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Hypnosis Past, Present, and Future: Its Medical and Psychiatric Applications

In January, 2000, during my last year of medical school, I did a rotation in child psychiatry with Dr. David Rosenberg, Director of Wayne State University's Child and Adolescent Research Services. During the rotation I had the task of writing a paper related to psychiatry and, due to my interest in hypnosis and neurolinguistic programming, I chose to do it on the topic of hypnosis and its use in medicine and psychiatry.

Hypnosis Past Present and Future: Its Medical and Psychiatric Applications


Howard M. Ditkoff

Wayne State University School of Medicine, Year 4

Child Psychiatry Rotation with Dr. Rosenberg

January, 2000

As we enter the new millennium, medicine is in a transitory period. Changes abound in both the practice, as well as the atmosphere in the field. Of these changes, one of the most pervasive is the demand for patient autonomy. This demand comes from both sides of the table. Patients scour the internet in an effort to be well informed on the latest cutting edge knowledge. Doctors are trained increasingly to be aware of the doctor-patient relationship as a partnership, no longer the paternalistic practice of yesteryear.

As we have seen in many areas before, it is not always new technology that improves a new situation, but often the application of an old tool in a new way. Such is the case with hypnosis. It is a method of giving the patient more control over their health, bridging the mind-body gap and opening up doors to parts of the mind that hold yet uncharted treasures. Therefore, its uses are widespread throughout both the medical and mental health fields, indeed lying squarely between the two, bringing into question the very split that has so long existed between them.

When speaking in such terms, one would expect to be discussing a technique born in our modern age of electron microscopy and molecular biology by a Harvard trained scientific wizard. However, this would not be the case with hypnosis. For all of its potential uses, it is nonetheless an ancient technique. Evidence of its use dates back to the early Egyptians and Greeks, and images of hypnotic trances can be found in art from such cultures dating back thousands of years.

In the modern age, hypnosis enjoyed a revival of sorts through the work of Franz Anton Mesmer. An 18th century Austrian physician, Mesmer applied his hypnotic method of "animal magnetism", raising controversy in his path, and leaving his legacy in the phrase "to mesmerize". Many labeled his work as fraud, claiming any cures brought about were due to the patient's imagination, leading Charles d'Eslon, a pupil of Mesmer, to exclaim, "If the medicine of imagination is the best, why should we not practice the medicine of imagination."

In a fascinating historical note, the head of the committee who investigated Mesmer's claims and eventually dismissed them was none other than Benjamin Franklin, the ambassador to France from the newly founded United States, and an expert on magnetics and electricity. Sadly, Franklin was more interested in dismissing the attribution of cures to magnetism specifically, rather than in investigating what the actual explanation was in the very real cures that Mesmer was able to effect. Thus, Mesmer's belief that it was magnetism, rather than the patient's own mind, that created his outcomes turned out to be a setback for the field of hypnosis that would take some time to overcome. Nonetheless, Mesmer's work brought a newfound interest in understanding what exactly was behind these mysterious cures.

Hypnosis was further explored by James Braid, who, in the late 19th century, developed the eye fixation or swinging watch technique which many today consider almost synonymous with hypnotism. And indeed it was Braid who coined the term "hypnosis", after the Greek word for sleep, hypnos. Braid initially felt the trance was a form of sleep, but later grew to understand it as a different state entirely. He also brought to light the understanding that hypnosis is a state that a person reaches internally, with the therapist serving merely as a guide.

Emile Coue, a Frenchman, was an advocate of hypnosis near the turn of the century. Coue felt that the patient's own resources were most important in healing, and thus he became a pioneer in the area of autosuggestion. He would have his patients engage in affirmations, repeating mantras such as "Every day, in every way, I get better and better." twice a day. Coue's ideas foreshadowed the increasing focus that medicine is beginning to place, once more, on the patient's innate ability to heal himself.

Perhaps the largest luminary in the field of mental health is Sigmund Freud. Freud's involvement with hypnosis is an interesting one. The eminent neurologist initially was enamored with the methods, having learned them from his mentor Jean-Martin Charcot, who used them extensively in dealing with hysteria patients in his Paris practice. Indeed, this early exposure to the powers of the mind may have greatly shaped Freud's future ideas on the unconscious.

Freud's interest in the specifics of hypnosis eventually faded, though he did at one point deliver two papers about the topic. Nonetheless, Freud's contributions to the understanding of the mind have helped to create a household name for the unconscious and its inner workings. In fact, the father of psychoanalysis once quipped, "If ever we are to develop the perfect form of mental therapy, it would, by necessity, have to include hypnosis".

On the medical front, hypnosis has been used in some of the most widespread and common problems. Furthermore, it is applicable both diagnostically, as well as therapeutically. It can be applied to some of the most fierce enemies of humanity, such as cancer, and similarly applied to some of the more common garden variety nuisances such as warts, where some claim hypnosis is first line therapy.

It has been 42 years since the American Medical Association's 1958 endorsement of hypnosis as a valid medical therapy, and while different patients have different results with hypnosis, it can be a Godsend for those in whom it is successful. This is so because hypnosis can be applied in some of those situations for which medicine has never truly found a reliable solution. Some of these areas are pain control, cancer treatment, obstetrics and rehabilitation.

Pain is one of the most common symptoms seen by health care professionals, and it is seen throughout the entire spectrum of disease. Its burden on a patient can be immense, especially when pain is chronic. One of the most distressing aspects of pain is the loss of control the patient feels. Through hypnosis we are able to show patients how they can use their own mind to change the subjective feeling of pain, restoring that sense of control.

In addition, while hypnosis can be combined with analgesic medications, it holds several advantages over drugs. When done properly, it has no side effects, and while drugs often leave a sense of dependence for the patient, hypnosis shows them that they are the master of their pain. All hypnosis is truly self hypnosis with the therapist as a coach and patients can learn how to employ these techniques on their own. This not only gives the ability to relieve pain when it comes, but removes the ever-present fear of pain's return that so many patients feel even when they are currently feeling well.

Hypnosis has long been used for pain control. It has been used for surgical anesthesia for hundreds of years. For example, the well documented case exists of a Dr. Ephraim McDowell who removed an ovarian tumor from the patient, Mrs. Jane Todd Crawford as she repeated scripture verses, rendering an altered state of consciousness. Dr. James Esdaile performed and documented numerous surgeries in the 1840's using hypnotic anesthesia. Strikingly, his mortality rate of 5% in these cases compares with the average of 50% in that era.

Hypnosis may also be used effectively to continue pain control after surgery, aiding in recovery. In a more recent case, Lynch in his aptly titled article "Empowering the patient: Hypnosis in the management of cancer, surgical disease and chronic pain" describes the use of hypnosis in his urologic practice. For example, he describes one woman who required surgery for a transitional cell carcinoma who used breathing techniques along with audiotaped hypnotic programs in all phases of her case. She used it in advance of the operation for mental rehearsal, during the procedure, and then postoperatively, along with patient controlled morphine. It was noted that she required only half the anticipated dose of analgesic, only one day in the ICU instead of the usual two and her bowel function returned two days earlier than anticipated. In short, almost every part of her recovery was cut in half.

Lynch goes on to describe a set of audiotapes produced by Rogers specifically tailored to the surgical patient. It consists of specific tapes to be used preoperatively, intraoperatively and postoperatively. The use of hypnosis is not limited to any particular type of surgery, and it is particularly widely used in the dental field.

But, surgical and postsurgical anesthesia is only the tip of the iceberg in the use of hypnosis for pain control. Indeed, it can be used regardless of the source of pain. For all pain of any origin ultimately must travel through and be perceived by the brain. Thus, a patient trained to control pain at the level of his subjective perception will be a master to his pain. Some of the common areas that hypnotic pain control applies to are migraines, arthritis and, as we shall discuss, cancer.

Pain is dealt with hypnotically in a variety of ways. It is telling that studies show that pain control is not obtained simply through the process of hypnosis, but only when the hypnotic state is then utilized to give specific suggestions. There are countless types of suggestions that can be given once a trance is induced. The patient can be instructed that he or she will no longer feel pain, the pain can be changed to a numb feeling, time distortion can be used to shorten the duration of pain or lengthen the pain-free intervals. Patients can even be age-regressed back to a time before the pain started. The part of the body that is in pain can be dissociated so that it is no longer internally viewed as part of the person.

Imagery and visualization are also key factors in pain control. Once in trance, the patient is often asked to visualize the pain as an image, or the region of the body in pain. The patient is then asked to imagine his immune system attacking the source of pain. Metaphor can be used, and the pain can be seen as an enemy, with the patient's innate healing resources seen as a friend or a warrior that fights off the unwanted threat. Such story-like imagery can be especially effective in children.

In each case, it is the job of a trained hypnotic coach, be it a therapist, physician, or any other professional, to determine the most beneficial and safe application for each individual patient. Given the need for choice among the many methods, the wide variety of techniques and options makes hypnosis applicable to an immense range of patients.

Many studies have been done on the physiologic routes through which hypnosis affects pain. For instance, one pathway is through preventing the usual rise in cortisol that accompanies pain. However, previous theories that hypnosis worked through the endorphin pathways used by opiates have not been supported. Moret and associates showed, in their 1991 study, that naloxone, the opioid receptor antagonist, did not reverse hypnotic analgesia. Further research will be needed to elucidate more clearly the physiologic correlates of hypnotic analgesia. This is yet another medical case of knowing what works, while being unsure why it works. In the past, this has been the case in therapies ranging from antibiotics to psychiatric medications. We have a duty to our patients both to use what we know works, as well as to continue questioning in order to understand further why it works. This is the link of research and clinical medicine that is so important to progress.

Cancer is the second leading killer of man and a source of innumerable morbidities, both physical and mental. The relationship of cancer and stress has been known since the time of Galen in the second century, and the cancer patient is one who poses challenges that clearly cross the mind-body gap The physical toll cancer takes on a patient is striking to anyone who has witnessed the emaciated state of an advanced cancer patient. But, patients themselves will often mention the emotional devastation of the illness as its worst symptom. Thankfully, hypnosis offers avenues to deal with both sides of this horrible illness.

We have already discussed the vast applications of hypnosis to pain control, and pain is one of the most feared symptoms of cancer. For many, even dying of cancer is acceptable if only the horrid pain can be alleviated. The treatment of cancer pain is a study unto itself, and is often accomplished with doses of opioids that leave the patient in a state that, while alive, is functionally hardly worth calling that. Through hypnosis, we can use the various options discussed, alone or in combination with lower doses of these medications, to allow the patient more comfort, while still remaining in a functional state to attend to the many things that a person on death's door would like to be able to reconcile.

In addition to pain, the other symptoms of cancer can be addressed by hypnosis. Some forms of cancer have very specific symptoms. For example, the intense pruritus experienced in some biliary tract malignancies can be diminished. Also, many of the iatrogenic symptoms of cancer can be aided. The extreme nausea experienced by many patients on chemotherapy can be reduced. And even nuisances such as the unpleasant taste left by many of the drugs used in cancer treatment can be alleviated. Thus, one could say that hypnosis can help cancer to not leave quite as bad a taste in one's mouth. However, it is uncertain if hypnosis can help diminish the obvious pain a pun that bad must create.

As mentioned, death is an inseparable part of a disease such as cancer. Even in cases where the disease is ultimately cured, the patient nonetheless must deal with the specter of death and the fear that often accompanies it. In trance, a patient can be guided to more reasonably discuss his feelings and fears of death in an objective manner.

In doing so, we can then help the patient to determine a new way of looking at death. We can also help the patient prepare more thoroughly, in dealing with issues such as creating a will, determining what impression they would like to leave with their family, and so on, so that these issues can be dealt with in a timely fashion.

The sudden shock of cancer and the often quick death it causes may leave a person to die in a helpless state, leaving many things unsaid and undone. Hypnosis can help a person look more objectively at death, become more accepting and comfortable with it, and by lifting that veil of denial that so often accompanies the topic in our culture, allow the patient to die with dignity in a way that he or she chooses rather than has thrust upon him.

A similar approach can be taken with the many other emotional and psychiatric issues involved in cancer. Depression, anxiety and guilt are closely tied to a disease of this nature. This can be clearly seen in the simple gut reaction most of us have to the very idea of cancer. Thus, for a patient who has been diagnosed, hypnosis offers a chance to bring out and deal with these issues.

It is not surprising that many terminal patients contemplate suicide. Levitan discussed how he used hypnosis to deal with this. He would have the patient imagine committing the act, and then objectively discuss, under trance, the consequences. He would then have the patient imagine his family's reaction and the type of legacy and memory that this would create. He would finally have the patient imagine all of the things that he could yet say and do to make these areas better. Such a practice often helps a patient realize the desire to make the most of the time that is still remaining.

Hypnosis also gives us a chance to understand the motives behind the patient's contemplation of suicide, offering the clinician a chance to further improve the patient's quality of life. For instance, many of those who seek to end their lives in these circumstances do so out of miseducation. Under hypnosis it may be found that, for example, a patient wants to die because he feels he will be forced to experience horrible pain. Once we are aware of this fact, we can then give the patient more knowledge as to all of the ways that we can help him to deal with pain so that it can be tolerable.

Lynch found in his work that hypnosis was an invaluable tool in many facets of cancer treatment. In one case, a patient with metastatic breast cancer, he used hypnotic inductions both in person, as well as through audiotapes in order to enhance many aspects of the patient's recovery. Specifically, he cites stress and anxiety management, pain modulation, and mitigation of disease and treament-induced anorexia, nausea and vomiting. His work confirms the earlier work of Spiegel who found hypnotic techniques were able to nearly double the duration of survival in patients with metastatic breast cancer. Lynch also found hypnosis particularly useful in patients who required repeated stressful procedures, including bone marrow biopsies and blood draws.

Lynch focuses much attention towards the importance of a sense of control in a cancer patient's sense of well being. "Perhaps equally as important, successful mastery of hypnosis and self-hypnosis skills to manage cancer-related symptoms and side effects gives many patients the sense that they are back in control of their cancer, not simply reacting to it," he states. Later he reinforces the point eloquently. "An important but often overlooked benefit of hypnosis in cancer management is the sense of control and mastery of the disease it may provide. Patients with cancer, whose lives often become a confusing succession of doctor's appointments, radiation treatments, chemotherapy sessions, emergency room visits, and hospital admissions frequently describe their lives spinning out of control. Mastery of self-hypnosis provides the patient with a simple, portable, self-contained therapeutic technique by which they themselves can exert some control over their illness. The sense of mastery is often as important as the benefits of symptom and pain management in allaying the dread and depression which are often accompaniments to the diagnosis of cancer."

As we often hear, it is difficult to achieve a result until the mind can imagine it. This is why Einstein felt that imagination was far more important than intelligence. In this vein, patients are often guided to imagine themselves the way they would like to be. Through training the mind to imagine the desired outcome, patients can learn to then bring the reality closer to their thoughts, rather than being a slave to fear and doubt. Many patients spend most of their thoughts visualizing exactly the outcome they most fear. Hence, they are often aiding the disease in diminishing their full potential. Changing their internal imagery towards the desired outcome can help bring about the desired results. This conceptual way of looking at recovery and achievement has been utilized in the field of physical medicine and rehabilitation, often with great success.

It is said that rehabilitation must address four aspects: the physical, the affective, the cognitive and the sensory. Hypnosis can aid in each of these aspects. This is why Martin says "It behooves all care providers to include hypnotic techniques in their treatment arsenal" For instance, a common type of patient seen in rehabilitation is the post-stroke patient. In returning motor function, the patient can be guided through hypnosis to use imagery and visualization to train the mind for the actions that the patient would like to regain. This is a technique that athletes have used for years to achieve peak performance in their given sport. For example, a basketball player may use visualization to slow down the action of shooting a basketball and focus in the mind on the proper form in each step, culminating in a perfect shot. Similarly, the stroke patient can use visualization to see in the mind's eye the paralyzed limb again moving.

This type of activity has helped patients in various motor functions such as increasing range of motion, decreasing muscle tone and spasticity and regaining bowel and bladder control. It can help the patient relearn old tasks such as their general activities of daily living, as well as learning new tasks such as how to walk using a new prosthesis. The same type of motor rehabilitation through imagery and hypnosis has been applied to Parkinson's, multiple sclerosis, cerebral palsy, and traumatic brain injury patients.

In the affective and cognitive realms, we have discussed in other areas how hypnosis can be used to uncover a patient's emotions and thoughts about their situation. The types of conditions that lead a patient to rehabilitation are often ones that take a great toll on a patients self-image. Thus the emotional and cognitive components can create a great burden on a patient. In using hypnosis to deal with these areas of the disease, we see the complex interconnections of mind and body once more. For, as the patient is guided under trance to deal with his feelings and learn a more effective way of thinking, we see the effects in improved physical performance. As the patient, sees improvement in one area, his sense of overall control and motivation improve, and extend to all other areas. Much like a drop of water in a pond can lead to ripples throughout the entire pond, so does improving a patient's general mindset in any area improves the whole person and his performance.

Sensory disturbance is very common in the patients seen by the PM&R specialist. Multiple sclerosis and stroke are good examples of disorders that can create loss of sensation, burning, paresthesias or any number of sensory sequelae. As we saw earlier, hypnosis can be used to change in many beneficial ways the subjective sensory experience. Thus, not only can it help to reduce pain, but in contrast, it can also be used to amplify sensation. A patient with diminished sensation can learn to more fully appreciate the little sensation that may be left in a limb and learn to focus more completely on it. In this way, sensation can be regained, just as, in pain control, sensation is taken away..

All sensation occurs in the mind. If a person is hit, he will usually feel it. Yet in the middle of a fire, the same person may not even notice that same stimulus. The difference is in the mind and through hypnosis we can work directly with the mind to improve sensation for our rehabilitation patients.

Childbirth, to many of us, is synonymous with pain. Often as physicians, we ask a patient to rate her pain on a scale of 1 to 10, with 10 being childbirth. Thus, giving birth has become in a way the gold standard for excruciating discomfort. And yet, it is not the only type of discomfort that the obstetrician handles in his or her pregnant patients. Hence, pregnancy offers a number of scenarios in which to apply hypnosis to the benefit of the patient.

Indeed, it was the esteemed obstetrician J.B. Delee who, in 1939, said "The only anesthetic that is without danger is hypnotism." And even today, lamaze, one of the most utilized methods of pain control in childbirth deals with psychological control through relaxation and breathing. Hence, it is well established that the pain of childbirth can be managed through the patient's conscious control of the mind. Often this control in itself is a relief. It is widely held that there is a cycle of pain expectation, which leads to stress, intensifying the pain, and further reinforcing the expectation of more pain. Though hypnosis we break this cycle.

The patient is educated as to the meaning and cause of contractions and that they need not be accompanied by pain. This understanding of the physical leads to mental relief, which then translates back into improved physical comfort. The teaching begins at 28 weeks, giving ample time for the patient to mentally rehearse a new response to labor. This can be seen much like the athlete who mentally rehearses for the big contest or game. Such training has been shown to diminish the cesarean section rate from the usual 20-30% down to only 5%, making an ironic statement about the overuse of cutting edge technologies. This combination of one of the oldest forms of mental health combined with the even older activity of childbirth is a prime example of the complex entwinement of mind and body.

But the uses for hypnosis begin long before labor ensues. In fact, it can be helpful in ensuring that it does not ensue too soon. It can be used, in combination with medications or alone, to prolong pregnancy. Studies have shown that patients using hypnosis can prolong pregnancy 18.8% longer than with medications alone. This is due again to a strengthening of the mind-body connection. The woman is made more aware of her contractions, thus knowing sooner when to take the medication and also needing less medication to accomplish the task of preventing premature labor.

While prolonging pregnancy is an admirable goal, the woman may at times feel otherwise in the midst of the common complaints of nausea and vomiting and the trials of pregnancy induced hypertension. Therefore, it is helpful to understand the uses of hypnosis in making pregnancy more comfortable for the patient. As for the case of hyperemesis gravidarum, hypnosis is used both in diagnosis and treatment. Initially, it is used to assess the cause of the vomiting, specifically searching for any underlying gain seen by the patient. For instance, it has been widely found that women hold a belief that more vomiting signifies a healthier baby. This is especially true in patients who have miscarried before. Hence, there are unconscious motives for the woman to continue vomiting. Under hypnosis, this type of belief can be uncovered and a more empowering belief can be instilled. Fuths, et al. found in 1989 that of 138 patients studied, 88% stopped vomiting completely after only one to three sessions of hypnosis.

In the patient with pregnancy induced hypertension, it is often said that delivery is the only cure. However, with hypnosis these patients have been shown to have half the number of hospital visits and a decrease in systolic and diastolic blood pressure, leading to a much more comfortable and safe pregnancy.

Incidentally, the other medical uses of hypnosis are various and interesting. It can be especially useful in certain infectious scenarios, as one of its main functions can be immune stimulation. The Psychoneuroimmunology Research Society was incorporated in 1993 as a non-profit organization devoted to "the study of interrelationships among behavioral, neural, endocrine and immune processes and to encourage collaborations among immunologists, neuroscientists, clinicians, health psychologists and behavioral neuroscientists." The field of psychoneuroimmunology is beginning to show certain very direct correlations between relaxation and immune function. Thus, in cases such as herpes and venereal warts, where constant immune suppression is the goal, hypnosis can be quite helpful.

It is also extremely useful in cases, much like the rehabilitation cases discussed above, in which the patient is affected on many levels. An example is that of a disfigured burn patient. In such a case, hypnosis can be utilized to deal with the pain, the need for an immune response to fight off infection, as well as the often devastating effects on the psyche. Severe burn patients often have serious psychiatric sequelae and must adjust both to living with the memory of the trauma, as well as adjusting to a new body image.

Members of the psychiatric community, predictably, have tended to be more open-minded than their medical colleagues towards the notion of the subconscious mind and its powers. Thus, hypnosis has been applied in a great variety of situations. Some of the most interesting disorders in which hypnosis has been used are the anxiety disorders, the dissociative disorders, post-traumatic stress disorder and eating disorders.

Two main features of anxiety disorders are an inability to consciously create relaxation and a subjective sense of loss of control. Patients will report feeling that the anxiety comes on despite their desires for relaxation, whether on its own in a panic disorder or generalized anxiety disorder, or when triggered by a specific phobia. As we have seen again and again, one of the main features of hypnosis that makes it so empowering is the sense of control it can give back to the patient. In fact, anxiety may be seen in a similar framework to the pain in childbirth, where the expectation of the symptom makes the symptoms more likely to occur and more severe, which further reinforces the continued expectation in a vicious cycle. As we saw in the case of obstetrics, hypnosis can be used with anxiety disorder patients in order to break this cycle.

Relaxation is the name of the game with treating an anxiety disorder, and it is no surprise that the first goal of treatment with such a patient should be working on the conscious ability to relax. This is done in a trance state by guiding the patient through internal imagery, visualization and a number of other techniques. For some patients, it will be the first time they have felt fully relaxed in a very long period. Once the patient is able to get to that state, then the goal becomes lengthening the periods of relaxation and teaching the patient how to control these internal images on his own.

This type of therapy overlaps with classical conditioning. An unconditioned subjective response to anxiety, such as tachycardia or a lump in the throat, can be used as a trigger for a new conditioned response of relaxation. Such a patient may be taught to rehearse so that every time they begin to get the racing heart signifying panic to that person, they begin to use their learned techniques of imagery to put their mind in a more relaxed place. After time, this will become their new unconscious response and relaxation can become the rule rather than the exception.

Not surprisingly, when there is a clear cut trigger, as in a specific phobia, it becomes that much simpler to know exactly when the new conditioned response is needed and responses in these cases tend to be even more successful than in generalized anxiety disorders. Somer describes how, along with biofeedback, patients may be assisted who are too fearful to attempt exposure to the object of their phobia even in a controlled setting. Such a patient clearly cannot be treated with systematic desensitization alone.

Somer also explains how "negative expectancies related to controllability function as self-fulfilling prophecies," repeating yet again the importance of instilling a sense of self-control in the patient. He cites Sanderson, Rapee and Barlow's 1989 study which showed that when patients were given even the illusion of control over CO2/O2 inhaled, panic diminishes greatly with only 20% panicing.

Contrastingly, when the illusion of such control is taken away, 80% panic. Biofeedback is a tool which gives immediate and objective evidence to the patient of his ability to control such processes as heart rate, breathing rate, skin temperature, skin resistance, and blood pressure consciously. Hence, its success in creating the feeling of self control so important in diminishing stress and anxiety.

Somer found that many of the more intractable phobic patients showed a pattern of attributing early therapeutic successes to the therapist's presence, thus not receiving the benefit of improved feelings of self-reliance. Through a combination of hypnosis, cognitive restructuring and biofeedback, he was able to use what he terms "biofeedback-aided hypnotherapy" to help these patients overcome their fears. Patients were hooked up to a biofeedback monitor using a tone. The tone was set to decrease in pitch or volume in conjunction with increased relaxation. Subjects were then hypnotized using relaxation and imagery. As the tone diminished, patients became increasingly aware of their ability to create relaxation as defined by the heart rate, skin temperature, or galvanic skin response.

The patients then worked on maintaining this relaxation in the face of more and more stressful imagery, culminating in the ability to relax even while imagining the specific phobic trigger. Cognitive coaching from the therapist was used to praise improved relaxation and to restructure "failures" as simply learning opportunities, cutting off at the head irrational thoughts that may accompany any increase in the tone.

The dissociative disorders bring up an interesting issue. Dissociation is in many ways a hypnotic state of its own, in which the patient enters and often remains in somewhat of a trance state, often in response to a traumatic occurrence. Perhaps the most commonly known example of this is in dissociative identity/multiple personality disorder. Evidence has suggested that this is quite often the result of childhood abuse or trauma. Hence, we can imagine a scenario in which a child exposed to such occurrences, and unable to psychologically handle the situation, enters what amounts to an altered state of consciousness during or after the events. In such a way the child can create different states of consciousness, or personalities, to handle different aspects of a troubling life. This is why Bliss described the disorder in 1986 as "an unwitting abuse of autohypnosis." In therapy, we can help by working on the unwitting and abusive nature of the disorder, leaving the patient in a more tolerable and functional state.

Experience with these types of cases led Coons to conclude in his 1986 study that hypnosis is the "treatment of choice" in multiple personality disorder. Whether one agrees with this assessment or not, it is advisable to keep it as one of the tools in our arsenal against this disorder. Its uses include age regression in which a patient can go back and examine the events that may have initially caused dissociation, in order to reintegrate any lost memories. We can maneuver between the separate personalities more freely, integrating them and substituting them for each other in various ways. We may even arrange for a "slow leak" type of debriefing in which the patient will become more and more conscious of certain information as his unconscious deems him ready to accept it.

In this way, the patient can deal, in a controlled setting guided by a trained professional, with ideas that have been repressed deeply. Upon discussing these topics and feeling a sense of understanding, the patient's sense of control is improved. The patient begins to feel stronger and more able to deal with the events, and use them as a learning tool rather than remaining a slave to their unconscious effects.

Boyd discusses a case with a 23 year old university graduate with dissociative identity disorder as diagnosed on a number of different scales and tests. He describes how hypnosis was used, in conjunction with other therapy and medication, to achieve a very successful outcome. He used 23 hypnotic techniques over a course of 19 sessions, and, overall, hypnosis was used in 35% of the sessions.

For example, after inducing trance using a combination of relaxation and downward counting along with explicit instructions for the patient to turn her attention inward, he questioned her subconscious mind, eliciting answers in the form of finger signals from the patient. This method was used to question the various personalities as to the meaning of a particularly disturbing nightmare the patient had experienced. Such methods were used to further probe for the source of dissociation.

In a more therapeutic light, he describes the "clenched fist technique" popularized by Hammond, in which, under trance, the patient is allowed to fully experience her repressed rage and direct those feelings into her fist. After a time, the fist is then opened, and the patient is guided back to relaxation. The patient can then be taught to do this type of maneuver on her own in self-hypnosis. Through this and many other types of treatment, the patient showed steady improvement as related by the Dimensions of Therapeutic Movement Instrument.

Boyd discusses how such treatment empowered the patient, through sequentially handling more and more disturbing issues, thus creating a growing sense of control and strength. After using Boyd's Macroabreaction Integration Technique, the patient related the removal of the memories from her subconscious to the removal of a tooth and to a bursting pillow, whose feathers spread to their proper places.

Such treatment led to a full unification of the patient's identities in 54 sessions over 10 month. So surprised was Boyd at this relatively speedy recovery, that he assessed the patient's status using no less than five different tests, each of which supported the patient's claim of unification. The tests included the DES, MMPI-2, questions from Lowestein's mental status interview, the SCID-D and Kluft's Hypnotic Inquiry Protocol. Hypnosis was then found useful yet again to make one last subconscious search for any secondary personalities that lingered. None were found.

Post-traumatic stress disorder, while not classified as a dissociative disorder, per se, can be looked at in a similar light. Patients who have been in combat, raped, or exposed to other trauma, often dissociate from it. For example, a woman may describe floating above herself and watching herself being raped as if from afar, an objective observer. Furthermore, these patients tend to live internally, constantly reliving the event in spite of very different external events taking place around them. In fact, the evidence shows that patients who have been in trauma are more hypnotizable, lending some credibility to the idea of dissociation and trauma as related to a hypnotic type of state. For this reason, hypnosis has been used to treat combat stress for many years, and veterans with PTSD are among the most easily hypnotized subjects.

Indeed, this brings up the fear of whether hypnosis could actually harm these patients who are already too dissociated by making them further so. However, experience has shown that generally hypnosis helps these patients to learn to make better use of the hypnotic state that they are already in. The idea is that if these patients are going to be in a trance anyways, it is better to make them aware of it and use it to their benefit, rather than have them walking around being suggestible to anything that happens to come their way.

An interesting controversy raised is that of the repressed memories and their validity. It is wise to keep a healthy sense of skepticism about issues that come out in trance. While the majority of information obtained is shown to be accurate, there are definitely cases in which patients report events which can not be confirmed or which can even be refuted subsequently. While of some significance in therapy, this can take on even greater importance when legal interests or forensics come into play. Thus, the wise clinician keeps an open mind, while not always taking the patient's words at face value. It may also be valuable to consider checking other sources to confirm certain information as appropriate and with the patient's consent.

Some have hypothesized that eating disorders also contain a component of dissociation. It is not difficult to see, for example, how a person who is emaciated, yet feels overweight, has created a mental split of sorts between mind and body. Thus, it is understandable that hypnosis has been applied in cases of anorexia nervosa and bulimia nervosa. Reports of such application date back to the early 1900's when a French psychiatrist named Pierre Janet used hypnosis to treat eating disorders. More recently, the Australian researcher Griffith found a significant reduction in binge and purge behavior in bulimics after a nine month course of hypnotherapeutic treatment.

Hypnosis has both a diagnostic and therapeutic role in eating disorders. Torem describes the importance of delving more deeply into the underlying etiology of the eating disorder. In doing so, he has come across some interesting findings. For example, using hypnosis he often uncovered in these patients past traumas, a struggle for autonomy from the family, or a feeling of deserving self-punishment. More interesting still, Torem found again and again evidence of dissociative qualities in these patients. In keeping with our earlier discussion, he also found that patients who had been involved in trauma were more hypnotizable. Therefore, hypnosis can be a significant aid in determining the underlying causes of the eating disorder. Once these are determined, they can then be helpful in determining how successful hypnosis will be for that particular patient.

Therapeutically, Torem describes introducing hypnosis to eating disorder patients initially in the form of self-hypnosis, framed as a technique to improve calmness and relaxation. As we have seen repeatedly, the ability for the patient to learn conscious relaxation is the first step in a feeling of control. After some time, Torem begins to utilize the hypnotic state for several very specific goals. These include ego-strengthening, healing suggestions, cognitive restructuring and reframing and symbolic guided imagery.

He mentions that the behavior is often a metaphor for something the patient cannot consciously express. For example, a bulimic may binge and purge as a symbolic gesture indicating her dissatisfaction with a home life, a purging of her parents' values and rules, if you will. Therefore, under trance, it is very helpful to address the underlying cause of the behavior, and work with the patient to find a better way of expressing that dissatisfaction. In this way, the patient's need for expression is appreciated and fulfilled, while doing it in a more healthy way.

One area that Torem talks about in detail is the need to "meet the patient where the patient is at." Techniques abound throughout hypnosis dealing with this basic principle. I have found it helpful to imagine the hypnotic process as that of a magnet and a piece of metal. In order for the magnet to lead the metal to where it wants, it must first go pick up the metal where it is at. Similarly, the therapist must go to where the patient is and not expect the patient to make the first move.

In following with this idea, Torem explains how, rather than explain the need to gain weight to the patient, we acknowledge her fear of this and instead talk in terms of strength units. Eating disorder patients are far more likely to be willing to improve strength than to agree to gaining weight. Weight gain may seem beneficial to the therapist, but to the eating disorder patient it may be seen as the ultimate failure. Thus, rather than force our views on the patient, we work from her perspective, reframing goals in a form that she can relate to. This method of working with the patient in a way that acknowledges and takes into full account all of her fears and desires is far more effective than trying to simply lead the patient to where you want. Hypnosis must be seen as a partnership, and the patient must be met where he or she is.

For a moment, I would like you to simply read this paper, and while you are doing so, make sure that you do not picture in your head a pink elephant. What happened when you read that last line? If you are like most humans, you immediately conjured up a picture of a pink elephant. This brings up an issue Torem and many in the field of hypnosis deal with, and that is language and how it is used most effectively in dealing with the subconscious mind.

The subconscious mind is extremely literal, and works in images, sounds, feelings, tastes and smells. It does not register words such as "don't" and "not". Therefore, it is quite ineffective, for instance, when a patient with an eating disorder constantly engages in self talk such as "don't binge" or "you have to stop purging". The subconscious cannot create an image of a person NOT binging. However, it can create an image of a person eating healthy and nutritious food. It can create an image of a person treating her body with respect.

When using hypnosis, the specific words you choose to get across an idea can be the difference between success and failure. That is because the subconscious mind speaks its own language, and you must speak in terms it can understand. When you go from speaking to the conscious mind to the unconscious, it is much like switching between people who speak different dialects. The subconscious responds to specific ways of structuring sentences, specific types of commands, metaphors, and a host of other methods to which the conscious mind would not respond. In fact, in hypnosis it is often advisable to speak in such a way that the conscious mind cannot understand, because in this way we avoid its power to reject the statement. Hypnosis is about speaking not to the conscious mind, but past it, to the level where deeper understanding and change takes place.

The concepts of specific language patterns and their effects on the unconscious mind have been studied extensively. There is an entire field, progressively growing in popularity, known as neurolinguistic programming, which addresses the specific applications of language to unconscious change. Developed in the 1970's by Richard Bandler, a graduate student at UC Santa Cruz, and John Grinder, a linguist and professor at the same school, it models the language patterns used by some of the most effective therapists and hypnotherapists in creating desired outcomes.

Some of the initial therapists modeled included Milton Erickson, M..D., the father of medical hypnosis, founder of the American Society for Clinical Hypnosis, a former assistant professor of psychiatry at Wayne State University's School of Medicine, and one of the most fascinating characters in the history of hypnosis. On one hand tone deaf, color blind, and left with a permanent limp by polio as a child, Erickson honed his observation skills to the point of legend among those who worked with him. Other therapists modeled included Fritz Perls, the father of gestalt therapy, and Virginia Satir, a very well known family therapist. Bandler and Grinder made an effort to make conscious the techniques and patterns of language that these therapists had grown to use instinctively without even realizing it themselves. In doing so, they were able to then systematically teach some of the most compelling ways to effect change in an individual.

Torem again uses these types of principles when he uses symbolic guided imagery. This is where he uses metaphors in order to create change in the eating disorder patient while in trance. He uses several different metaphors for the patient's body such as a room which they then decorate in a more pleasing way, a pet that they must take care of or a caterpillar who then grows and matures into a beautiful butterfly. While the conscious mind may make little sense of these metaphors, the unconscious quickly picks up on the connection to the patient's own body and works from that standpoint. To further reinforce the metaphors, he may even have the patient fulfill one of these tasks, actually redecorating her room or getting a pet, so that the unconscious becomes even further engaged by the similarities with the patient's own situation.

An issue that comes up frequently in hypnosis is time distortion. While in trance, there is a lost sense of time. Patients often report being unable to remember if they were in trance for 10 minutes or an hour. Therapeutically, the distortion of time can be used in many ways for the patient's benefit. In the case of eating disorder patients, they can be swung back and forth through time in order to bring out certain valuable lessons. For instance, age regression can be used to travel back in time to examine when the disorder first began. Or, on the other hand, the patient can be swung way into the future to examine how her life will be if she continues this behavior compared with if she stops it, offering a striking contrast between the different endpoints of two diverging paths. Using this "Back from the future" technique, she becomes more aware of how every day living this way is leading her further and further from what she really wants her life to become.

It has been said that great thinkers tend to see the interconnectedness of all things. In hypnosis, we have a technique which helps us to do just that. Hypnosis connects modern medicine with practices that have been used by the ancient Egyptians and enlightened Zen masters. It informs our understanding of how the mind connects with the body, as well as how the conscious mind connects with the unconscious. New studies are showing how the subjective experiences of patients in altered states connect with objective markers such as EEG readings and skin resistance. And the future of hypnosis offers an opportunity for strengthening the connection between research and clinical application.

A human being, as a whole individual, with all of his or her physical, mental and spiritual attributes is, by any definition, a miraculous creation. With this in mind, should it come as any surprise that in spite of all of our medical and technological advances, some of the most important answers for which we are searching lie within the person himself? The body and mind have been healing themselves since long before humans walked the face of the earth. And while medications and surgery surely have their place in our arsenal against disease, let us never forget that nature is the original healer and often the most powerful. Through hypnosis, we are able to connect to this ultimate healer, giving power back to the patient, and in the process, empowering ourselves with the ability to improve life in an infinite number of ways.

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Dr. Howard Ditkoff is a personal coach, group/organizational/business consultant and trainer through his company, Emergent Associates, LLC, which shares its unique knowledge, understanding and tools to support health in human systems of all types. Howard helps people discover and develop their deepest talents and potentials, bringing greater satisfaction to all areas of their lives, ranging from health to career to relationships, while helping groups, organizations and businesses of all kinds achieve greater success. For more information, or to contact Howard about setting up a Free Introductory Consultation, visit Emergent Associates, LLC's Website or email him.

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