This article was downloaded by: [University of Iowa Libraries]

On: 13 March 2015, At: 18:20

Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954
Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

American Journal of Clinical

Hypnosis
Publication details, including instructions for authors and
subscription information:
http://www.tandfonline.com/loi/ujhy20

Hypnosis Complications, Risk

Factors, and Prevention
Frank Machovec Ph.D.
Published online: 21 Sep 2011.

To cite this article: Frank Machovec Ph.D. (1988) Hypnosis Complications, Risk
Factors, and Prevention, American Journal of Clinical Hypnosis, 31:1, 40-49, DOI:
10.1080/00029157.1988.10402766

To link to this article: http://dx.doi.org/10.1080/00029157.1988.10402766

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information
(the Content) contained in the publications on our platform. However, Taylor
& Francis, our agents, and our licensors make no representations or warranties
whatsoever as to the accuracy, completeness, or suitability for any purpose of the
Content. Any opinions and views expressed in this publication are the opinions and
views of the authors, and are not the views of or endorsed by Taylor & Francis. The
accuracy of the Content should not be relied upon and should be independently
verified with primary sources of information. Taylor and Francis shall not be liable
for any losses, actions, claims, proceedings, demands, costs, expenses, damages,
and other liabilities whatsoever or howsoever caused arising directly or indirectly in
connection with, in relation to or arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Any
substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,
systematic supply, or distribution in any form to anyone is expressly forbidden.
Terms & Conditions of access and use can be found at http://www.tandfonline.com/
page/terms-and-conditions
 AMERICAN JOURNAL OF CLINICAL HYPNOSIS
VOLUME 31. NUMBER I, JULY 1988

Hypnosis Complications, Risk Factors, and

Prevention

Frank MacHovec
Richmond, Virginia

There is a substantial body of clinical and experimental research data docu-

Downloaded by [University of Iowa Libraries] at 18:20 13 March 2015

menting the incidence of mild to severe after effects coincident with the use
of hypnosis in persons with no prior history of similar medical or mental
problems. This article provides an overview of relevant clinical and experi-
mental research and a review of pertinent literature since 1887. Subject, hyp-
notist, and environmental risk factors are listed, a definition and classification
system for hypnosis complications is suggested, and recommended preventive
practices are described.

There is a substantial body of published
clinical and experimental research docu-
menting mild to severe, unexpected side
effects coincident with the use of hyp-
nosis in persons with no prior history of
similar medical or mental symptoms.
Clinical case histories, empirical studies
of observed hypnotic behaviors and post-
hypnotic interviews, subject self-reports,
and practitioner questionnaires comprise
a growing database. It is international in
scope and is multidisciplinary, involving
medicine, psychiatry, psychology, and
dentistry and encompasses the history of
Received May 16, 1987; revised September
28, 1987; second revision December 16, 1987;
accepted for publication December 21, 1987.
For reprints write to Frank MacHovec,
Ph.D., Center for the Study of the Self,
3804 Hawthorne Road, Richmond, VA
23222.
hypnosis in its entirety, from Mesmer and
Braid to current professional journals
(MacHovec, 1986).
Empirical Evidence
Six studies published from 1962 to 1986
reported unexpected, unwanted side ef-
fects coincident with the use of hypnosis.
Methods of gathering data and reporting
the incidence, severity, and duration of
the side effects differed markedly from
one study to another. Subject populations
varied also, involving clinical, experi-
mental, and stage hypnosis. The inci-
dence of reported side effects or first- or
second-hand knowledge of side effects
ranged from 24% to 49%. These variables
make comparison of the studies difficult
and impractical.
Averback (1962) mailed 828 question-
naires to psychiatrists. Of these, 414
completed forms were returned, 120 of
which reported knowledge of 210 adverse

40
 COMPLICATIONS, RISK FACTORS, AND PREVENTION
reactions coincident with hypnosis use. He
grouped these into 10 categories: psy-
chotic decompensation (n = 119, much
higher incidence than other studies);
symptom substitution; extreme anxiety;
overdependency; depression; actual or at-
tempted suicide; acting out behaviors;
sexual seduction; conversion symptoms;
and masking of organic disorders. More
recent studies have reported anxiety as
occurring more frequently than psychotic
decompensation or symptom substitution
Downloaded by [University of Iowa Libraries] at 18:20 13 March 2015
(Echterling & Emmerling, 1987; Hilgard,
1974; Judd, Burrows, & Dennerstein,
1986).
Echterling and Emmerling (1987) con-
tacted 292 college students by phone, 94
of whom had attended a 3-hour stage hyp-
nosis show on campus. Of these, 18 agreed
to face-to-face interviews. Time in trance
ranged "from a few minutes to nearly the
entire program." Seven were "enthusi-
astically positive" about the experience.
Seven others "reported both positive and
negative experiences." Four students
"described their hypnosis experience in
essentially negative terms." One reported
that she "ran out of the auditorium, down
the hall and started to cross the field when
a security guard caught me... " (p. 151).
"I didn't sleep for the next 2 days,"
another student reported, "I hibernated and
hid from everybody. It has still left me
shook up. I'm going to drop out of school.
This has messed up everything. I lost con-
trol. This forces me to think about stuff I
don't want to." A third student "behaved
in a manic fashion for about 6 hours, was
unable to sleep or concentrate, and laughed
a great deal. Her residence adviser had to
intervene to calm her." Several days after
being hypnotized, a fourth student was
"listening to the radio while studying.
When she heard harmonica music she en-
41
tered into a trance. Later she was awak-
ened by a weather broadcast" (p, 152).
Echterling and Emmerling described
factors which can precipitate adverse re-
actions unique to stage hypnosis: testing
the entire audience for hypnotizability can
induce trance in some who do not go on
stage, and who are not observed by the
hypnotist; eagerness to "put on a show"
renders subjects the means to that end-and
can add to embarrassment and humilia-
tion; insufficient screening; inadequate
informed consent; and no follow-up. They
concluded: "The potential hazards of stage
hypnosis make it difficult to jus-
tify...hypnosis is a powerful technique that
can dramatically affect our conscious-
ness, experiences and behavior - for bet-
ter or for worse" (p. 154).
Josephine Hilgard (1974) reported 31 %
of 120 university students participating in
a hypnosis study experienced aftereffects
persisting from 5 minutes to 3 hours after
trance. Nineteen had "short-term ef-
fects" for up to an hour, including drow-
siness, cognitive distortion, anxiety, and
dreams. She suggested these may be a
continuation of trance rather than the re-
sult of it. "Long-term effects," up to 3
hours' duration, were similar to short-term
symptoms, but headaches, dizziness,
nausea, and stiff arm or neck were also
reported (p. 288).
One student reported that "his heart
pounded and he experienced intense anx-
iety" (p. 286). Another student described
"feeling apart from myself - my hands
were 20 feet away from my body" and
"drowsiness lasting for an hour or so"
(p. 286). Other reports: "I felt kind of
strange as I walked to my next class .. .like
when I just get up in the morning. Things
were blurry; I was somewhat in a daze,
not receptive to everything around me yet"
 42
(p. 288). "I was groggy for about 8 min-
utes"; " not exactly with it or ready to
think"; " drowsy for 19 minutes" (p.
288).
A student reported he was "confused,
anxious ...walked around in a daze," and
"felt queazy." He "tried to remember
things but could not." The confusion
"lasted through the night" and he "had
many vivid dreams" relating to "embar-
rassment over mistakes" (pp. 289-290).
Another student "suddenly blanked out"
Downloaded by [University of Iowa Libraries] at 18:20 13 March 2015
at her typewriter "which she had never
done before" (p. 290). Another felt "dizzy
and mild nausea for 3-1/2 hours" (p. 294).
Drowsiness was frequently reported: "I
slept after hypnosis and fell asleep later
that day in class despite sleeping well the
night before - I seldom feel sleepy dur-
ing the day" (p. 280). "I had a headache
1-1/2 hours, then slept 3 hours, and awoke
without the headache" (p. 291). "I had
a headache during hypnosis and for 2 hours
until I took a nap and got rid of it" (p.
291).
Hilgard suggested that headaches may
represent ambivalence, "a conflict be-
tween the desire to be hypnotized and the
anxiety and wish not to be" (p. 282). Re-
flecting on the students reports of side ef-
fects, she speculated that during hypnosis
there may be "a kind of restructuring of
their control systems" with possible "as-
sociations of mystery and magic" (p. 295).
Sixteen students associated uncomforta-
ble side effects of hypnosis with unpleas-
ant medical or dental anesthesia in the past,
though 51 others with similar memories
suffered no discomfort from hypnosis.
Judd, Burrows, and Dennerstein (1986)
mailed 1086 questionnaires and received
202 responses from 133 physicians, 53
psychologists, and 16 dentists. Of the 202
returns, 88 reported knowing of adverse
effects to hypnosis. Most frequently re-
MacHOVEC
ported were panic, extreme anxiety, ex-
cessive dependency, and difficulty
terminating hypnosis. Less frequent were
exacerbation or precipitation of signifi-
cant depression, symptom substitution,
acting out behaviors, fantasied sexual se-
duction, psychosis, difficulties managing
organic conditions, and suicidal ideation
or attempts by subjects already depressed.
Levitt and Hershman (1962) received
866 of 2500 mailed questionnaires from
members of the American Society of
Clinical Hypnosis and the Society for
Clinical and Experimental Hypnosis. Of
these, 301 reported that they had "in one
patient or another observed an unusual,
unexpected, and probably alarming reac-
tion to hypnosis either during the state
itself or immediately afterward" (p. 59).
The "unusual reactions" reported, in de-
scending rank most to least frequent, were
anxiety, panic, depression, headache,
vomiting, fainting, dizziness, crying, "loss
of rapport," overt psychosis, "difficul-
ties involving sex," excessive depend-
ency, and "difficulties resulting from
inadvertently given suggestion."
Coe and Ryken (1979) tested 209 col-
lege student volunteers to compare after
effects from the Stanford Hypnotizability
Scale Forms A and C with those from the
nonhypnotic conditions of a brief verbal
learning experiment, taking an exam, at-
tending class, and college life in general.
A 24-item postexperiment questionnaire
yielded a 48.6% reported incidence of
negative sequelae from hypnosis which
included "headaches, stiff necks, light
headaches, dizziness, drowsiness, and a
desire to take a nap" (p. 678). But this
did not differ markedly from nonhypnotic
samples: "In no case did hypnosis have
any more negative effects than at least
some of the other samples and for the more
serious negative sequelae it had fewer ad-
 COMPLICATIONS, RISK FACTORS, AND PREVENTION
verse effects than the exam, class, and
daily life examples" (p. 677).
Coe and Ryken (1979) recommended
that hypnosis research subjects "not be
led to expect any more negative responses
than they normally would as they go about
their lives as college students" (p. 678).
They cautioned against "too conservative
a direction" where excessively detailed
informed consent might suggest negative
experiences and increase risk to the sub-
Downloaded by [University of Iowa Libraries] at 18:20 13 March 2015
ject. They suggested a middle ground
"between overconservative and over-
liberal views" which is "reasonable, ra-
tional, and in the best interests of all
concerned" (p. 680).
Clinical Evidence
In 1981, Kleinhauz and Beran reported
a case of a teen-age female who felt "un-
well" after being hypnotized at a stage
show. At home her tongue "collapsed into
her throat and she began to strangle." She
was rushed to the hospital where "her
eyeballs rolled up into their sockets." She
fell into "a deep stupor...unable to re-
spond to questions or identify people or
things ... retaining urine and therefore
catheterized...maintained on intravenous
fluids" (pp. 150-151). Clinical and lab-
oratory tests, EKG, EEG, skull series,
neurological exam, and spinal tap were
all normal, but she had no sense of touch.
The stage hypnotist was called, came to
the hospital, and was unable to rehypno-
tize her.
One week later she remained "stupor-
ous, without significant change, in total
anesthesia...catheterized and fed intrave-
nously" (p. 152). She developed second-
ary complications, upper respiratory and
urinary tract infections. Hypnosis was at-
tempted by a psychiatrist trained and ex-
perienced in its use. It required one 4-
hour session to restore her from stupor to
43
the simplest sensing and ideomotor sig-
naling and another 4-hour session the same
day to overcome amnesia to her name,
address, and her life and family situation.
She improved and returned to her school
work.
Three months later and one day before
her appointment with the treating psychi-
atrist, she relapsed, was unable to con-
centrate or study, was socially withdrawn,
and suffered headache, asthenia, and
"general distress." When she was rehos-
pitalized, hypnotherapy was "much more
difficult," and it required 2 days to re-
store her to normal function and 6 months
of weekly sessions to prevent relapse. Be-
fore being hypnotized by the stage enter-
tainer she had "no previous signs of
physical or emotional disorder or partic-
ular problems in physical development,
education, or social relations with family
or friends" though within a year of the
hypnosis incident she required catheteri-
zation once immediately following her
father's death (p. 152).
Kleinhauz, Dreyfuss, Beran, Gold-
berg, and Azikri (1984) described the case
of a woman born in France who at age 6
during World War II lived in hiding from
the Nazis. At middle age she was hyp-
notized in a stage show. She "felt some-
thing was wrong" while still in the theater.
The next day she experienced "a disso-
ciative state...derealization, depersonali-
zation as well as childish behaviors" with
mild to severe headaches, anxiety, obses-
sive preoccupation, nausea, vertigo,
drowsiness, depression, spontaneous
trance, and episodic psychotic decompen-
sation (p. 220). For 10 years she experi-
enced increased fatigue, irritability, and
tension in family relationships which
"arose from her own strange behaviors"
(p. 221). Unusual regressive behaviors
lasted hours to days when she spoke only
 44
French and did not know how to use a
water faucet. Symptoms abated after a
single hypnotherapy session by a trained
professional and were in permanent re-
mission 2 months later.
KIeinhauz and Beran (1984) described
two cases of severe complications coin-
cident with hypnosis. The first was a mid-
dle-aged woman hypnotized to stop
excessive smoking. She became "agi-
tated and depressed and had suicidal
thoughts" (p. 288). When she was re-
Downloaded by [University of Iowa Libraries] at 18:20 13 March 2015
hypnotized by a trained professional, her
symptoms remitted. The second case was
a man who stole a gun within hours of
being hypnotized on stage and being told
he was "a crack shot and the best cowboy
in the wild west." After hypnosis he
"continued to feel confused, restless and
as though there was 'something missing
in his head'" (p. 286). He had no prior
history of antisocial acting out and no po-
lice or criminal record.
Haberman (1987) reported a case of a
chronic schizophrenic male who had no
sexual relations for 16 years due to erec-
tile dysfunction. A lay hypnotist sug-
gested he would achieve erection when he
thought about oral sex. Subsequently he
became "increasingly preoccupied with
sex ...achieved erections...and enjoyed
masturbating" (p. 167). But he "devel-
oped increasing fears of homosexuality,"
paranoid ideation, and was convinced that
hypnosis had contributed to these prob-
lems. He consulted a psychiatrist for
"corrective suggestion," and symptoms
remitted after two sessions with no re-
lapse reported at 6-months and one-year
follow-up.
KIeinhauz and Eli (1987) reported four
cases of "deleterious effects of hypnosis
used in the dental setting" (p. 156). The
first was a woman successfullytreated with
dental hypnosis for apprehension and an-
MacHOVEC
algesia. She asked the dentist to use hyp-
nosis to help her stop smoking. He did so
and she stopped smoking, but "in a very
short time developed an anxiety/depres-
sive reaction with obsessive thoughts" and
"was unable to cope with everyday activ-
ities" (p. 156). The second was a woman
with dental phobia preventing dental
treatment for 10 years. Five dental hyp-
nosis sessions for relaxation and anxiety
reduction without dental treatment were
successful. It was decided to start the den-
tal work: "Although the patient was in
deep relaxation and showed no tension
whatsoever, the moment local anesthetic
injection was attempted she manifested a
spontaneous abreaction including uncon-
trollable weeping and hyperventilation"
(p. 157).
The third case was a woman treated in
four sessions for dental phobia. It was
suggested that her usual "good hypnotic
response" would occur whenever she
would "come for dental treatment." She
arrived at the next session "feeling con-
fused; she felt in a 'trance' ... from the time
she left her house." She was responding
literally to "the precise suggestion given
to her a week before." The suggestion
was changed to "the moment she sat in
the dental chair" and there were no fur-
ther incidents (p. 157). The fourth case
was a young woman treated with dental
hypnosis for analgesia because of hyper-
sensitivity to local anesthetics. She re-
ported feeling dizzy driving her motorcycle
home. "It became apparent that the de-
hypnotization was too quick and incom-
plete" (p. 157).
From The Literature
Respected authorities have been urging
caution in the use of hypnosis for more
than a hundred years. In 1887 Bjomstrom
cautioned that "by suggestion of such a
 COMPLICATIONS, RISK FACTORS, AND PREVENTION
kind that with or without the operator's
intention they can cause injurious and even
fatal effects" (p. 411). Janet (1925) rec-
ommended that "awakening should be
postponed if a morbid symptom of any
sort should intervene during the hypnotic
state" (p. 9). Williams (1953) com-
mented that hypnosis is "so varied and
subtle that a great variety of behaviors can
be theoreticallyexpected from the process"
(p. 3). Meldman (1960) described hyp-
nosis as "not entirely innocuous" and with
Downloaded by [University of Iowa Libraries] at 18:20 13 March 2015
it "things seem to have a strange sym-
bolic meaning." Barber (1961) charac-
terized hypnosis as "a complex matrix of
interacting variables." Kleinhauz and
Beran (1984) expressed concern that hyp-
nosis may render a subject "vulnerable to
an intense interpersonal encounter."
During the past 30 years there have been
specific suggestions for preventive prac-
tice. Weitzenhoffer (1957) contended that
adverse effects are not caused by hypno-
sis but are related to "the competence and
integrity of the practitioner." Meares
(1961) expressed concern about prema-
ture termination: "To make a split second
change from hypnosis to waking on the
count of a certain number.. .is manifestly
not so." Gravitz, Mallet, Munyon, &
Gerton (1982) urged "precautions should
be taken to avoid the premature departure
of a subject after hypnosis" (p. 306). It
would seem reasonable to have drowsy
subjects remain in the clinical or research
setting a few minutes after hypnosis, rarely
standard practice. Age regression is de-
scribed as "potentially the most risky
hypnosis phenomena" because of "in-
advertently regressing a subject to a trau-
matic experience" (Weitzenhoffer, 1957).
Rosen (1962) warned against inappro-
priate symptom removal: " ... before
symptoms are suggested away some of
the functions they serve should be deter-
45
mined" (p. 671). In a 1960 paper, Rosen
commented that "pain can persist for
emotional rather than physical reasons
(and) suggesting away a symptom may be
dangerous unless there are symptoms to
fall back on" (p. 142).
Discussion
Based on a review of published clinical
and experimental research and the au-
thor's clinical and consulting experience
in hypnosis since 1970, including serving
on three ethics committees in Manitoba,
Alaska, and Virginia, many complica-
tions coincident with hypnosis have been
reported in persons with no prior medical
or psychiatric history of them or similar
symptoms (See Table 1) (MacHovec,
1986).
For clinical and experimental research
to be meaningful and useful, a definition
and standard diagnostic criteria are needed.
Terminology used to describe side effects
varies widely: adverse effects, afteref-
fects, case failures, complications, dan-
gerous aspects, dangers, difficulties,
hazards, misapplications, misuse, psy-
chopathological effects, sequelae, side ef-
fects, undesirable effects, and unexpected
reactions. Some of these words are emo-
tionally charged and negative, others
shallow and superficial. Aftereffect im-
plies occurring only after hypnosis. We
now know that problems can emerge dur-
ing trance. Side effect is exclusively from
the medical model, primarily relating to
effects of medication. Hypnosis compli-
cations is suggested as a more appropriate
term, being less subjective and applicable
to multidisciplinary professional practice.
Diagnostic terms and criteria should re-
flect current standards of practice as in
the latest edition of the Diagnostic and
Statistical Manual of Mental Disorders
(1987) of the American Psychiatric As-
 46 MacHOVEC

Table 1
Summary list of complications associated with hypnosis
anergia, fatigue fear or fearfulness psychomotor retardation
antisocial acting out guilt psychosis
anxiety, panic attacks headache regressed behaviors
attention deficit histrionic reactions sexual acting out
body/self-image distortions identity crisis sexual dysfunction
comprehension/concentration loss insomnia somatization
confusion irritability spontaneous trance
coping skills, impaired medical emergencies stiffness, arm or neck
decompensation, psychotic-like memory impaired, stress, lowered threshold
delusional thinking distorted stupor
depersonalization misunderstood suggestion symptom substitution
Downloaded by [University of Iowa Libraries] at 18:20 13 March 2015

depression nausea, vomiting tactile hallucinations

derealization obsessive ruminations traumatic recall
dizziness overdependency tremors
dreams personality change weeping, uncontrolled
drowsiness, excessive sleep phobic aversion
fainting physical discomfort,
injury

sociation. The following definition is sug-
gested: Hypnosis complications are
unexpected, unwanted thoughts, feelings
or behaviors during or after hypnosis which
are inconsistent with agreed goals and in-
terfere with the hypnotic process by im-
pairing optimal mental function. There is
no prior incidence or history of similar
mental or physical symptoms. They are
nontherapeutic (would not be part of a
treatment plan or research protocol) or an-
titherapeutic (treatable conditions of and
by themselves). Many clinical and exper-
imental cases have been relieved by re-
hypnosis, and this may be a distinguishing
feature and a diagnostic sign.
Intensity varies from mild, moderate to
severe: from uncomfortable, annoying,
transient symptoms which fade with or
without treatment (mild), to those per-
sisting with significant anxiety or agita-
tion and disrupt the subject's everyday
living (moderate), to totally disabling or
life-threatening medical or psychiatric
emergencies (severe). They are acute
(short-term), lasting hours to weeks, or
chronic (long-term), lasting months to
years.
Risk factors cluster into three major
categories: subject, hypnotist, and the en-
vironment (treatment or research setting).
Subject variables. Williams (1953) ob-
served that hypnosis involves "signifi-
cant personal participation in the process...
fitted into a background of needs and ob-
jectives that is distinctive for each indi-
vidual" (p. 7). MacHovec (1986)
described subject risk factors as most fre-
quently involving repressed material or
unconscious needs, personality dynamics
(resistance, regression, secondary gain),
misunderstood suggestion, attitude, and
expectation.
Hypnotist variables. Miller (1979) de-
scribed subjects as "highly vulnera-
ble...subject to considerable anxiety, guilt,
and emotional disturbance. Great care must
therefore be exercised not to unduly dis-
 COMPLICATIONS, RISK FACfORS, AND PREVENTION
turb patients in this state and to avoid cre-
ating conflicts and symptoms which later
may be difficult to eradicate" (p. 331).
Hypnotist risk factors fall into two cate-
gories: professional and personal. Profes-
sional risk factors are deficiencies or
weaknesses in education, training,
knowledge, skill, ability, or experience
which impair judgment and proficiency,
and theoretical bias which limits aware-
ness of other factors or dynamics. Per-
sonal risk factors are those listed for
Downloaded by [University of Iowa Libraries] at 18:20 13 March 2015
subjects, plus unmet sexual or social needs,
alcohol or drug dependence, and personal
bias (sexist, ethnic, racial, religious).
Environmental risk factors are any as-
pects of the physical setting which are
uniquely affect-laden or perceived nega-
tively by the subject consciously ("This
chair reminds me of the dentist - I'm
terrified of it!") or unconsciously (verbal
and nonverbal signs of distress). Sensi-
tized subjects can misperceive or exag-
gerate physical stimuli such as background
music, suggested "ocean breeze" with
"white sound" as a storm, crossed legs
or folded arms as being restrained, bound,
or paralyzed, or the hypnotist's asexual
touch as sexual. Ringing phones, door-
bells or door knockers, and overheard
conversations can be integrated into or in-
terfere with the hypnotic process.
When subject, hypnotist, and environ-
mental risk factors combine and con-
verge, it seems likely that risk potential
would increase. In this way, the three risk
factors function like a nuclear "critical
mass" or static electricity building up be-
tween clouds and earth or between two
electrodes. This cumulative effect has oc-
curred in the most severe complications
(Echterling & Emmerling, 1987; Klein-
hauz & Beran, 1981; MacHovec, 1986).
In carefully controlled and monitored
clinical and experimental settings there
47
would be little or no buildup of risk fac-
tors. As West and Deckert (1965) pointed
out, hypnosis itself as a process is rela-
tively benign. Its misuse makes it a ve-
hicle for excess and high risk. Sound
preventive practice is to reduce risk in all
three categories: subject, by careful
screening, good history, and informed
consent; hypnotist, by assuring competent
diagnostic, observational, and interven-
tion skills; environment, by providing
physically comfortable, emotionally sup-
portive, unobtrusive surroundings.
Conclusions
There is a substantial and increasing
body of data documenting the possibility
that hypnosis can precipitate mild, mod-
erate, or severe complications in suscep-
tible individuals with no prior, similar,
mental or physical problems. Risk factors
which increase the likelihood of compli-
cations involve the subject's personality
dynamics, life history and situation, and
current mental state. Hypnotist risk fac-
tors are personal and professional. Per-
sonal problems can intrude into treatment.
Professional weaknesses and deficiencies
impair judgment and proficiency. Envi-
ronmental risk factors are anything in the
physical setting especially affect-laden for
the subject.
In view of these factors and variables,
the following two-step risk management
program is recommended for both clini-
cians and researchers:
1. Standard of practice. While some
argue that hypnosis may not "cause com-
plications any more than the stressors of
everyday life" (Coe & Ryken, 1979), there
remains an ethical responsibility to estab-
lish the same level of care and practice as
any other treatment modality or human
research practice. In their book on the
negative aspects of psychotherapy, Mays
 48
and Franks (1985) cited 16 factors taken
from Strupps' 1977 Vanderbilt Psycho-
therapy Research Project. They are all
relevant to hypnosis practice. These neg-
ative therapist factors were cited: exac-
erbation of presenting symptoms; creation
of new symptoms; patient misuse and
abuse of therapy; inaccurate diagnosis or
assessment; incorrect interpretation or lack
of insight; inadequate training or skill;
personality factors; misuse of technique;
technical or theoretical rigidity; inappro-
Downloaded by [University of Iowa Libraries] at 18:20 13 March 2015
priately intense therapy; and fostering de-
pendency. Negative patient factors: misuse
of the therapy process; personality fac-
tors; overreaching self; disillusionment
with therapy or the therapist. They cited
two shared negative factors: therapist-pa-
tient mismatch and problems of commu-
nication.
Screening, informed consent, history-
taking, documentation of services pro-
vided, competent and prompt interven-
tion, treatment or referral out as appropriate
apply to hypnosis as for any other treat-
ment and research method. As is true for
all health professionals there is an ethical
obligation to upgrade skills and remain
well informed. Attention to continuing
competence in diagnostic, observational,
and intervention skills would seem to be
part of that obligation.
2. Standard of training. Professional
hypnosis courses and workshops vary
widely as to content and the number and
type of hypnosis demonstrations and su-
pervised practice inductions by students.
There are no standardized requirements
for written, oral, and practice examina-
tions or course content. Little time is spent
on diagnosis and treatment of complica-
tions, how and when not to use hypnosis.
There is no universally accepted level or
measure of competence assessed by ex-
amination other than postgraduate doc-
MacHOVEC
toral-level hypnosis diplomates in
medicine, psychology, and dentistry. If
social work, nursing, and professional
counselors established similar training,
experience, and examination-based stand-
ards, it would provide a visible level of
proficiency externally validated and would
reduce complications risk.
REFERENCES
American Psychiatric Association (1987). Di-
agnostic and statistical manual. Revised
(DSM-IlIR). Washington, DC: American
Psychiatric Press.
Averback, A. (1962). Attitudes of psychia-
trists to the use of hypnosis. Journal of the
American Medical Association, 180, 917-
92l.
Barber, T. X. (1961). Antisocial and criminal
acts induced by hypnosis. Archives of Gen-
eral Psychiatry, 5, 301-302.
Bjornstrom, F. (1970). Preface to hypnotism,
its history and present development. In M.
M. Tinterow (Ed.), Foundations of hypno-
sis. Springfield, IL: Charles C. Thomas.
(Original work published in 1887)
Coe, W. C. & Ryken, K. (1979). Hypnosis
and risks to human subjects. American Psy-
chologist, 34, 673-68l.
Echterling, L. G. & Emmerling, D. A. (1987).
Impact of stage hypnosis. American Journal
of Clinical Hypnosis, 29, 149-154.
Gravitz, M. A., Mallet, J. E., Munyon, P.,
& Gerton, M. I. (1982). Ethical consider-
ations in the professional applications of
hypnosis. In M. Rosenbaum (Ed.), Ethics
and values in psychotherapy. New York:
Free Press.
Haberman, M. A. (1987). Complications fol-
lowing hypnosis in a psychotic patient with
sexual dysfunction treated by a lay hypno-
tist. American Journal of Clinical Hypno-
sis, 29, 166-170.
Hilgard, 1. R. (1974). Sequelae to hypnosis.
International Journal of Clinical and Ex-
perimental Hypnosis, 22, 282-298.
Janet, P. (1925). Psychological healing. Vol-
ume I. New York: Macmillan.
 COMPLICATIONS, RISK FACTORS, AND PREVENTION
Judd, F. K., Burrows, G. D., & Dennerstein,
L. (1986). Clinicians' perceptions of the ad-
verse effects of hypnosis: A preliminary
survey. Australian Journal of Clinical and
Experimental Hypnosis, 14, 49-60.
Kleinhauz, M. & Beran, B. (1981). Misuses
of hypnosis: A medical emergency and its
treatment. International Journal of Clinical
and Experimental Hypnosis, 29, 148-161.
Kleinhauz, M. & Beran, B. (1984). Misuse
of hypnosis: A factor in psychopathology.
American Journal of Clinical Hypnosis, 26,
283-290.
Kleinhauz, M., Dreyfuss, D. A., Beran, B.,
Downloaded by [University of Iowa Libraries] at 18:20 13 March 2015
& Azikri, D. (1984). Some after-effects of
stage hypnosis: A case study of psychotic
manifestations. American Journal of Clini-
cal Hypnosis, 27, 219-226.
Kleinhauz, M. & Eli, I. (1987). Potential del-
eterious effects of hypnosis in the clinical
setting. American Journal of Clinical Hyp-
nosis, 29, 155-159.
Levitt, E. E. & Hershman, C. (1962). The
clinical practice of hypnosis in the United
States: A preliminary survey. International
Journal of Clinical and Experimental Hyp-
nosis, 32, 55-65.
MacHovec, F. J. (1986). Hypnosis compli-
cations: Prevention and risk management.
Springfield, IL: Charles C. Thomas.
49
Mays, D. T. & Franks, C. M. (1985). Neg-
ative outcome in psychotherapy and what to
do about it. New York: Springer.
Meares, A. (1961). An evaluation of the dan-
gers of hypnosis. American Journal ofClin-
ical Hypnosis, 4, 90-97.
Meldman, N. J. (1960). Personality decom-
pensation after hypnosis. Journal of the
American Medical Association, 173, 359-
364.
Miller, M. N. (1979). Therapeutic hypnosis.
New York: Human Sciences Press.
Rosen, H. (1960). Hypnosis: Application and
misapplication. Journal of the American
Medical Association, 172, 683-687.
Rosen, H. (1962). Technical modification:
Therapeutic considerations. In Medical uses
ofhypnosis, Symposium S, New York: Group
for the Advancement of Psychiatry.
Weitzenhoffer, A. M. (1957). General tech-
niques of hypnotism. New York: Grone and
Stratton.
West, L. J. & Deckert, G. H. (1965). Dangers
of hypnosis. Journal of the American Med-
ical Association, 192, 9-12.
Williams, G. W. (1953). Difficulties in de-
hypnotizing. Journal of Clinical and ex-
perimental Hypnosis, 1, 3-12.