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CHAPTER 1
Current Theories of Hypnosis
SUMMARY
This chapter reviews the neodissociation theory of hypnosis because it is the most widely accepted theory of hypnosis in the clinical domain. However, this focus on the neodissociation theory does not undermine the role of psychosocial factors emphasized by the sociocognitive theorists. Psychosocial factors can be judiciously utilized in the clinical setting to enhance compliance, positive expectancy and therapeutic alliance. From the review of the brain-mapping studies of hypnosis and conscious- ness, it is apparent that it is unrealistic to expect a single physiological signature of hypnosis. The brain correlates of the hypnotic phenomena are determined by the quality (associated with imagery, relaxation or alertness) of the hypnotic induction, the trance level (hypnotic ability, degree of absorption and dissociation), and the nature (specificity and intensity of suggestions) of the hypnotic suggestions. Just as we do not have a complete theory of hypnosis, we do not have a perfect defi nition of hypnosis. Several definitions are discussed, and finally a working definition of clinical hypnosis is presented. The chapter also highlights the strengths and limitations of hypnotherapy to provide the reader with a realistic view of the clinical potential of hypnotherapy.
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INTRODUCTION
The aim of this chapter is to describe the neodissociation theory of hypnosis, which is one of the most dominant contemporary theories of hypnosis. Apart from having inspired – and still inspiring – extensive research, the theory provides a rationale for clinical work. Rather than reviewing the literature on the applica tions of hypnosis, the strengths and limitations of clinical hypnosis are reviewed to provide the reader with a critical perspective on the clinical applications of hypnosis to medicine and psychiatry. Finally, a contemporary working definition of hypnosis is provided. Although hypnosis has existed as a treatment for medical and psychological disorders since time immemorial, as yet we do not have a clear definition or theory of hypnosis. Most of the theories advanced to explain hypnosis can be loosely classified under state and non-state, intrapersonal and interpersonal, or single and multifactor theories (Yapko, 2003). State , intrapersonal and single theorists conceptualize hypnosis as a trance state or an altered state of consciousness (Barber 1969). The non-state , interpersonal and multifactor theorists, also known as sociocognitive theorists , suggest a social– psychological explanation of hypnosis. These theorists maintain that there is nothing unique about hypnosis and argue that most of the hypnotic phenomena can occur without a hypnotic induction or trance (Barber, 1979). The intrapersonal theories of hypnosis emphasize the subjective and inner states of the hypnotized person, whereas the interpersonal models attach more importance to the social context or relational aspects of the hypnotic interaction (Yapko, 2003). The single model of hypnosis stresses the importance of a single variable such as relaxation or dissociation that influences the hypnotic experience. The multifactorial approaches attach importance to the role of a variety of interactional forces, such as patient expectation and clinician demands, which combine to produce the hypnotic phenomena (Kirsch, 2000). Although none of these theories have satisfactorily explained all the phenomena associated with hypnosis, the different formulations have certainly broadened our understanding of the subject. It is beyond the scope of this book to discuss the merits and controversies surrounding each theory ( see Kallio and Revonsuo, 2003, for a review, and rejoinders in the whole issue of Contemporary Hypnosis , 2005; 22(1): 1–55). For the present purpose it is sufficient to restate the conclusions drawn by Rowley (1986, p. 23) from his review of the well-known theories of hypnosis 20 years ago:
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Multilevel explanations are an absolute necessity in understanding human mind/ brain/body phenomena because we are both neurally-based and social creatures who experience the world in mental phenomenal terms. To choose one of these domains as the complete explanatory context is to be by definition wrong.
Clinicians, who are mainly concerned with reducing patients’ distress, are not overly concerned whether hypnotic trance exists or does not exist, or whether trance induction is necessary or not necessary. To the clinicians, the clinical context and the skilful negotiation of subjects and other variables to maximize thera peutic gains are of paramount importance. Heap (1988, p. 3) regards this bidirectional relationship between the patient and the hypnotist in the clinical context as:
An interaction between two people characterized by a number of inter- and intra-personal processes of which the ‘essence of hypnosis’ only forms a part, if indeed it is present at all. These processes, which are not independent of one another (and which may apply to the behaviour and experience of both the sub- ject and the hypnotist) include the following: selective attention, imagination, expectancy, social conformity, compliancy, role-playing, attribution, usually though not necessarily, relaxation, rapport, suggestion, and hypnotic or trance experience.
Moreover, clinicians emphasize the subjectivity of hypnosis and recognize that hypnotic techniques must be individualized for the patient, which can involve drawing upon techniques from more than one theoretical model. The treatment approach described in this book utilizes different therapeutic techniques derived from diverse theoretical conceptualizations. Golden et al. , (1987) describe this approach as technical eclecticism. In this approach the clinician, in order to maximize therapeutic effects, borrows techniques freely from diverse therapeutic approaches without necessarily accepting the theories from which the techniques were derived. In this context, the therapist is more concerned with reducing the patient’s level of distress rather than adhering blindly to a particular theoretical orientation.
NEODISSOCIATION THEORY OF HYPNOSIS
The neodissociation theory of hypnosis is described in detail here because it (a) has inspired extensive research, (b) provides a rationale for clinical work
CURRENT THEORIES OF HYPNOSIS 5
(Kihlstrom, 2003; Lynn and Kirsch, 2006) and (c) continues to be one of the most influential contemporary theories of hypnosis. The focus on the neodissociation theory is not meant to discredit the contributions made by other competing or complementing theories of hypnosis. The aim here is to describe a theory that has been traditionally embedded within the clinical context. Indeed, the hypnotherapeutic techniques described in this book freely draw on other theories to enhance positive expectancy and treatment gains. For example, the cognitive hypnotherapy for depression described in Chapter 5 actively utilizes the subject’s variables and placebo effects (emphasized in the sociocognitive theories of hypnosis) to maximize treatment gains. Hilgard (1973, 1974, 1986) describes hypnosis in terms of dissociation or divided consciousness. Dissociation is a psychological process whereby information (incoming, stored or outgoing) is actively deflected from integration with its usual or expected associations, producing alteration in thoughts, feelings or actions, so that for a period certain information is not associated or integrated with other information in the usual manner or in a logical way (West 1967). Such an experience can be regarded to be either normal or pathological. Ever since Janet (1907), the close relationship between hypnosis and dis- socia tion has been established. Janet (1889) held the view that systems of ideas can become split off from the main personality and exist as an unconscious subordinated personality, but capable of becoming conscious through hypnosis. The theory was applied to hypnosis and various other normal and pathological states such as automatism, amnesia, fugues and multiple personality. Hilgard, by deriving ideas and concepts from information processing, selective attention, brain functioning and the cognitive model of consciousness, reformulated the theory in contemporary terms and called it neodissociation theory. In Hilgard’s reformulation, dissociation is seen as an extension of normal cog- ni tive functioning. He posited that during ordinary consciousness information is pro cessed at a number of levels by a hierarchy of cognitive operations and controls. Ordinarily these operations are integrated, but during hypnosis or dissociation the integration decreases, and certain aspects of experiences may not be available to consciousness. Within this model, dissociation or hypnotic involvement is not seen as an either/or phenomenon, but a cognitive process ranging on a continuum from minor or limited to profound and widespread dissociation. Hilgard also considered the role of self and will when formulating his neodissociation theory of hypnosis. He maintained that hypnosis and other dissociative experiences all involve some degree of loss of voluntary control or division of control (e.g. a hypnotized subject experiencing eye catalepsy may not
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Besides hypnosis, other factors such as fatigue, stress, relaxation and daydreaming can also produce dissociation. Moreover, hypnosis can occur spontaneously, or it can be externally induced or self-induced. Hilgard was ahead of his time in linking hypnosis with the concept of consciousness. With the recent renewed interest in the scientific study of con- sciousness in the areas of affective and cognitive neuroscience (e.g. Gazzaniga, 2000; Mesulam, 2000; Zeman, 2001), we have a better understanding of the relationship between consciousness and hypnosis. For example, some striking parallels have been observed in the mental processes involved in dreaming and hypnosis. Llinas and Pare (1991) observed dissociations between specific and non-specific thalamocortical systems underpinning dreaming, implying that a state of hyperattentiveness to intrinsic activity can occur without the registration of sensory input. Similarly, Furster (1995), in dreaming observed a dissociation between context/sensory input and the cognitive features of dreaming such as altered sense of time, absence of temporality, lack of guiding reality and critical judgement, anchoring in personal experience, and affective coloring. These fi ndings led Gruzelier (1998, p. 18) to draw parallels between hypnosis and an altered state of consciousness:
The fragmented networks activated in the dream seem to lack the associative links to a time frame, anchored as they are in the present, without time tags and references. This could equally be a description of the hypnotic state as high susceptibles experience it.
Although Hilgard’s neodissociation theory of hypnosis appears logical, intuitive and subject to empirical validation, his theory is incomplete. For instance, he proposed cognitive structures to explain dissociation, but he gave little informa- tion about what happens inside them and it is not clear how many cognitive systems a person possesses and how many of these are engaged in hypnosis. However, Woody and Sadler (1998) have argued that the neodissociation theory of hypnosis is a ‘good’ theory despite being ‘incomplete’. They believe a good theory provides a provisional framework that casts the phenomena in ques- tion in a new or distinctive light that can be subjected to empirical verification to extend our understanding of the phenomena. They believe a good theory can serve this role even if it is incomplete or has obvious areas of inadequacy. Since the neodissociation theory has generated and provoked extensive empiri- cal research, the theory can be seen as ‘quite successful’ (Woody and Sadler, 1998, p. 192). Even Hilgard (1991, p. 98) openly admitted: ‘I regret to leave the
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theory in this incomplete form, so that it is more of a promise than a finished theory’. The neodissociation theory has also been criticized for ignoring the role of social compliance. This limitation of the theory was again readily acknowledged by Hilgard (1986), who moved towards a moderate position by using the word ‘state’ metaphorically to de-emphasize hypnosis as a purely special state. Moreover, some of his followers have addressed the role of social compliance in hypnosis. For example, Nadon et al. , (1991) have proposed an interactionist approach in which both cognitive and social factors play a part. Some criticisms have also been levelled at the scientific validity of the hidden observer phenomenon. Although Hilgard (1986) and Watkins and Watkins (1979) have provided experimental evidence for the presence of the hidden observer ( see Hilgard, 1986), the studies and interpretation of the hidden observer have been questioned by sociocognitive theorists. In several studies, Spanos and his colleagues demonstrated that the reports of the hidden observer varied as a function of the explicitness of instructions the subjects received about the nature of the hidden observer. For example, Spanos and Hewitt (1980) obtained reports of ‘more’ or ‘less’ hidden pain as a function of whether the subjects were told that their hidden parts would be either ‘more aware’ or ‘less aware’ of the actual amount of pain. These findings led Spanos and Coe (1992) to conclude that the hidden observer phenomenon may not be an intrinsic characteristic of hypnosis, but a social artefact shaped by subject’s expectations and situational demand characteristics. One study (Spanos et al. , 1984) manipulated the instructions to produce two hidden observers: one sorting memories of abstract words and the other storing memories of concrete words. This led Lynn and Kirsch (2006) to argue that the hidden observer is implicitly or explicitly suggested by the hypnotist, and hence they dubbed the hidden observer phenomenon the ‘flexible observer’. However, the fact that the hidden observer reports vary with instructions does not disprove the neodissociation theory of hypnosis. On the contrary, Kihlstrom and Barnier (2005) declare that it is in the very nature of hypnosis for the hypnotized subject’s behaviors and experiences to be influenced by the wording of suggestions and the subject’s interpretations of them. Therefore, studies supporting the hypothesis that covert reports are influenced by suggestions are not evidence that the hidden observer is a methodological artefact, or not a reflection of the divided consciousness. Kihlstrom and Barnier (2005) point out that researchers:
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He believes it is unproductive for scientists from different theoretical backgrounds to work in isolation from each other and continue to ignore findings from opposing theoretical orientations. He claims the field of hypnosis can be easily unified through active collaboration of scientists with neurophysiological and social orientations. Further support for the state or neodissociation theory of hypnosis comes from the research on pain and hypnosis. From his review of the recent neuro- imaging studies of the hypnotic modulation of pain, Feldman (2004, pp. 197–8) highlights several findings that elucidate the nature of hypnosis and the clinical implications for pain management.
❍ Although the perception of pain is an integrated process, hypnotic suggestions enable subjects to distinguish between the sensory and affective components of pain.
❍ The degree of hypnotic modulation of sensory or affective response to pain correlates with hypnotic suggestibility.
❍ Hypnosis enables hypnotically responsive individuals to do what they cannot do in a non-hypnotic state (e.g. control the sensory aspect of pain).
❍ Hypnosis is a more potent clinical tool for pain management than non- hypnotic approaches such as relaxation and cognitive behavior therapy.
❍ When utilizing hypnosis for pain management, clinicians should not make the common error that pain is a purely sensory experience.
❍ In a non-hypnotic state (e.g. distraction, relaxation) a person cannot differentiate between the sensory and affective dimensions of pain. In contrast, a person in a hypnotic state, in response to hypnotic suggestions, can not only make a distinction, but can differentially modulate sensory and affective dimensions of pain while producing corresponding differential activation of brain structures. These findings support the state theory of hypnosis.
❍ Further support for the state theory of hypnosis is reported by Freiderich et al. (2001), who found that highly suggestible individuals were able to significantly lower pain, either by distraction of attention or via hypnotic analgesia, compared to the control condition. However, amplitudes of laser-evoked brain potential demonstrated that hypnotic analgesia and non-hypnotic distraction of attention involved different brain mechanisms.
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❍ The original proposal of the neodissociation theory that hypnotic analgesia involves the disruption or dissociation of sensory information from conscious awareness is supported empirically.
❍ The recent fi ndings provide a new hypnotic technique for moderating or facilitating dissociation from the affective component of pain. If an individual is unable to dissociate from the sensation of pain, especially when in severe pain, the individual may respond to suggestions of diminishing the affective component of pain. Rainville and his associates (e.g. Rainville et al. , 2002) have demonstrated that hypnotic suggestions can reduce distress, although the degree of pain sensation may remain unchanged.
❍ Hypnotic induction and hypnotic suggestions activate different brain areas respectively (e.g. Rainville et al. , 2002). These findings demonstrate that hypnotic induction alone is not as powerful as hypnosis associated with specific suggestions.
❍ Therefore, crafting of suggestions relevant to the nature of pain is very important.
❍ The left prefrontal cortex is activated by suggestions for pain reduction. This brain area corresponds to the elicitation of positive emotional affect.
❍ The above ‘findings are consistent with the notion that hypnotic states are achieved through the modulation of activity within a distributed network of cerebral structures involved in the regulation of consciousness states’ (Rainville et al. , 2002, p. 898).
ALTERED STATE OF CONSCIOUSNESS
Because hypnosis is related to the concept of consciousness, a brief description of the different states of consciousness is in order here. Ludwig (1966) defines altered state of consciousness (ASC) as an altered state according to subjective experience and altered psychological functioning. According to Ludwig, alteration in sensory input, physiological changes and motor activity can produce an altered state in which ‘one’s perception of an interaction with the external environment is different than the internal experience’ (Brown and Fromm, 1986, p. 34). Tart (1975), in order to avoid the debate about whether hypnosis is or is not a state, from a clinical perspective distinguishes (a) a baseline state of consciousness (b-SOC), (b) discrete states of consciousness (d-SOC) and (c) a discrete altered state of consciousness (d-ASC).
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changes in brain dynamics such as disconnectivity, and changes in neurochemical and metabolic processes. As regards hypnosis, the review stated that ‘studies suggest that hypnosis affects integrative functions of the brain and induces an alteration or even breakdown between subunits within brain responsible for the formation of conscious experience’ (p. 110). Gruzelier (2005) believes that the reawakening of ASC in cognitive neuroscience will offer new perspectives on the understanding of ASC and will facilitate revisiting old considerations in a fresh way. From these recent developments it is becoming clear that it will be unrea- listic to expect a unique physiological signature of hypnosis. Since the hypnotic induction and production of the hypnotic experience/phenomenon involve a variety of multifactorial and interactional forces, different levels of the hypnotic experience may involve different parts of the brain. In other words, there is no direct neuropsychophysiological correlate of hypnosis. The neuropsychophysi- ological correlates of hypnosis depend on the nature and quality of the hypnotic induction and the types of suggestions and imagery used. As noted before, for example, the left prefrontal cortex, which corresponds to the elicitation of posi- tive emotional affect, is activated by suggestions for pain reduction.
STRENGTHS AND LIMITATIONS OF HYPNOTHERAPY
Although hypnotherapy can be used as an adjunct with a variety of medical and psychological conditions, it is not a panacea for all ailments. Just like any other approaches to treatment, hypnotherapy has its strengths and limitations. Recently, Alladin (2007) reviewed the strengths and limitations of clinical applications of hypnosis, and some of these are summarized below.
Strengths of hypnosis
Adds leverage to treatment
By producing rapid and profound behavioral, emotional, cognitive and physiological changes (De Piano and Salzberg, 1981), hypnosis facilitates treatment and shortens treatment time (Dengrove, 1973).
Strong placebo effect
Most of the patients receiving hypnotherapy are self-referred or referred by other therapists or physicians, so an element of positive expectancy already exists. As the therapist gains reputation as a hypnotherapist or an expert in clinical hypnosis, not only do the number of referrals increase but also the credibility
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of the therapist increases. According to Lynn and Kirsch (2006, p. 31), these ‘patients almost invariably hold positive attitudes and expectations about hypnosis, which makes them good candidates for hypnotic interventions’. For these patients, hypnosis acts as a strong placebo. Lazarus (1973) and Spanos and Barber (1974) have provided evidence that hypnotic trance induction procedures are beneficial for those patients who believe in their efficacy. The creative and sensitive therapist can build the right atmosphere to capitalize on suggestibility and expectation effects to enhance therapeutic gains (Erickson and Rossi, 1979).
Breaking resistance
Hypnotherapy allows the therapist the flexibility to utilize either direct or indirect sug gestions. Very often patients resist direct suggestions for change. Erickson (Erickson and Rossi, 1979) utilized various indirect hypnotic suggestions to break patients’ resistance. For example, he devised paradoxical instructions to minimize patients’ resistance to suggestions. In the case of an oppositional (to sug ges tions) patient, he would instruct (paradoxically) the patient to continue to resist, as a strategy to obtain compliance. Erickson also used ‘pacing’ and ‘leading’ strategies for reducing resistance. Pacing is when the therapist’s suggestions match the patient’s ongoing behavior and experiences. As the patient becomes receptive to pacing, the therapist can lead and offer more directive suggestions. For example, the therapist may pace the patient by suggesting ‘as you exhale’ as the patient exhales and then lead by adding ‘you will begin to relax’ (Golden et al. , 1987, p. 3).
Therapeutic alliance
Skilful hypnotic induction and repetition of positive hypnotic experience foster a strong therapeutic alliance (Brown and Fromm, 1986). When patients perceive the positive experience to be emerging from their own inner resources, they gain greater confi dence in their own abilities, and this helps to foster greater trust in the therapeutic relationship.
Rapid transference
Full-blown transference can occur very rapidly, often during the initial stage of hypnotherapy, because the hypnotic experience allows greater access to fantasies, memories and emotions (Brown and Fromm, 1986). Such transference reinforces the therapeutic alliance and positive expectancy.
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me’ or ‘I can’t handle the situation’) is validated. The induction of an intense positive experience via hypnosis provides the validation of an alternative or positive reality. The best way to change an experience is to produce another experience. Hypnosis provides rapid induction of an alternative reality.
Access to non-consciousness processes
Various medical and psychological conditions can be caused and/or maintained by unconscious factors. Hypnosis allows access to psychological processes below the threshold of awareness, thus providing a way to explore and restructure non- conscious cognitions and experience related to the symptoms.
Integration of cortical functioning
Hypnosis provides a vehicle whereby cortical and subcortical functioning can be accessed and integrated. Since the subcortex is the seat of emotions, access to it provides an entry into the organization, processing and modification of primitive emotions.
Imagery conditioning
Because hypnosis, imagery and affect are all predominantly mediated by the same right cerebral hemisphere (Ley and Freeman, 1984), imagination is easily intensi- fied by hypnosis (Boutin, 1978). Hypnosis thus provides a powerful modality for imagery training, conditioning and restructuring. Hypnotic imagery can be used for (a) systematic desensitization (using imagination the patient rehearses coping with in vivo diffi cult situations), (b) restructuring of cognitive processes at various levels of awareness or consciousness, (c) exploration of the remote past (regression work), and (d) directing attention to positive experiences.
Dream induction
Hypnosis can be utilized to induce dreams and increase dream recall and understanding (Golden et al. , 1987). Hypnotic dream induction thus provides another vehicle for uncovering unconscious maladaptive thoughts, fantasies, feelings and images.
Expansion of experience across time
In addition to facilitating diverse emotional experience, hypnosis also provides a vehicle for exploring and expanding experience in the present, the past and the future. Such strategies can enhance divergent thinking and facilitate the reconstruction of dysfunctional ‘realities’.
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Mood induction
Negative or positive moods can be easily induced and modulated by hypnosis, which makes it a useful method for teaching patients (through rehearsal) strategies for modulating and controlling negative or inappropriate affects. Hypnotic mood induction can also facilitate recall. Bower (1981) has provided evidence that certain materials can only be recalled when experiencing the coincident mood (mood-state-dependent memory).
Post-hypnotic suggestions
Post-hypnotic suggestions, especially when delivered during deep trance, can be very powerful in altering problem behaviors, dysfunctional cognitions and negative emotions. Post-hypnotic suggestions can also be used to shape efficacious behavior. Barrios (1973) considers post-hypnotic suggestion to be a form of ‘higher-order- conditioning’, which can function as positive or negative reinforcement for increasing or decreasing the probability of desired or undesired behaviors, respectively. Drawing on this idea, Clarke and Jackson (1983) have utilized post-hypnotic suggestions to enhance the effect of in vivo exposure among agoraphobics.
Positive self-hypnosis
The focus of modern hypnotherapy is on empowering patients by teaching them self-help skills, such as self-hypnosis training, that can be easily transferred to real situations. Self-hypnotic skills increase confidence and reduce dependence on the therapist. Self-hypnosis training can be enhanced by hetero-hypnotic* induction and post-hypnotic suggestions. Most of the techniques mentioned above can be practiced under self-hypnosis, thus fostering positive self-hypnosis by defl ecting preoccupation away from negative self-suggestions.
Perception of self-efficacy
Positive hypnotic experience, coupled with the belief that one has the ability to utilize self-hypnosis to alter symptoms, gives one an expectancy of self- efficacy, which can enhance treatment outcome. According to Bandura (1977), expectation of self-efficacy is central to all forms of therapeutic change.
- In the clinical setting it is advisable to start with hetero-hypnosis (hypnosis induced by the thera- pist) and then introduce the concept of self-hypnosis, as this increases the patient’s confidence in self-hypnosis.
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impact with certain disorders (e.g. depression, obsessive-compulsive disorder). Moreover, these attitudes created the myth that hypnosis is harmful with certain psychological disorders, such as depression (Hartland, 1971). Alladin (1989, 1994, 2006, 2007; Alladin and Heap, 1991) and Yapko (1992, 2001) have challenged these beliefs and have demonstrated that when hypnotherapy is appropriately combined with cognitive therapy, it can become a very effective treatment for clinical depression.
Passivity in therapy
In line with the traditional omnipotent and omniscient view of psychoanalysts, the patient has taken a passive role in hypnotherapy. The patient is not informed how the hypnotherapy will help him or her, or modify the underlying pathology. Often patients are offered post-hypnotic suggestions, but as a rule they are not actively involved in monitoring and restructuring thoughts, feelings, behaviors and physiological responses. In fact, active participation from the patient should be encouraged, especially when treating such chronic psychological disorders as anxiety, depression or chronic pain.
Hypnosis is not therapy
Hypnotic induction, on its own, has no therapeutic value. Hypnotic techniques are mainly used as adjuncts to other forms of psychotherapy. Unfortunately this integration can cause confusion. At times it is difficult to differentiate hypnotic adjunctive techniques from other cognitive behavioral interventions, although some hypnotherapists insist on calling the adjunctive techniques hypnotherapy. However, Wadden and Anderton (1982) state that ‘it is unclear from both a theoretical and practical standpoint what criteria are used to identify a treatment as uniquely hypnotic’. Instead of defining a treatment as hypnotherapy just by labelling it as such (Lazarus, 1973), it would be more beneficial to examine the similarities and differences between the hypnotic and non-hypnotic treatment procedures and try to ensure they complement each other to increase the treatment effect.
Symptom removal
To a large extent hypnotherapy focuses on symptom removal. Few attempts are made to teach and establish active coping skills. Even Ericksonian therapists, who talk of unconscious experiential learning, do not directly teach coping skills to their patients; instead they focus on symptom relief. In fact, some of these therapists believe direct intervention produces patient resistance. Moreover,
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traditionally hypnotherapists have not actively addressed maladaptive cogni- tions and behaviors. In such chronic conditions as anxiety and depression, ‘insight-oriented methods based on persuasion, reasoning and re-education are necessary to achieve symptom alleviation’ (Golden et al. , 1987, pp. 1–2) and ‘therapeutic results are more enduring if symptom amelioration includes the modification of thoughts, feelings, and behavior patterns that maintain the symptoms’ (Golden et al. , 1987, p. 7).
Negative self-hypnosis not addressed
Although hypnotherapists usually emphasize teaching their patients self- hypnosis, the influence of negative self-hypnosis (NSH) (Araoz, 1981, 1985) is not actively addressed. Routine self-hypnosis unmindful of the power of NSH can be easily countered by NSH, thus minimizing treatment effect. When teaching self-hypnosis, both patient and therapist should be aware of the powerful sabotaging effect of NSH.
Hypotheses lack support
Data are rarely provided to support the hypotheses as to why hypnotherapy works. For instance, the efficacy of hypnosis is often attributed to either heightened expectancy (Lazarus, 1973), the therapeutic effects of the trance state (Weitzenhoffer, 1963), or enhancement of bodily relaxation and visual imagery (Kroger and Fezler, 1976), but the data are rarely provided to support them.
DEFINITION OF HYPNOSIS AND TRANCE
Recently, the Division of Psychological Hypnosis (Division 30) of the American Psychological Association (Green et al. , 2005) defi ned and described hypnosis as a procedure during which the subject is told that suggestions for imaginative experiences will be presented. The hypnotic induction is an extended initial suggestion for one’s imagination, and may contain further elaborations of introduction. A hypnotic procedure is used to encourage and evaluate responses to suggestions. When using hypnosis, one person (the subject) is guided by another (the hypnotist) to respond to suggestions for changes in subjective experience, altera- tions in perception, sensation, emotion, thought or behavior. People can also learn self-hypnosis, which is the act of administering hypnotic procedures on oneself. If the subject responds to hypnotic suggestions, it is generally inferred that hypnosis has been induced. Many believe that hypnotic responses and
