained prior to surgery and


Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon et al.

four weeks post-surgery. Significant p-values between 0.01 and 0.05 characterized
differences in NK-cell cytotoxicity between the trial arms.
These two reports are coherent. Although both used small sample sizes, significant
objective effects of hypnosis on NK cells were observed concerning one of the key immune
parameters in cancer. This is not proof of any effect on disease progression or overall
survival, but suggests a direction of research, in particular for those concerned by
psychoneuroimmunology. Moreover, these trials show the feasibility of small studies of
psychosocial intervention and sound immunological end-points. Because longitudinal studies
of biological parameters are quantitative and most inter-individual variability does not
interfere thanks to paired statistical tests, surveys using small sample numbers still have
adequate statistical power.

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, their circadian
rhythms (principally the amplitude of rhythms) give a better point of view on metabolism
homeostasy: this includes major hormones (melatonin, cortisol) that rule main immune
functions, temperature and rest/activity cycles. Indeed, circadian rhythms appeared to be a
significant prognostic factor for overall survival in metastatic colorectal cancer patients
[Mormont, 2000]. The main clock hormones, melatonin and cortisol, can easily be sampled in
saliva at different times of the day, making them suitable candidates for kinetic studies. An
other hormon, leptin, has recently gain importance in this type of studies, because of its crossactivity between adipocytes and immune cells.
Finally, blood oxygen saturation (SPO) 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. Cellular responses to hypoxia may explain neoangiogenesis, the spread of
malignant cells, and a portion of the resistance to chemotherapy [Brahimi-Horn, 2007]. SPO
is relatively easy to measure, using a non invasive infrared electronic device at the surface of
the skin. For more detail, the circadian rhythm of SPO could be also studied with a portable
device recording continuously over a couple of days.
Up to now, no published research has tested the effect of hypnosis on circadian
fluctuation in biological functions. The authors of the present article are undertaking one such
trial [Kwiatkowski, 2007a, b], with intermediate results expected in 2010.


Patients well-being is an imprecise notion which covers a wide range of aspects,
including quality of life (QOL), depression, anxiety, mood, etc.
Although QOL is well-correlated to other psychological dimensions4, the need for more
precise scales can occur, especially when testing psychosocial interventions. For example,

Correlations between QOL and dimensions like depression are easy to understand : depression damages self
esteem and social relationships; it is often associated with poor sleep, fatigue, etc. In QOL questionnaires, each
of these characteristics are probed by a few specific questions that combine to give a global estimate of

Hypnosis and Cancer: A Dead-End Story?


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.


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 Liossis, 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. Daltons 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

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?


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 Rosss 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 Becks 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.


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?


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.,
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
Associations 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.


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-

Hypnosis and Cancer: A Dead-End Story?


based guidelines on the use of hypnotism for pain management will be available to both
patients and clinicians. 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, 2007].

Hypnosis and Treatment Side-Effects

As stated previously, pain is one of the major side-effects of cancer treatments, in
particular with advanced cancer, where drastic measures need to be taken. In fact, the goal of
the great majority of clinical investigations is to define the optimal balance between antitumor efficacy and toxicity. Typically, to be efficient, drugs have to be toxic, surgery
invasive, and radiotherapy cannot avoid irradiating normal tissues. The development of
targeted treatments, such as monoclonal antibodies, stereotactically guided radiotherapy and
perhaps immunotherapy, is beginning to change this situation. Considerable progress has
been done to prevent side-effects; for example, potent anti-emetic medications (5-HT3
receptor antagonists in association with dexamethason) enable patients to better cope with
chemotherapy and radiation. Patient management including hematological follow-up helps
avoid major sepsis. The major remaining side effects are pain (see previous section), nausea
and vomiting, hot flushes, neuropathy, fatigue, and psychological problems more or less
related to these symptoms. These symptoms are not without consequence, since they interfere
with treatment (by requiring dose reductions, or delaying schedules) and compromise the
patients therapeutic alliance with his physician.

Nausea and vomiting

Although anti-emetic medications are widely used, chimiotherapy-induced nausea and
vomiting still represent a significant problem for cancer patients [Koeller, 2002]. 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. Anticipatory symptoms cannot neither
be treated by such medications. The use of hypnosis against nausea and vomiting is quite old.
In a study of chemotherapy-related effects, patients practicing relaxation and guided imagery
experienced significantly less anxiety, nausea, and depression than patients supported by a
therapist or the control group [Lyles et al., 1982], a result that carried over into the follow-up
Richardson et al. conducted a meta-analysis on this subject in 2007. They could only find
four trials satisfying their selection criterias [Zelter, 1991; Syrjala, 1992; Jacknow, 1994;
Hawkins, 1995]. Outcomes varied since trials addressed sometimes anticipatory symptoms
and some others chemotherapy-induced ones. Among the four trials, three tested the impact
of self-hypnosis and Zelters one tailored hypnosis. Three of them concerned pediatric cancer
patients, except in Syrjala. All trials presented methodological weaknesses, mainly reduced
sample sizes, which made a meta-analysis pertinent. Richardson et al. concluded that
hypnotherapy lessened nausea and vomiting, but the effect size was not associated to any
probability. 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 patients request in both arms. In spite of Richardsons conclusion, we
agree with Genuis when he stated in 1995 that the consensus is that hypnosis to manage


Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon et al.

nausea and vomiting in cancer patients shows encouraging results but yet not compelling
evidence [Genuis, 1995].

Hot flushes
Hypnosis has begun to be used to treat hot flushes in breast cancer patients, an often
underestimated symptom that affects up to 78% of female chemotherapy recipients and 72%
of hormonotherapy recipients. [Carpenter, 2001]. Hot flushes concern patients and survivors
of various types of cancer, and are associated with many physical symptoms (headaches,
palpitations, paresthesia, insomnia...) and psychological troubles (irritation, embarrassment,
sense of loss of control...), making their control of general interest [Elkins et al., 2004]. 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., 2008]. This reduction had an overall impact on, or was synchronous with
patients well-being, as shown by the significant improvement of mood scores and sleep
The effect of hypnosis on fatigue has not been well studied. In one pilot study of
cognitive-behavioral therapy plus hypnosis (CBT+H). fatigue was evaluated weekly on a
subscale of the FACIT questionnaire (Functional Assessment of Chronic Illness Therapy) and
daily on a visual analogue scale. Trend analysis was statistically significant despite the small
sample size, showing that fatigue remained unchanged in the CBT+H arm, whereas fatigue
increased linearly in the control group [Montgomery et al., 2009].
Hypnosis thus seems to be useful at different moments of cancer management: before,
during and after treatments. This is to say: always. Although trials often target specific endpoints, case studies exhibit a much wider range of difficulties that hypnosis may help with.
Hypnosis may be of some assistance when medical treatments fail. We agree with Liossis
conclusion: hypnosis can be generalized to many circumstances. 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, to address dysphagia for pills or to enhance their
performance in their favourite sport. For clinician, hypnosis is an opportunity to be inventive,
spontaneous and playful and to build a stronger therapeutic relationship with a patient while
providing symptom relief [Liossi, 2006].


We have reviewed most researches investing the impact of hypnosis on either biological
or psychological end-points. Results are encouraging. But hypnosis includes a large range of
practices. Besides, it can be used by varied professionnals, sometimes shortly trained, and in
trials, the competences of theses persons can influence outcomes and issues addressed during
sessions. Finally, different measures can be taken that qualify the trance, the relation between
hypnotist and patient. These can later appear of importance if significant results are obtained

Hypnosis and Cancer: A Dead-End Story?


on the disease itself. We suggest here different directions to facilitate researches on hypnosis
with cancer patients.

What Kind of Hypnosis Should be Proposed?

Ericksonian hypnosis: what else ?
Setting aside mesmerism, two main historical periods apply to hypnotism: before
Erickson and after. Before Erickson, the use of classical hypnosis consisted of mastering a
subjects will through vigorous induction using direct suggestions of sleep and surrender.
Freuds initial interest in hypnotism under Charcots teaching is an example of such an
approach. One of the problems they faced was the low proportion of people able or accepting
to enter a trance (less than 50%). Moreover, the results obtained were not lasting, since the
patients acceptance was not achieved, or even sought. Freud presented this as the reason why
he searched for a new approach and created psychoanalysis.
Ericksons renewal of hypnotism overcame this difficulty. Because of the effort made to
meet patients goals and adapt to their cognitive patterns, Ericksonian hypnotism is often
described as a sort of guided self-hypnosis, though it is not this simple. Ericksons 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. Sorry Milton !
Erickson also showed that a very deep trance was rarely necessary: most desired effects
could be obtained with a light trance, as long as no unconscious resistance inteferes with
explicit goals. Inductions thus do not need to be very technical. Usually, a good relaxing
approach is sufficient for appropriate suggestions to take effect. For this reason, relaxation
with guided imagery is usually considered a form of hypnosis, as we have done here. Since
the goal is to increase the suggestibility of patients without no large alteration of the state of
consciousness, other practices also probably meet this condition, including sophrology
[Caycedo, 1964], meditation [Biegler, 2009], biofeedback, and perhaps prayer, all of which
induce specific kinds of trance and quite often use suggestions (positive thinking, creative
imagination, etc).
Many different techniques may be appropriate to address a narrowly defined goal: for
example, yoga plus meditation was as efficient as hypnosis in ameliorating chronic
depression [Butler, 2008]. For more complex goals addressing the past or the personality of
patients, more sophisticated approaches and deeper trances are often necessary.
Psychologist or not ?
With cancer patients, the expectations are usually simple to formulate, and the aims of
therapy rather straightforward: ameliorate pain, side-effects, depression, etc. 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, a single
session to reduce anxiety before an invasive medical procedure), induction and suggestions
can probably be made by a nurse or physician with limited training in hypnosis. A study of
chronic pain management [Anbar, 2002], involving more extensive interventions and with


Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon et al.

some components left to the physicians discretion, obtained significant results in spite of the
pulmonologists having undergone a single 20-hour training workshop.
When taking care of chronic or terminally ill patients, the situation is not the same. More
training is useful when the interventions are more extended and varied. As discussed in
section 2.3, 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. The end of life is also a time when essential questions are addressed, and even
psychologists may need special training to be able to help patients with these issues.
Psychologists and psychiatrists are also the only persons with the expertise to care for
depression. Physicians and nurses trained in other specialties often do not appropriately
manage the emotional crises that frequently occur in depressed cancer patients, or help
patients reduce their distress level.
Medical research may require hypnotists that are psychologists, depending on the
legislation or regulation of the country where the research takes place, the requirements of
the local ethics committee, and on the type of intervention described in the trial protocol. No
special skill may be required if the intervention concerns a limited aspect of patient
management, using a standardized technique and a predetermined set of suggestions. But if
investigation is not so limited and may concern various aspects of the patients psyche or
behavior, then formal training in psychology is necessary. In particular, cancer can
temporarily mask deep psychosocial problems. Psychologists are the best equipped to face
these situations. The hypnotist needs to be trained to listen to the patient, as well as to propose
suitable directions that the patient will be able to follow and develop.

Individual or group sessions ?

Several trials observed better results with individual rather than with group sessions, as
summed up by Smedlungs [2004] in his meta-analysis on psychosocial interventions and
survival of cancer patients. But we have found no trial testing individual versus group
approaches specifically using hypnosis. Here again, there might not be a single best method,
but methods more or less appropriate to the type of investigation.
Group training sessions, however, seem less well adapted to studies were personal needs
and demands are to be taken into account. Although personal topics may appear unrelated to
the pathology, gains or improvements in these areas may indirectly help patients improve
their quality of life and reinforce the progress made on pain or anxiety. Individual session are
thus more suitable when the suggestions are made to fit patients personal difficulties or
wishes, or when allegories need to be personalized. This is only possible when the patients
current context, culture and background can be taken into account.
We recommend that hypnosis in group sessions be limited to the teaching of selfhypnosis. Group sessions favor the expression of practical difficulties, and the sharing of
problems encountered by the participants may help others address similar problems later in
personal practice.
In practical terms, group sessions may be more difficult to organize, especially if groups
are large and patients come from outside of the hospital. This simple consideration may itself
determine what type of session to use, although a combination of both types may be the best
solution for some trials: for example, group sessions to teach self-hypnosis plus individual
sessions to address personal needs. The number of practitioners available may also be a
limiting factor that favors group sessions.

Hypnosis and Cancer: A Dead-End Story?


Tailored hypnosis or self-hypnosis ?

Self-hypnosis can be taught to patients quite easily, in either individual or group sessions.
Chronic pain is a good indication for self-hypnosis training, where patients can develop skills
to manage their symptoms ad libitum. One study of children, however, reported an advantage
of personal sessions, but the benefit was lost when patients were switched to self-hypnosis
[Liossi, 2003], highlighting the difficulty of ensuring compliance of patients. In spite of
audiotapes that could facilitate the exercises, it is difficult to obtain regular practice from
subjects. Although the hypnotist should give post-hypnotic suggestions to favor effective
self-practice, the quality of trance and the power of suggestions may also diminish greatly
with self-hypnosis.
Finally, the therapeutic alliance, i.e. the quality of the affective relationship established
between the patient and his therapist, has proven to be one of the most important factors in the
success of psychotherapy [Crits-Christoph, 2006]. This is very important if patient faces
irrational fears [Burish, 1983], or is blocked by severe defenses that prevent access to past
distress or trauma. Fawzy [1990] confirmed that affective changes had more impact on the
immune system than coping management. The therapist who can enhance these affective
patterns, is able to solve more painful problems: his propose alternatives will appear more
secure. The absence of the therapeutic alliance makes self-hypnosis more limited and less

How Theories of Cancer May Modulate the Suggestions Made During

It is common sense to state that the ideas people have of cancer, its causes and probable
development, will influence the way hypnotists manage their sessions. Whether these ideas
correspond to scientific truths or not is not relevant to the therapy, as long as these ideas do
not drive patients to dangerous experimentation or acts. The therapist may even share some of
these opinions with his patients. Many of these beliefs may shape the expectations of both
patient and therapist, and thus modify the outcome, or the perceived outcome, of the
intervention [Montgomery, 2001; Roscoe, 2006].
For example, some chemotherapeutic drugs produce nausea and vomiting in many
patients. Symptoms may appear as early as the first cycle. Surprisingly, in the following
cycles it is not rare to discover that these symptoms begin as soon as patients arrive at the
hospital, and not, as expected, once their chemotherapy has started. There are several
different strategies that can be used to prevent symptoms, 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, 2006].
In a randomized prospective trial (i.e. with a control group) where the endpoint is
survival and the impact of a short series of personal hypnosis sessions is being tested, 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. This is relevant, but in the practice of hypnotherapyas in any other kind of psychotherapy,
the therapist should be prepared to explore areas not immediately identified by the patient.
There are several points of view to consider:


Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon et al.

1. Most practitioners favor a neutral attitude. The primary goal, following the requests
of patients, is controlling the symptoms of disease and improving patients wellbeing. This attitude appear rather safe, in terminally ill patients, where the objective
can be limited to the quality of end of life. In an example of this strategy, a 4-stage
hypnotic intervention that fits Kubler-Ross analysis of terminally ill patients (initial
crisis, transition/rebellion, acceptance and preparation for death), the aim was to
facilitate patients coping in their last moments [Marcus, 2003].
2. Hypnosis may also be directed toward behavior modification : if a patients habits
include behaviors that increase the risk of relapse or aggravation (smoking, disturbed
circadian rhythms, eating disorders, reduced physical activity, etc), why not use
suggestions to ameliorate their behavior? Group educational sessions are partly
efficient here. Complementary work under hypnosis may be useful in facilitating
such changes, especially when they are multifactorial. Behavioral changes in activity
and diet may yield significant gains in survival. For example, physical activity after
breast cancer was found to improve survival, in particular through the coordinate
lowering of cardiovascular mortality [McNeely et al., 2006]. Breast cancer survival
improved more significantly when activity was coupled to dietary modifications
(higher vegetable-fruit consumption) [Pierce, 2007].
A same strategy could be used to reinforce circadian rhythm [Rossi, 2002 ; Moser,
2006]. The human ultradian cycle (of about 90 minutes) is of particular interest.
Every cycle, we have a small period of inattention, and if we do not try to work
through to the next cycle, but accept to stop our activity and empty our mind, this
may reinforce the circadian activity/rest cycle as well as numerous metabolic
functions, including immunity. Why not use that moment for a few minutes of selfhypnosis or relaxation? This strategy may be the last that remains, when patients are
too ill to leave their bed.If we pay attention, there are many domains that could
benefit from sessions targeting behavioral changes. It might be effective to focus on
positive behaviors, which will bring satisfaction and in turn reinforce the patients
will to manage other domains of his life.
3. The positive imagery approach stems from psycho-neuro-immunology theory,
mainly the idea that immune cells may be boosted by suitable imagery, this being
more effective if the patient is temporarily relaxed and disconnected from his
surrounding [Strosberg, 1989]. The strategy requires good familiarity with the patient
in order to choose appropriate allegories. Although examples of remission have been
attributed to this approach, it has not proven efficient in well-designed randomized
trials measuring survival.
4. Changing beliefs and/or expectations. Between 20% and 50% of therapeutic efficacy
is often attributed to the placebo effect itself, that is the beliefs and expectations of
patients concerning their treatment. In oncology, the placebo effect is usually
considered ineffective against the disease, but to our mind, this is questionnable.
Generating a placebo effect is equivalent to changing beliefs and/or expectations.
With many cancer patients, this is a very delicate point: when the prognosis is very
pejorative, one cannot let the patient believe he will get cured. This risks placing him
in a very distressing situation when he realizes he was misled. Perhaps, ethically, the
least that can be done is to weaken the patients certainty of not having time to live,
since this often prevent him from maintaining projects, even very short term ones.
Alternative projects may be suggested as for example, the surprise to obtain new
insights on his personality or reducing anxiety for death. On the other hand, not to

Hypnosis and Cancer: A Dead-End Story?


use the powerfully therapeutic lever of new beliefs/expectations would be

regrettable. Metaphors can be used to replace an unethical message of excessive hope
by a story presenting positive unexpected change.
5. It has been suggested that traumatic events in the patients history may be
psychological risk factors for cancer (Fig. 3) [Duijts, 2003; Lillberg, 2003].


Traumatic events
Death of the spouse
Death of child, parent, friend...
Personal health difficulties
Health difficulties of relatives
Divorce, separation
Financial changes
Environmental changes



Figure 3. Breast cancer risk in relation to life events in the six months before diagnosis [Duijts, 2003].

It is possible too that persistent psychological trauma can lower the overall health of
an individual, in particular the ability of the organism to fight disease. The
hypotheses behind this proposal are a bit audacious, suggesting that psychological
patterns can durably depress the immune system, and that resolving past trauma can
relieve this depression. There is evidence that the immune system can suppress
cancer cells in the absence of treatment : once cancer appears, its development does
not follow the exponential growth predicted from in-vitro cell culture models [Horii,
2005]. In many cases, the biological environment of the tumor plays an important
role, both favorable (neo-vascularization of the tumor bed) and unfavorable
(activation of immune defenses). Spontaneous recoveries from usually aggressive
tumors have been documented: melanoma may be eliminated by the immune system
[Wagner, 1998; Curiel-Lewandrowski, 2002], and leukocyte infiltration of tumors is
common. These discoveries do not indicate that cancer is curable, but create
opportunities for new strategies based on enhancing immunity, and here with the
help of hypnosis. The success of these new strategies will naturally depend on
numerous clinical, biological or genetic factors, whether the tumor is hormonedependent, and the state of the disease. The known link between immunity and the
psyche suggests that the resolution of past psychic trauma with hypnosis could be
useful, and should be tested in cancer patients

Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon et al.


Beyond Clinical and Biological Parameters, What to Measure When

Hypnosis is Used in a Trial ?
Hypnosis differs largely from other types of psychotherapy. In contrast to
psychoanalysis, hypnotherapy does not require years of treatment. Unlike other cognitivebehavioral therapies, it provides indicators that researchers can use, in order to assess a
posteriori if the outcomes are correlated to the strategy employed. In this last chapter, we
present some of the possible indicators.
1. Hypnotisability, or susceptibility to hypnosis [Smith, 1996; Hawkins, 1998]. Several
studies indicate that the results may depend on the level of hypnotisability of the
patients. Although Erickson claimed that non-hypnotisable persons do not exist;
there are only bad hypnotists, the power of suggestions may vary with the subjects
sensitivity to hypnotic induction. According to a large meta-analysis of 57 trials
comparing hypnosis to a control group, the hypnotic suggestibility was responsible
for 19% of the treatment outcomes6 [Flammer, 2003]. This means that 80% of
hypnosis efficacy depend on other parameters. Several tools have been developed to
measure hypnotisability:

the Stanford Hypnotic Susceptibility Scale (SHSS) developed in 1965 has been
widely used and often treated as a gold standard (but arguably, according to
Benham [2002]). After a very short induction, individuals are tested for certain
hypnotic behaviors. The test can be administered and graded by a hypnotist in
about a quarter of an hour.
The Creative Imagination Scale [Barber, 1978] uses a short hypnotic session
including 10 experiences, after which the subject answers questions about his
feelings in each experience. This scale was tested against the SHSS and shown to
have a weak predictive power [Kurtz et al., 1996].
The Hypnotic Induction Profile [Speigel, 1976]. Also known as the eye roll test,
the person is asked to roll his eyes upward, and the size of the visible iris and
cornea is measured. The smaller this part of the eye is, the more hypnotically
susceptible the person is supposed to be. The results correlate poorly with other
hypnotic scales [Orne, 1979] and this scale is no longer used.
Other scales can reflect hypnotic susceptibility, such as the TAS (Tellegen
Absorption Scale), a self-questionnaire of 34 items. In a multidimensional
analysis, Crawford [1982] showed a good correlation between SHSS and TAS.
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.

2. Trance depth may be a useful factor to measure, even during each session.
Physiological characteristics will eventually become the best means to evaluate the
quality of trance. Bio-feedback techniques can play a role in this direction. Heart-rate

In this study, six randomized study reported numerical values for the correlation between hypnotisability scores
and treatment outcomes, with a correlation coefficient r = 0.44. Hence, r = 0.19, which means that 19% of the
outcomes variation is due to the variation of hypnotic suggestibility.

Hypnosis and Cancer: A Dead-End Story?


variability (HRV) may be one such parameter, as it has been linked to self-rated
hypnotic depth evaluation, possibly through the parasympathetic branch of the
autonomic nervous system [Diamond et al., 2008].
Trance depth may also be evaluated by the subject and/or by the hypnotist, as is done
for pain with visual analogue scales. Such measures may not be as accurate and
reliable as physiologic measures. SHSS relies on the same kind of evaluations
through its referenced hypnotic behaviors which can be observed by the hypnotist
during a session.
3. Other variables can probably also be scored: for example, the therapeutic alliance.
Despite the subjectivity of such an evaluation, it could be evaluated by the therapist
with a visual analogue scale . This may appear surprising, but the patient-therapist
couple also influences the therapist, with a very well-known symptom known in
psychoanalysis as counter-transferance. 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.
Various qualitative and quantitative elements could facilitate the evaluation of hypnotic
sessions. These are of little interest in common practice, but when a research protocol tries to
evaluate the impact of hypnosis on clinical outcomes, it might be a useful to have some
standardized indicators that, later, will help understand what works and what does not. Small
portable devices may soon be available to measure different physiological parameters in realtime, and enable better control of the sessions of hypnosis. We stand once again at the crossroad of hypnosis, biology and neurosciences.

Most studies of the use of hypnosis with cancer patients indicate that this approach is
very helpful when facing psychosomatic or psychological symptoms (pain, side effects of
treatments, quality of life, anxiety, depression...) but the effect on the prognosis itself is still
controversial. Some authors are pessimistic about supportive-expressive group therapy and
self-hypnosis training having any effect on survival [Speigel, 2007; Kissane, 2007]. One
could thus decide to abandon research in this domain, but the impact of clinical hypnosis on
survival, 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, as new experimental designs have emerged showing that hypnosis may improve
the efficacy of standard treatments.
The success of hypnosis in enhancing well-being confirms its place in the management of
cancer patients, regardless of the stage of the disease or the age of the patient. 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. Simple biological hypotheses
can then be addressed in trials that are far less expensive than those testing new molecules or
monoclonal antibodies.
Other major advantages are that hypnosis is harmless and non toxic, in contrast to
products from the pharmaceutical industry. Moreover, since no medical solution can be


Fabrice Kwiatkowski, Nancy Uhrhammer, Yves-Jean Bignon et al.

proposed to cancer patients in palliative care, this population seems very appropriate to test
new hypotheses. To paraphrase Goodwin [2005], the least we can offer them is to live better,
if not longer !
Although there is a need for standardized procedures, hypnosis sessions should not be too
strictly predetermined. Patients differ: sessions must differ. What should be practiced is not
some special set of suggestions, always delivered in a same manner, but the global
management of patient in which hypnosis is a better way to facilitate personal adjustment and
learning. Cancer deprives of life: lets reintroduce life, flexibility and spontaneity. And if in
some sub-group, an effect can be established, it will be time to focus on the matter and
develop new directions for new studies using randomized prospective trials. This
methodology is no longer the privilege of selected research teams. With the dissemination and
sharing of knowledge and expertise in clinical research and statistics now so largely spread
by accessible major medical reviews, it is possible to perform clinical studies in most
hospitals. This is particularly true for specialized cancer centers, where areas of expertise are
already shared by groups of physicians. The limiting factor today is not means, but ideas and
A large amount of data on psychosocial intervention has accumulated, and supportiveexpressive group therapy has not been found to increase the survival chances of patients. Our
intent was not to replace a disappointed hope by another labeled hypnosis. Our purpose was
to show that clinical hypnosis is still promising, while most of other types of psychological
approach have failed to meet the great expectations of the last three decades. If we consider
the constant development of new classes of ever more efficient psychotropic drugs, the
decline of the psychiatric use of psychotherapy [Mojtabai, 2008] in favor of
pharmacotherapy, and the progress of neuroscience, perhaps new research into hypnosis is
our last chance to promote a more human paradigm of medicine, rather than a short-sighted
mechanical symptom-pill attitude that gives full latitude to industry and leaves patient with
more dependencies. 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. It helps patients to
handle the major side-effects of cancer and its treatments, notably pain. It spares place for
living. Evidence is lacking for any improvement in survival, but well-being is not without
value. We have no doubt that the gains in quality of life will eventually translate to a
significant impact on the disease itself. As beliefs about hypnosis progress, expectations
change, leading to new data that may change beliefs. And so on, and so forth ! Didnt
Benham [2002] show that in western countries, hypnotic susceptibility scores were

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In: Hypnosis: Theories, Research and Applications

Editors: G. D. Koester and P. R. Delisle

ISBN 978-1-60456 2009 Nova Science Publishers, Inc.

Chapter 10


Antonio Capafonsa and M. Elena Mendozaa, b

University of Valencia, Spain;

Private Practice, Sta. Cruz de Tenerife (Spain)

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 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 cognitive-behavioral 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 selfhypnotized 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

Antonio Capafons and M. Elena Mendoza


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.


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. 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.
Likewise, waking hypnosis, due to its characteristics, presents a great deal of practical
possibilities and is accessible for more people than traditional hypnosis.
Waking hypnosis cannot be considered as merely waking suggestion, since the latter can
be used without any induction ritual, whereas waking hypnosis counts with a set of hypnotic
induction rituals.
The Valencia Model of Waking Hypnosis (VMWH) was developed on the basis of the
socio-cognitive or cognitive-behavioral paradigm of hypnosis (Capafons, 2001), and is
considered as a therapeutic model embracing a variety of methods combined to change
attitudes and use suggestions maximizing their effects. The main characteristics of the
VMWH are as follows:

There are not suggestions of drowsiness, restriction of the attention, or relaxation.

People are asked to keep their eyes open, to expand their attention, to be mentally
and physically activated, with increased sensation of self-control.
The hypnotized person can speak fluently, walk, and perform almost any of his/her
everyday tasks, while experiencing the hypnotic suggestions.
Hypnotic suggestions are, essentially, direct and permissive.
Hypnosis is introduced as a coping skill avoiding allusions to trance or altered states
of consciousness.


Suggestion and other related variables, such as beliefs, expectancies, imagination, and so
on, have been considered for many years components of the hypnotic experience. For
instance, authors like Bernheim (1884), Wundt (1882), and Hull (1933) advocated for these
ideas on the base of their experimental studies of hypnosis. Nevertheless, until the 1960s,
hypnosis was associated with the methods based on Braid (1843) or Charcot (1882) views, in
which relaxation, drowsiness, trance, and eye closure were suggested. Additionally, the terms
used to designate hypnotic reactions were taken from psychopathology and some of them still
remain, such as, hallucinations, catalepsies, regression, etc.

The Valencia Model of Waking Hypnosis and Its Clinical Applications


Subsequently, studies conducted by T.X. Barber and his colleagues (Calverley, Wilson,
Spanos, and Chaves, among others) in the 1960s questioned the necessity of the concept of
hypnotic trance itself, as well as the methods utilized to achieve it in promoting exceptional
responses (Spanos & Barber, 1976). In this way, alternative methods were developed to bring
about responses to the suggestions. Thus, T.X. Barber proved that the subjective experience
of involuntarity, besides the objective response to the hypnotic suggestions, could be
achieved by using task motivating or think-with instructions (Barber & Calverley, 1965;
Wilson & Barber, 1978).
Later in the 1970s, in Hilgards laboratory, active-alert hypnosis was created by making
up different methods of inducing hypnosis formally opposed to the traditional ones (Bnyai &
Hilgard, 1976). Other authors, like Kratochvil (1970), and Wark (1998), ruled out the
concepts of drowsiness and focus on a narrow range of stimuli, proposing methods of alert
hypnosis [such as hyperempiria (Gibbons, 1979)], or started to use hypnosis without a formal
induction (Kuhner, 1962).
On the other hand, Ericksonian authors quit traditional hypnosis and focused on
communication and social influence, emphasizing permissive and indirect suggestions in a
hypnotic setting away from the usual one (use of analogies, metaphors, etc.) (Hawkins, 1998;
Matthews, Conti, & Starr, 1998). Finally, recently, Iglesias and Iglesias (2005) used
waking/alert hypnosis from a dynamic perspective to treat panic attacks and other disorders.
Another questioned concept was the trait-like quality of hypnotic suggestibility. Several
methods were developed to increase it, and experimental research proved the possibility of
increasing hypnotic suggestibility (Diamond, 1974; Gorassini & Spanos, 1986; Sachs &
Anderson, 1967). There were even procedures proposed from a behavioral perspective
resorting to basic principles of Functional Behavior Analysis (Pascal & Salzberg, 1959), in
which differential reinforcement of successive approximations or the use of instigators helped
more people use hypnosis, thus increasing hypnosis efficiency.
On the basis of this theoretical background, 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.

They should be straightforward for clients to apply and learn (self-hypnosis).
The clients should be able to use the procedures with their eyes open and to
generalize them to their everyday life.
The procedures should not create iatrogenic reactions.
They should emphasize self-control and be versatile enough to be used as methods of
either relaxation or activation depending on the clients needs.

To this end, the procedures of VMWH derive from the methods for increasing hypnotic
suggestibility by Sachs and Anderson (1967), and recover Wells basic ideas of waking
hypnosis and Gibbons concept of hyperempiria. Moreover, the essential theoretical rationale
of VMWH lies on the Response Expectancy Theory by Kirsch (1990, 1991, 1993), and
disregards the concept of trance as Barber (1969), and Coe and Sarbin (1991) proposed. In
this way, the model advocates the continuity between hypnotic and non-hypnotic behavior,
resorting to variables such as expectations, motivation, attitudes, beliefs, etc. to produce the
hypnotic responses (Capafons, 1999; Lynn & Kirsch, 2005; Spanos & Coe, 1992).


Antonio Capafons and M. Elena Mendoza


Waking hypnosis has several advantages; some of them had already been pointed out by
Wells in 1924, namely: a) it has a less mysterious appearance and its impression is more
desirable; b) it takes less time in obtaining results, usually two or three minutes if not earlier,
than traditional hypnosis; c) requires less effort on the part of the therapist and it is easier for
the beginner to learn; d) it can be used with more people successfully since the start; e) when
it is needed or preferred to employ hypnosis by relaxation, the methods can be adapted with a
greater chance of success if the suggestions given in waking hypnosis were successful (Wells,
Our experience with the VMWH allows us to add further advantages. First, that the fact
that clients can remain self-hypnotized while keeping their eyes open, talking, walking, and
engaged in any other activities of their everyday life allows them to experience therapeutic
suggestions where the problem they need them for arises (Alarcn & Capafons, 2006;
Capafons, 1998b, 2004a, b). Accordingly, when homework assignments are included in the
therapy, they are easier to carry out since the clients count with a coping strategy to go
through them successfully. Thus, many of the post-hypnotic therapeutic suggestions can be
supported by the client in situ, who, in this way, obtains benefits faster.
Secondly, waking hypnosis strengthens clients expectancies for success, reinforces their
motivation for subsequent sessions and therapy more generally, and magnifies their sense of
general efficacy and self-control (Capafons & Mendoza, in press).
Additionally, the VMWH introduces waking hypnosis as a strategy for coping and selfcontrol (Capafons, 1998b, 2001) disregarding the concept of an altered state of consciousness.
Finally, it is worth pointing out that the VMWH fosters an active participation on the part
of the client. In contrast, the Wells model was authoritarian promoting passivity in clients
(John F. Chaves, personal communication to the first author, 12-1-2005), and was framed in a
trance setting (Wells, 1924).


As mentioned before, the methods of the VMWH are intended to be efficient and at the
same time pleasant, easy and quick to learn and apply for both therapists and patients. In this
sense, the Model puts forth a sequence that serves as a guide in the intervention with waking
hypnosis (Fig. 1) and that can be adapted to each specific case.
In order to establish a good rapport with patients, three procedures have been
implemented as part of the Model, namely, a cognitive-behavioral introduction to hypnosis, a
clinical assessment of hypnotic suggestibility, and a metaphor for hypnosis. Additionally, two
hypnotic induction methods (Rapid Self-Hypnosis (RSH) and Waking-Alert Hypnosis
(WAH), the latter also known as Alert-Hand Hypnosis (Cardea, Alarcn, Capafons, &
Bayot, 1998)) complement the VMWH. The core of the Model is RSH, and it is very
structured, but, at the same time, flexible enough to be adapted to the cases and patients
preferences and necessities. In the next paragraphs these procedures are explained in detail.

The Valencia Model of Waking Hypnosis and Its Clinical Applications


Figure 1. Clinical intervention sequence of the VMWH (Taken from Alarcn & Capafons, 2006).


After the therapist has a diagnosis and a functional analysis of the problem, the
intervention plan is established without mentioning hypnosis and a good rapport is
established. Then, it is convenient to assess the misconceptions about hypnosis that the


Antonio Capafons and M. Elena Mendoza

patient holds as well as his/her attitudes toward it (Capafons et al., 2005). The most popular
myths are as follows (Capafons, 1998a):
1. Hypnosis is beyond the scope of scientific research. Those who use it are showmen,
quack doctors, and charlatans. People who improve through hypnosis are gullible,
ignorant and dependent.
2. Hypnosis can make people get stuck in a trance, in a way that, being unable to
come out of such state, they would lose their will and become insane.
3. Hypnosis can worsen peoples latent psychopathologies. It even can make healthy
people to develop psychological alterations. People with psychopathological
problems may get even worse by using hypnosis.
4. Hypnosis produces a sleep-like state, in which people show special characteristics.
If such characteristics are not achieved, the person is not hypnotized. That special
situation can only be achieved by means of a hypnotic induction method.
5. Hypnosis makes people lose their voluntary control. Thus, the person becomes an
automaton in the hypnotists hands, and can commit crimes, or immoral or socially
ridiculous acts.
6. Hypnosis generates exceptional, unusual, and quasi-magic reactions in people.
7. 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. However, only very
suggestible people can benefit from it.
Accordingly, these myths about hypnosis are dispelled and explained in detail, answering
all doubts the clients may have.
Subsequently, the therapist initiates the introduction to hypnosis from a cognitivebehavioral standpoint (Capafons, 2001; Capafons & Amig, 1993; Coe, 1980; Kirsch, 1994),
in which the following ideas are important to be conveyed: a) responses to suggestions are
acts committed by the clients, and therefore not dependent on any power of the therapist.
The hypnotist simply facilitates the experience of suggested responses. b) Actions during
waking hypnosis are automatic, but at the same time, they are voluntary in the sense that
individuals have the ability to initiate, stop, or resist suggested responses. c) What happens
during hypnosis depends mainly on persons ability to utilize their resources, which are
activated in a manner similar to how they are activated on an everyday basis. d) Accordingly,
hypnosis involves reactions in everyday life that can be activated or deactivated at will at any
given moment. e) From this perspective, hypnosis is a form of self-control, even if less
conscious effort is required on behalf of people to regulate certain behaviors. f) To be
hypnotized does not require entering into a trance or altered state of consciousness, but rather
involves preparing the mind to access resources that facilitate perceiving responses in daily
life as automatic (Alarcn & Capafons, 2006; Capafons, 2001; Capafons & Mendoza, in
To this end, the therapist performs an exercise with the Chevreul pendulum illusion (see
the script of this exercise in Appendix I) (Capafons, 2004a; Capafons & Mendoza, in press).
Obviously, the examples provided in this exercise can be adapted to the patients preferences,
including cultural ones, as in some countries such type of exercise is used to get in touch
with spirits, and the patient can be scared if the pendulum is used.

The Valencia Model of Waking Hypnosis and Its Clinical Applications


The information conveyed through the presentation increases the probability that clients
will feel comfortable with the hypnotic procedures, and reinforces the explanations given
before when dispelling the above-mentioned myths. Additionally, according to a recent study
(Capafons et al., 2006), 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. These results
are in accordance with the findings of a study by Lynn, Vanderhoff, Shindler, and Stafford
(2002), although they used a different trance explanation suggesting that an altered state of
consciousness was instrumental to responding during hypnosis. However, it has been found
that when reluctant people are offered to received a self-hypnosis method, no such differences
in dropout rates are observed (Capafons et al., 2005).


According to the VMWH, the initial assessment of hypnotic suggestibility is performed
outside the hypnotic context and as a form of assessing patients collaboration with, and
confidence in the therapist and the hypnosis itself. Patients expectancies and attitudes
towards hypnosis are assessed as well, since it has been found that they are related to positive
outcomes of psychological treatments that include hypnosis as an adjunctive (Barber, Spanos,
& Chaves, 1974; Chaves, 1999; Schoenberger, Kirsch, Gearan, Montgomery, & Pastyrnak,
Even though there are many forms of assessing hypnotic suggestibility, the VMWH puts
forth these exercises that help reduce the fear many people have of being hypnotized and
familiarize patients with waking suggestions.
For the first exercise, postural sway, patients are asked to stand with their feet together
and their eyes closed. Afterwards, the therapist suggests with a monotonous, firm, but nice
voice to sway back and forth. If clients begin to gently sway, we can assume that they are not
interfering or blocking reactions, since they are in an unbalanced position that, in itself, with
no intervention of suggestions produces swaying. If clients markedly sway, that means they
are collaborating and experiencing the effect of suggestions. Nevertheless, if clients do not
sway at all, there is a high likelihood that they are resisting the natural effects of suggestions.
In this case, it is convenient to determine the reasons why they are resisting. It may be due to
their fears, reluctances, skepticism, or other interfering beliefs that should be further
explained and dispelled. Additionally, clients are informed that, because of the posture,
everyone sways slightly, unless they block the effects of the suggestions.
The next exercise, falling back (Hilgard, 1965; Capafons, 2001; 2004a) is aimed to assess
the clients confidence in the therapist with greater certainty than the previous one, since the
therapist will catch the clients when they fall backwards. The exercise starts asking clients to
close their eyes and try to guess the location and distance of the therapist from them. In this
way, they can be sure that the therapist is in the right place to hold them when they fall
backwards. Actually, the angle of fall should be small, just enough to allow therapists to test
whether clients try to avoid falling in any way. 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


Antonio Capafons and M. Elena Mendoza

them. After this, clients adopt the same position than in the postural sway exercise and the
therapist gives them suggestions for feeling unbalanced and falling backwards.
If clients avoid falling, the therapist asks for determining the reasons of their lack of
confidence. Given that they let themselves fall before the exercise, it is assumed that their
lack of confidence is not toward the therapist but toward hypnosis. Conversely, if the clients
let themselves fall backwards, it can be assumed that they trust hipnosis and are collaborative.
If they also report that they felt unbalanced, it can be assumed that clients experienced the
subjective reaction suggested.
In view of the fact that certain clients prefer to use their imagination to completely
experience suggested reactions (T.X. Barber, 1999), the therapist can complement this
exercise by using a metaphor to facilitate a postural sway and fall backwards response. 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, and that the magnet is being passed around
clients head, which feels the attraction toward the magnet. Then the therapist indicates that
the magnet is moving to the left and drawing the clients body with it, after that to the right,
then forwards, then backwards (which are the postural sway movements). Finally, the magnet
attracts the client so strongly backwards that s/he becomes unbalanced and falls into the
supporting hands of the therapist. In case there are better responses after the application of the
magnet metaphor, it can be concluded that this client benefits more from imaginative
In the next exercise, clients are asked to roll up their eyes and then close their eyelids
without lowering their eyes. After this, they are instructed to attempt to raise their eyelids,
without moving their eyes from this position, and the therapist inform that they will not be
able to do so (challenge exercise). Often times, clients find it difficult to roll up their eyes and
hold them in that position with their eyelids closed. If this is the case, the therapist can ask
clients to look at a given spot on the ceiling. Obliging them to lift their gaze and then to lower
their eyelids without moving their eyes from the target spot.
If the clients do not open their eyes, the therapist ask them how they feel and explain the
trick behind this exercise (i.e., it is virtually impossible to raise ones eyelids while
maintaining your eyes in this position). If, on the contrary, they open their eyes, the therapist
asks them about any reluctance they experienced, and assesses whether they understood the
instructions. In case the clients open their eyes because they were afraid, the therapist leaves
aside the hypnotic suggestibility assessment, and addresses the possible causes of lack of
confidence. When these difficulties are overcome, the exercise is repeated, and the trick is
At this point, the therapist clarifies to the clients that the tricks will be always explained
to them, and that certain tricks are employed as a part of the treatment in order to improve
their responsivity to suggestions, thus converting them into prompts for suggested responses.
The last exercise is a motor challenge suggestion, hand clasping. It is introduced as an
exercise involving mental self-control, 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. When clients do not interfere with the reaction, they
will feel they cannot separate their hands until they break the response and stop
experiencing that their hands are stuck.
If clients fail the challenge by separating their hands, they are asked if at least they felt
tension in their fingers, or felt as if their hands were stuck together. If this is the case, the

The Valencia Model of Waking Hypnosis and Its Clinical Applications


therapist asks them why they separated their hands. If clients report that they did so because
they feared losing voluntary control, it is convenient to remind them of the trick, namely, the
importance of experiencing the tension without interference. Also, they are reminded about
the difference between automatic response and involuntary response explained in the
cognitive-behavioral introduction to hypnosis.
If the clients fail to experience any reaction, the exercise is repeated using counting and
imagination techniques (i.e., a strong glue that sticks the hands together). If none of these
endeavors succeeds clients are told that they are not in hypnosis, and that with some practice
they will probably be able to perform the exercise while in hypnosis.
In case the clients respond appropriately and do not become frightened by their failure to
separate their hands, then the mechanism behind the exercise is explained, and they are told
that there is a very high probability that they will respond well to the therapeutic suggestions
that follow, since they have activated the tension response in their hands and have not
interfered with it.
If the clients have performed correctly most of these exercises and have a positive
attitude toward hypnosis, the therapist may proceed to teach them a self-hypnosis method.
Finally, it is worth pointing out that the way of using and interpreting these classic
exercises is different to the usual one. By including the assessment of attitudes and
expectancies in a qualitative way, the therapists can obtain useful information about the
willingness of patients to collaborate and get involved in the therapy. Additionally, all these
exercises are carried out in a relaxed atmosphere, using jokes to help establish rapport, and to
decrease tension and concerns about testing.


At this point, clients are invited to initiate their experience with self-hypnosis. 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.
Before inducing hypnosis it is convenient to warn clients about the expected effects they
can experience during the hypnotic induction. In case of suggesting relaxation, these reactions
are similar to the ones experienced when relaxing by any other method, namely, dizziness,
tingling, drowsiness, feeling of heaviness, lightheadedness, etc. Additionally, it is appropriate
the establishment of a sign indicating the therapist that the client wants to come out of
hypnosis. On the other hand, when RSH is used as an activation method, it should be
explained what is expected from the clients so that they do not confuse the activation
instructions with anxiogenic instructions. Finally, the therapist gives the clients strategies for
them to cope with interfering thoughts and images that prevent them from concentrating.
Rapid Self-Hypnosis consists of the three following steps: (1) hand clasping, (2) falling
backwards, and (3) a challenge suggestion (confirmation exercise). The clients are
informed that these exercises are designed to produce sensations of relaxation, heaviness and
immobility, as well as to activate the brain so that it works in a rapid and effective way.
The steps are very structured and the way the training is done is based on Applied
Functional Behavior Analysis. That is, it consists of the shaping of the behavior through
successive approximations to the goal, verbal explanations, modeling and the chaining of the


Antonio Capafons and M. Elena Mendoza

behaviors. Therefore, the patients learn the steps separately and then they are put together.
The ability to respond is then generalized to new therapeutic suggestions with no need of
further shaping exercises. In this way, the whole procedure is similar to a process of stimulus
fading and generalization. The therapists instructions, the instigating exercises, and the
sensations of heaviness are faded, although the last two can be used to maintain the habit and
optimize overlearning, or when relaxation is needed. A detailed description of the steps of
these procedures is in Appendix II.
Once this procedure is over, clients are interviewed to know their reactions and
preferences, which will help the therapist to adapt exercises in future sessions to the clients
characteristics. Additionally, clients are told that it is important to practice the method three
times in a row in the morning, afternoon, and night, and they are also advised to perform it in
various places according to the principle of stimulus generalization.
With practice, these self-hypnosis procedures becomes more abbreviated and better
disguised. Moreover, clients capable of reproducing extreme heaviness in their arm, with very
little practice, can concentrate on the arm (with the eyes open, without interrupting their
activities) and give themselves suggestions for feeling their arm heavy and immobile, as if it
were not theirs, and experiencing a dissociation of the arm from the body. At that moment
they are in self-hypnosis and, therefore, are ready to implement the therapeutic suggestions
they need in a given situation. Simply put, RSH can be reduced in this way to a single
instruction of reproducing a sensation, which, since it requires neither overt exercises, nor the
closing of the eyes, nor the adoption of a relaxed posture, goes unnoticed by others. Clients
thus gain access to self-hypnosis by fading the relaxation exercises and relinquishing the
traditional hypnotic appearance (eyes closed, relaxed, sleepy). Accordingly, 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. This brief variation of RSH is called Arm
Dissociation (AD) (Capafons, 1999), and it has been found that the AD method makes RSH a
more efficient and effective hypnotic method. AD surpasses the initial method in a number of
relevant characteristics: (1) it is more pleasant; (2) it can be applied easier to the clients
everyday life; (3) it is shorter; (4) it is less noticeable in public; and (5) it results in an
increase of the clients suggestibility (Reig, Capafons, Bayot, & Bustillo, 2001).


Once clients have experienced self-hypnosis, the therapist provides them with a metaphor
aimed to convey the following ideas: (a) hypnosis is not dangerous, (b) successful responding
does not imply a lack of effort or perseverance to achieve a change in behavior, and (c)
hypnosis is an important tool that can act as a catalyst of other treatments, such as cognitivebehavioral interventions. Likewise, 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, 1987), as well as to activate self-efficacy expectations to facilitate therapeutic
outcomes (Callow & Benson, 1990).
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. They overcome them successfully with their own effort, creativity, and use of a

The Valencia Model of Waking Hypnosis and Its Clinical Applications


multipurpose tool, a machete that represents hypnosis (see the full text of this metaphor in
Appendix III).
According to research, after listening to this metaphor, most participants change their
opinion about hypnosis and consider it as an adjunct technique to the intervention that helps
gain self-control (Capafons, Alarcn, & Hemmins, 1999).


This procedure (also known as Alert Hand Method, Cardea, Alarcn, Capafons, &
Bayot, 1998) was designed by the first author (Capafons, 1998a, b; 2001) as a part of the
VMWH and to complement the RSH. It is especially helpful for those clients who prefer to be
hypnotized by the therapist (Capafons, 1998a; 2001). In these cases, the therapist can
hypnotize clients with the aim of reinforcing the efficacy of the self-administered suggestions,
but with the understanding that clients will eventually use hypnosis on themselves.
Waking-Alert Hypnosis, like RSH, encourages clients to keep their eyes open, adopt a
normal everyday appearance, and even maintain a pleasant conversation with the therapist.
Among the methods of alert hypnosis developed, the one created by Bnyai (Bnyai &
Hilgard, 1976; Bnyai, Zseni, & Turi, 1993) is probably the most researched of them, and the
most similar to WAH in the sense that both promotes to keep the eyes open and general
activation while remaining hypnotized. Nevertheless, current findings from research have
shown that WAH counts with a number of advantages over Bnyais method as follows: (a)
WAH is more pleasant (Cardea, Alarcn, Capafons, & Bayot, 1998), and promotes a greater
level of suggestion (Alarcn, Capafons; Bayot, & Cardea, 1999); (b) it includes some
exercises to be performed previously to avoid that clients confuse the concepts of being
activated with being anxious, something that could happen (Ludwig & Lyle, 1964); (c) it is
easier to conduct that Banyis approach, since the latter requires an ergonomic bicycle, or a
spacious room in which the clients can walk around and activate themselves; (d) WAH is
easier to generalize to everyday life, since clients always keep their eyes open, whereas in
Banyis method it is not this way all the time; (e) WAH produces fewer dropouts than
Banyis method; and (f) it can be performed by clients who are in poor physical condition
but still can benefit from suggestions of alertness (Cardea, Alarcn, Capafons, & Bayot,
A description of the introduction, pre-induction exercises, and WAH method can be
found in Appendix IV.


One of the purposes of hypnosis, especially waking hypnosis, is to increase clients selfefficacy and outcome expectancies (Kirsch, 1985; 1986) fostering their motivation to get
involved in the intervention. Insofar as in the VMWH the suggestions are given while clients
keep their eyes open, it is possible to conduct several practice exercises in which clients start
realizing that a series of stimuli (pencils, watches, or any object even imaginary ones) can
provoke reactions that in a natural way, they would never provoke.


Antonio Capafons and M. Elena Mendoza

These exercises start asking the clients to self-hypnotize. Then, reactions of heaviness
and lightness are suggested to be evoked and associated to seeing or touching different
objects. Next, these suggestions are reversed, that is, if it has been suggested that seeing a ball
pen will generate heaviness, to reverse the suggestion means that the ball pen will evoke
lightness later. By using Hulls (1933), terminology the therapist explains the client that these
exercises are useful to facilitate homoaction (i.e. the improvement of the responses through
practice) and heteroaction (i.e. the improvement of the performance in difficult suggestions
by practicing others less complicated). In this way, 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. Clients also learn that they are developing their own
ability to respond to hypnotic suggestions that is based on a sort of mental discipline.
On the other hand, these exercises allow asking the following motivational questions to
the clients:
Do you think that there is any objective reason by which seeing or touching those
objects would generate heaviness or lightness? Answer: No
Do you think that the way you think, or imagine, as well as your attitude has favored
those reactions? Answer: Yes.
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.
Do you think that the magnitude and implications of your problem partially depend
on your way of thinking, of imagining, and on your attitude towards it? In other
words, do you think that your problem depends on the meaning that you have
associated to it? Answer: Yes.
Do you think that changing your way of thinking, of imagining, and your attitude
towards the problem can help you solve it? Answer: Yes.
Do you think that hypnosis can help you manage better your thoughts and your
imagination, and keep a better attitude towards your problem? Answer: Yes.
Usually, clients tend to respond adequately to the questions, what lead them to change the
meaning of their symptoms. Now those symptoms are no longer out of their control, on the
contrary, they are modulated, determined, and/or maintained by their attitude and
understanding of the problem. In this way, self-hypnosis reveals to be an adjunctive method
that helps increase self-control and self-regulation.

Once a patient has learned the procedures described so far, the therapist proceed to chose
the kind of therapeutic suggestions more suitable for the case and the patients characteristics.
An array of types of suggestions that the therapist can use is as follows:
Suggestions for the efficacy of suggestions and techniques.
Ego-strengthening suggestions: confidence, ability, strength, energy.
Well-being: joy, satisfaction, relaxation.

The Valencia Model of Waking Hypnosis and Its Clinical Applications


Distancing: indifference, objectivity, calmness, serenity.

Desire / Control.
Anxiety, confusion, sadness, excessive worry, panic.
Repugnance, repulsion, rejection.
Satiety appetite.
Analgesia / Anesthesia.
Motor suggestions: immobility, slowing down or acceleration of movements.
Automatic writing.
Dissociation of parts of oneself, from surroundings. Amnesia, hallucinations of
solutions, etc.
Time distortion: acceleration (while in pain) and slowing down (while enjoying a
Age regression to the time the person did not have the problem (without looking for
precision of the recall).
Time progression to a date in which the problem has already solved.
Alteration of the physiologic experience of anxiety or similar.
Reinterpretation of psychophysiologic reactions and thoughts.
Paradoxical intention (as a variant of challenge suggestions).


It is important to take into account the following aspects when using direct suggestions:
To use the appropriate tone of voice for each message: emphasizing key words and
talk with the rhythm, pauses, and pace adequate to the client. To modulate the tone of
voice all the time, showing confidence and fluency.
To use short suggestions or break them in short sentences.
To use a positive wording. It is better to say tobacco is indifferent to you, than
you do not feel like smoking.
To involve as many sensory stimuli in the visualization as possible.
Post-hypnotic suggestions will have a short and specific limit of time: In a moment,
when you come out of hypnosis, and during the next half an hour, you will feel
refreshed and active during the next half an hour, you will feel refreshed and
The suggestions have to be credible for the client. It is better to say: As I face the
situations I am afraid of, they will quit bothering me, than saying: From now on, I
will always enjoy riding my bicycle (in case of an agoraphobic patient).
To have available a variety of suggestions to prevent boredom or habituation.
To express suggestions forcefully and with confidence, even showing an intense
emotional involvement. To avoid repeating the suggestions dully and mechanically.
Finally, in case of failure in responding to the suggestions the following strategies may be

Antonio Capafons and M. Elena Mendoza


To turn to the learning of sensory/emotional recall control or the reproduction of

responses in general. It has to be stressed that the idea is to evoke responses already
in the repertoire of the patient, or to promt those not still in it.
To emphasize the concept of interference, removing distrust and/or impatience.
To distinguish between involuntary and automatic behaviors (the later can be
To perform exercises to correct the response as outlined below:
o Instigation and observation of the response aimed to suggest.
o Association of that response to a verbal, visual, or both cue (optional).
o Encouraging the response reproduction by activating the cue.
To emphasize individual differences in speed and style of learning.


The patient is a 47 years old male who was in psychological therapy for Generalized
Anxiety Disorder (GAD). In the course of this treatment he suffered an accident that resulted
in an injury in his right wrist. At first, it was supposed to be a severe sprain and the patient
was given a Velcro wrist splint that he took on and off, and was prescribed pain medication.
After seven days, since J. had not improved at all, the physician decided to check for a hidden
scaphoid fracture through an MRI. This diagnosis was confirmed and due to failure to
diagnose and treat the fracture earlier and acutely, the only option left was surgery.
The patient asked for help through hypnosis to manage pain and cope with peri-surgery
anxiety, distress, and pain. Given that he was receiving cognitive-behavioral treatment for his
GAD, J. was familiar with cognitive restructuring of irrational thoughts, diaphragmatic
breathing, and progressive muscle relaxation. The goal of this part of the treatment was for J.
to learn self-hypnosis and its applications to the problems he was facing at that time related to
the injury of his wrist.

Session 1
First, the cognitive-behavioral explanation of hypnosis was introduced to the patient. By
the means of several practical examples, including exercises using a pendulum, the
presentation consisted of the following concepts:

Correction of the misconceptions about hypnosis offering precise information

supported by scientific research.
Explanation of how hypnosis works.
Explanation of the ways one can interfere with hypnotic procedures, such as different
ways of not following the suggestions, distractions, unrealistic expectancies, and so

The Valencia Model of Waking Hypnosis and Its Clinical Applications


J. was able to understand all these concepts and showed a good attitude to continue with
the next exercises.
Second, the initial assessment of hypnotic suggestibility was performed in order to assess
J.s collaboration with, and confidence in the therapist and the hypnosis procedure itself. All
the exercises were done outside the hypnotic context. The first one was the postural sway
as explained before in this chapter. The patients sway was pronounced in response to the
suggestions to do so, therefore, it was assumed that J. was collaborating and experiencing the
effect of the given suggestions.
In the next exercise, falling back, the patient allowed himself to fall backwards and
reported to have felt unbalanced as soon as the exercise started.
The third exercise, roll up the eyes, was explained to the patient, who responded
appropriately and found this exercise very amazing.
Finally, the hand clasping exercise was not carried out, due to the patients injury in his
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. Therefore, J. had confidence in
her and it was easy for him to do the exercises without fears. Also, he reported that he liked
the exercises and found the session very fun, pleasant, and interesting.

Session 2
The patient came back a week later for this session. After asking him general questions
about how he was doing and if there was something new about his wrist treatment, the
therapist proceeded to teach J. Rapid Self-Hypnosis (RSH).
Since the patient had pain in his wrist, a variant of the first step of the method (hand
clasping) had to be made up. In this case, the therapist used a small rubber ball that the patient
squeezed with his healthy hand to exert the pressure, and at the moment of dropping the hand
on his leg, he let the ball go and relaxed his hand, while focusing on the feelings of heaviness
in this hand.
The other steps were taught to the patient separately without any other variants, and then
they were chained together to complete the method. J. found the exercises easy to perform
since they are closely related to the hypnotic suggestibility exercises practiced in the previous
Subsequently, the patient was asked to hypnotize himself using the method he just
learned and the therapist proceeded with the following exercise. 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, Alarcn, & Hemmings, 1999)). The goal of this exercise was to convey the ideas
that hypnosis is safe, that it is required an effort on his part to change behaviors, and that
hypnosis is a helpful agent in the treatment but not the entire intervention in itself. Therefore,
the metaphor helped consolidate the information about hypnosis already given in the
Finally, in this session another exercise was proposed to the patient. While he was selfhypnotized and kept his eyes open, the therapist suggested the patient to evoke reactions of


Antonio Capafons and M. Elena Mendoza

heaviness and lightness. Then, each reaction was associated to the sight or touch of different
objects; in this case, heaviness was associated to the touch of a red pen and lightness to the
sight of a small notebook. The patient needed some time to do the associations and, when he
had achieved them, the therapist asked him the questions mentioned in the practice and
training suggestions section, that he answered as expected. J. 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, and his attitudes toward them, and that selfhypnosis would be a good tool to accomplish these changes.
The assignments for the next session were to practice RSH three times in a row in the
morning, afternoon, and night, and to make a list of the main worries he had about his
surgery, his staying in the hospital, and the pain and difficulties this injury was causing him.

Session 3
This session took place one week after the last one. A review of the assignments
indicated that the patient had understood well the RSH proc