Hypnosis and Hypnotherapy Volume 1 - Deirdre Barrett

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Hypnosis and Hypnotherapy
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Volume 1: Neuroscience, Personality,
and Cultural Factors
Deirdre Barrett, Editor

Copyright 2010 by Deirdre Barrett
All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted, in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise,
except for the inclusion of brief quotations in a review, without prior
permission in writing from the publisher.
Library of Congress Cataloging-in-Publication Data

Hypnosis and hypnotherapy / Deirdre Barrett, editor.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-313-35632-2 (hard copy : alk. paper) — ISBN 978-0-313-
35633-9 (ebook) — ISBN 978-0-313-35634-6 (vol. 1 hard copy : alk.
paper) — ISBN 978-0-313-35635-3 (vol. 1 ebook) — ISBN 978-0-313-
35636-0 (vol. 2 hard copy : alk. paper) — ISBN 978-0-313-35637-7 (vol.
2 ebook)
1. Hypnotism. 2. Hypnotism—Therapeutic use. I. Barrett, Deirdre.
[DNLM: 1. Hypnosis—methods. 2. Mental Disorders—therapy. WM 415
H9961 2010]
RC495.H963 2010
615.80 512—dc22 2010015824
ISBN: 978-0-313-35632-2
EISBN: 978-0-313-35633-9
14 13 12 11 10 1 2 3 4 5
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Contents
Acknowledgments vii
Introduction
Deirdre Barrett ix
Chapter 1 The Hypnotic Deactivation of Self-Conscious Source

Monitoring
Robert G. Kunzendorf 1
Chapter 2 Dissociaters, Fantasizers, and Their Relation

to Hypnotizability
Deirdre Barrett 15
Chapter 3 Hypnosis, Mindfulness Meditation, and Brain Imaging

David Spiegel, Matthew White, and Lynn C. Waelde 37
Chapter 4 Forensic Hypnosis: A Practical Approach

Melvin A. Gravitz 53
Chapter 5 Hypnosis in Popular Media

Deirdre Barrett 77
Chapter 6 Hypnotic-Like Procedures in Indigenous Shamanism

and Mediumship
Stanley Krippner and J€urgen W. Kremer 97
Chapter 7 Lay Hypnotherapy and the Credentialing of Zoe

the Cat
Steve K. D. Eichel 125
vi Contents
Chapter 8 Pedagogical Perspectives on Teaching Hypnosis

Ian E. Wickramasekera II 145
About the Editor and Contributors 161
Index 165
Acknowledgments
I would like to thank Debbie Carvalko from Praeger Publishers for her
advocacy of this project, and for her advice, organization, and review of
these volumes. I would also like to thank the book’s advisory board:
Arreed Barabasz, PhD, EdD; Elvira Lang, MD; Steve Lynn, PhD; and
David Spiegel, MD, for their help in identifying topics to be covered and
advice on the best authors to cover them.
Finally, I want to acknowledge the professional hypnosis societies that
introduced me to the members of the advisory board and to most of the
chapter authors. These organizations taught me much of the hypnosis I’ve
learned since my basic graduate school training, as they have for many of the
chapter authors. They provide forums in which advances in hypnosis are
shared in a timely manner among practitioners. The first two societies listed
here publish academic journals in which much of the research and clinical
techniques summarized in these volumes has appeared. All five conduct stim-
ulating conferences with research presentations and workshops—for students
as well as practicing professionals. All maintain referral lists from which
potential clients can locate skilled hypnotherapists in their geographic area.
They constitute a rich resource for readers wishing to pursue more learning
about hypnosis.
The Society for Clinical and Experimental Hypnosis

SCEH Executive Office
P.O. Box 252
Southborough, MA 01772
Tel: 508-598-5553
Fax: 866-397-1839
Email: info@sceh.us
Publishes International Journal of Clinical and Experimental Hypnosis
viii Acknowledgments
American Society of Clinical Hypnosis

140 N. Bloomingdale Rd.
Bloomingdale, IL 60108
Telephone: 630-980-4740
Fax: 630-351-8490
Email: info@asch.net
Publishes American Journal of Clinical Hypnosis
Society of Psychological Hypnosis

Division 30–American Psychological Association
APA Division 30 Membership
1400 N. La Salle, Unit 3-S
Chicago, IL 60610
http://www.apa.org/divisions/div30/homepage.html
European Society for Hypnosis

ESH Central Office
Inspiration House
Redbrook Grove
Sheffield, S20 6RR
United Kingdom
Telephone : þ44 11 4248 8917
Fax : þ44 11 4247 4627
E-mail : mail@esh-hypnosis.eu
http://www.esh-hypnosis.eu/index.php?folder_id¼14&file_id¼0
International Society for Hypnosis

http://www.ish-web.org/page.php
Introduction
Deirdre Barrett
Hypnosis is named for the Greek god of sleep though, even in ancient
times, few thought of it as literal sleep—this was simply the best analogy
for an altered state so far from waking cognition and behavior. Western
medicine first called the phenomena “mesmerism” after Franz Mesmer,
who conducted group trance inductions in eighteenth-century Europe.
Mesmer attracted attention for his flamboyant style and his cures of hyste-
ria that eluded other physicians of the time. Of course, Mesmer did not
invent hypnosis, he merely rediscovered techniques that had been prac-
ticed around the world since the dawn of history. A fourth-century BCE
Egyptian demotic papyrus from Thebes describes a boy being induced into
a healing trance by eye fixation on a lighted lamp.1 Third-century BCE
Greek temples in Epidaurus and Kos, dedicated to the god Asclepius—
whose snake-entwined staff is now our modern medical symbol, the
caduceus—used hypnotic-like incubation rituals to produce their dramatic
cures.2 Mesmer’s contribution was that he reminded the Western world of
this marvelous therapy. Young doctors flocked to him to study, but the
medical establishment was no friendlier to alternative medicine then than
now. Mesmer was exiled from medical practice, but therapists and the
general public have remained fascinated with hypnosis ever since.
In recent years, we have been able to understand hypnosis much better
than Mesmer did with his eighteenth-century versions of magnetic and
electrical fields of the body. Indeed we are able to see what real changes in
brain activity occur during the process, but also a wealth of modern cogni-
tive, linguistic, and personality research help explain it. Hypnosis and
Hypnotherapy brings together the latest research on the nature of hypnosis
and studies of what it can accomplish in treatment. Volume 1 addresses
the question of what hypnosis is: the cognitions, brain activity, and per-
sonality traits that characterize it, as well as cultural beliefs about hypnosis.
In Chapter 1, Robert Kunzendorf describes how cognitive processing differs
x Introduction
during hypnosis from usual waking modes. He characterizes the core

change as “the deactivation of self-conscious source monitoring.” This lack
of awareness of the self as the origin of many perceptions during hypnosis
leads to experiencing imagery as hallucinations and to alterations of memory
processing including dissociation, amnesia, and hypermnesia. Kunzendorf
explains how these changes can sometimes enable hypnosis to recover
repressed memories but also increase the possibility of creating false ones.
The most common misconception in hypnosis lore is the notion that
trance, hallucinatory imagery, the will to carry out suggestions—indeed all
the phenomena of hypnosis—emanate from the hypnotist. In fact, it is the
subject who produces these. In Chapter 2, I examine personality traits
associated with the ability to enter hypnotic trance. Very few people are
totally unhypnotizable, but the number able to experience the deepest
hypnotic phenomena—eyes open hallucinations, negative hallucinations
(failing to perceive something that is right in front of one), suggested
amnesia and analgesia sufficient for surgery—is similarly small. Hypnotiz-
ability is not a present/absent dichotomy but a continuum. Many traits
were historically hypothesized to determine hypnotizability such as hysteric
personality, passivity, “weak will,” and “need to please,” but these actually
bear little or no correlation when subjected to modern research analyses.
This chapter summarizes the cluster of traits that do predict response to
hypnotic induction. All of the interview and test questions that correlate
highly concern hypnotic-like experiences of everyday life vividness of
imagery, propensity to daydream, and the ability to block out real
sensory stimuli. I also present a distinction between two types of high
hypnotizables—one of whom has more of a propensity toward vivid, hallu-
cinatory imagery, and the other toward dissociative, amnestic separation of
memory. The first group “fantasizers” tend to have a history of parents who
read them much fiction and encouraged fantasy play, while the second
group “dissociaters” have a history of trauma or isolation during which they
learned amnestic defenses.
In Chapter 3, David Spiegel, Matthew White, and Lynn Waelde review
the effects of hypnosis on physiologic functions. Past studies have found
that induction of the hypnotic state reduces sympathetic nervous system
activity and increases parasympathetic activity, as measured by the low fre-
quency/high frequency ratio in spectral analysis of heart rate, and by
increases in vagal tone. Both of these changes are associated with the abil-
ity to self-soothe. Hypnosis has also been found to affect the secretion of
cortisol and prolactin and to modulate other neural and endocrine compo-
nents of the stress response. The authors then describe recent brain imag-
ing of hypnosis at their lab and other research facilities. The most
consistent changes are found in the frontal attentional systems. Spiegel,
White, and Waelde explain why these often track with the alterations of
autonomic tone noted in the peripheral studies of hypnosis. They describe
Introduction xi
how hypnosis is associated with changes in the executive attention func-

tion of the anterior cingulate gyrus and involves “activation” rather than
“arousal” in neurological terms—and dopaminergic rather than noradren-
ergic in biochemical ones. This type of activation promotes “chunking,” or
reducing the number of parallel systems, and indicates an inner rather than
outer focus. Spiegel, White, and Waelde compare brain imaging findings
in hypnosis with those associated with mindfulness meditation and discuss
the physiological similarity of states produced by the two techniques.
Finally, they discuss shifts in brain activity associated with particular hyp-
notic phenomena such as alterations of pain perception and with the
lessened sense of self-agency during hypnosis that was characterized as
essential in Chapter 1.
In Chapter 4, Melvin Gravitz describes forensic hypnosis—the role it has
played in police investigation and the court system. Views of hypnosis have
swung from touting hypnosis as a truth serum to seeing it as inherently inva-
lidating witness testimony. Gravitz reviews the precedents and opinions at
all levels, up to and including the U.S. Supreme Court, and offers his own
balanced view of appropriate uses and safeguards. He discusses how the
hypnotic alterations of memory discussed in Chapters 1 and 3, and the hyp-
notic-associated personality traits dealt with in Chapter 2, manifest specifi-
cally during criminal witness proceedings. Next, in Chapter 5, I discuss the
depiction of hypnosis in art and media—film, television, theater, music, and
cartoons. These depictions emphasize behavioral control rather than rich
alterations of subjective experience. Most films cast hypnosis in a dark
light—as a tool for seduction or murder. When hypnosis is portrayed posi-
tively, it is often either as a truth serum—similar to the overly optimistic
court opinions discussed in Chapter 4 (in fact, these often appear in court-
room dramas) or as endowing subjects with impossible psychological, men-
tal, or athletic abilities. The chapter concludes with a discussion of how
more realistic depictions of hypnosis in media might be encouraged.
In Chapter 6, Stanley Krippner and J€urgen Kremer discuss hypnotic-like
practices in shamanism and folk medium traditions with illustrative
examples from various North American tribes, Balinese folk customs,
contemporary Sami (indigenous Scandinavian) practices and African-
Brazilian mediumship. They describe the many similarities in these soci-
eties’ inductions and Western hypnosis, including verbal inductions and
suggestion, sleep analogies, and heavy reliance on imagery and storytelling
(the latter being characteristic mostly of Ericksonian hypnosis to be
described in Volume 2, Chapter 1, rather than of all Western hypnosis).
Krippner and Kremer also contrast trance-induction practices that are
common in the indigenous cultures but not in Western hypnosis including
chanting, percussion, dance or other ritualistic movement, and the burning
of incense. They note a fundamental difference in the two types of indige-
nous practices of shamanism versus mediumship. Shamans are usually
xii Introduction
aware of everything that occurs while they converse with spirits, even
when a spirit “speaks through” them, whereas mediums claim to lose
awareness once they incorporate a spirit, and purport to remember little
about the experience once the spirit departs. This distinction is similar
to the two types of high hypnotizables—fantasizers and dissociaters—
described in Chapter 2. Krippner and Kremer describe how these cultures
foster fantasy proneness and train dissociation to some degree, but that
there also seem to be significant “demand characteristics” to produce the
culturally sanctioned behavior. Krippner has also researched individual
variables of subjects within these cultures, finding some of the same char-
acteristics associated with improvement by Western psychotherapy such as
“willingness to change one’s behavior” predict beneficial outcome to treat-
ment with shaman or medium.
In Chapter 7, Steve Eichel describes the responses of the main lay hyp-
nosis credentialing groups (those not associated with the mental health
professionals, dentistry or medicine, but purporting to represent the
“profession” of hypnosis) to applications for credentialing from a distinctly
unqualified practitioner . . . his pet cat Zoe. Eichel uses the humorous ploy
of getting Zoe certified with applications listing study at ImaCat U and
hefty licensing fees to point out what’s wrong with the concept of com-
mercial “credentialing” groups unaffiliated with state licensing or university
certification. Eichel goes on to describe why it is important to have clini-
cians trained in the underlying disorders that they are treating before
applying hypnosis to them.
Finally, in Chapter 8, Ian Wickramasekera describes in more detail how
this training should be conducted. He reviews the history of how hypnosis
has been taught—in Western psychotherapy and medicine, but also in the
indigenous cultures covered in Chapter 6, ending with a description of the
modern training guidelines established by the American Society of Clini-
cal Hypnosis. Wickramasekera discusses how it is possible to draw together
the best elements of each of these different pedagogical traditions into a
training program for teaching hypnosis either within a university setting or
a postgraduate certificate program.
Volume 2 addresses the clinical applications of hypnosis in psychotherapy
and medicine. In the term hypnotherapy, the second half of the term is as im-
portant as the first. Except for some generalized effects on relaxation and
stress reduction, it is not the state of hypnosis itself that affects change, but
rather the images and suggestions that are utilized while in the hypnotic
state. Because hypnosis bypasses the conscious mind’s habits and resistances,
it is often quicker than other forms of therapy, and its benefits may appear
more dramatically. However, the reputed dangers of hypnotherapy are really
those of all therapy: first, that an overzealous therapist may push the patient
to face what has been walled off for good reason before new strengths are
in place; and second, that the therapist will abuse his or her position of
Introduction xiii
persuasion. People come to hypnotherapy with similar complaints and hopes

to those they bring to any treatment for physical or psychological problems.
Despite the added role of hypnotizability, most of the same factors deter-
mine the outcome: the skill of the therapist, the patient’s motivation to
drop old patterns, the rapport between patient and therapist, and how sup-
portive family and friends are of change.
Volume 2 begins by introducing the different branches of hypnotic psy-
chotherapy. In Chapter 1, Stephen Lankton describes Ericksonian hypno-
therapy—the approach derived from the body of writing, training, and
lectures of the late Milton Erickson. Ericksonian techniques include design-
ing individualized inductions in the client’s distinctive language, incorporating
the client’s metaphors for their disorders into the suggestions for change and
using indirect suggestion—which is ambiguous, vague, and more permissive—
to avoid provoking resistance. In Chapter 2, Arreed Barabasz traces the his-
tory of psychodynamic and ego psychology applications to hypnosis and then
describes in more detail modern ego state hypnotherapy. Ego state theory pos-
its that people’s personalities are separated into various segments. Unique
entities serve different purposes. Ego states often start as defensive coping
mechanisms and develop into compartmentalized sections of the personality,
but they may also be created by a single incident of trauma. Ego states main-
tain their own memories and communicate with other ego states to a greater
or lesser degree. Unlike alters in multiple personalities, ego states are a part
of normal personalities. Conflicts among states take up considerable energy,
often forcing the individual into withdrawn, defensive postures. Hypnosis can
facilitate communication between ego states, allow memories associated with
one to become available to the whole person, and teach people to shift states
more consciously and adaptively.
Chapter 3 continues the discussion of psychodynamic uses of hypnosis,
with my summary of the research and clinical work on hypnotic dreams
and the variety of ways of combining hypnosis and dreamwork for the mu-
tual enhancement of each. One can use hypnotic suggestions that a person
will experience a dream in the trance state—either as an open-ended sug-
gestion or with the suggestion that they dream about a certain topic—and
these “hypnotic dreams” have been found to be similar enough to noctur-
nal dreams to be worked with using many of the same techniques usually
applied to nocturnal dreams. One can also work with previous nocturnal
dreams during a hypnotic trance in ways parallel to Jung’s “active imagi-
nation” techniques to continue, elaborate on, or explore the meaning of
the dream. Research has also found that hypnotic suggestions can be used
to influence future nocturnal dream content, and that hypnotic suggestions
can increase the frequency of laboratory-verified lucid dreams. Hypnotic
suggestion can also be used simply to increase nocturnal dream recall.
In Chapter 4, Michael Yapko discusses the newest branch of hypnotherapy—
cognitive behavioral—and especially its use in treating depression. He describes
xiv Introduction
how the classic conceptualization of hypnosis as “believed-in imagination” is

consistent with modern cognitive behavioral theory. Hypnosis can serve as a
means of absorbing people in new ways of thinking about their subjective
experience and as a method of replacing automatic negative thoughts with
positive beliefs and expectancies. It can foster skill acquisition, breaking old
associations and instilling new ones. Yapko reviews the growing body of
research on the effectiveness of such techniques. Finally, because insomnia is
such a common symptom of depression, he describes in detail how hypnosis
can resolve insomnia by inducing relaxation and interrupting the rumina-
tions that interfere with sleep.
The remainder of the volume addresses applications of hypnosis to med-
ical problems. In Chapter 5, Nicole Flory and Elvira Lang review the use
of hypnosis for analgesia from nineteenth-century surgery prior to the dis-
covery of ether up to modern times. The authors describe how surgery has
evolved from more traditional large-incision techniques toward the inser-
tion of surgical instruments through tiny skin openings under the guidance
of X-rays, ultrasound, magnet resonance imaging (MRI), and endoscopes.
They then review in detail their own carefully controlled research on uti-
lizing hypnosis to alleviate pain, anxiety, and other distress associated with
surgery in the new interventional radiological settings. Despite previous
speculation by others that it would add excessive costs or time to the pro-
cedures, the authors found that teaching hypnosis-naive patients techni-
ques on the operating table shortened procedures by decreasing patient
interference and decreased costs by lowering subsequent complication
rates. In addition to reducing the main target symptoms of pain and anxi-
ety, hypnotic interventions kept patients’ blood pressure and heart rate
more stable. Flory and Lang conclude that hypnotic techniques can be
safely and effectively integrated into high-tech medical environments.
In Chapter 6, Kent Cadegan and Krishna Kumar review studies on using
hypnosis to treat smoking, alcoholism, and drug abuse. There is much more
research on its use for smoking cessation than for any other addictive disor-
der. They report that results are encouraging even for two-session hypnotic
smoking cessation treatment, but that there is no evidence for the efficacy
of the one-session approach, though clinically, this is frequently practiced.
Efficacy of hypnotherapy is less rigorously documented for other addictions,
though there is growing interest in its use. Research on hypnosis to aid so-
briety in alcoholics has found positive effects, but with small sample sizes
and only short-term follow-up. There is less data yet on hypnotic interven-
tions in drug addiction. In one recent study, veterans at an outpatient sub-
stance abuse treatment center benefitted from training in self-hypnosis, with
a very strong main effect for practice—the more regularly they practiced
their self-hypnotic suggestions, the likelier they were to remain abstinent.
Cadegan and Kumar predict that, with more research like this, it will even-
tually become possible to say to a potential client that hypnosis can help
Introduction xv
them control their addiction if they have certain characteristics (e.g., hyp-
notizability, motivation to quit, and availability of social support), and if
they are willing to practice (with specification about the nature and amount
of practice).
Finally, in Chapter 7, Nicholas A. Covino, Jessica Wexler, and Kevin
Miller briefly review the research on hypnotic pain control, already
described in Chapter 6 as establishing a clear efficacy for hypnosis in that
area. They then review the research on hypnosis in other health related
areas, such as insomnia, asthma, bulimia, and a number of more function
gastrointestinal disorders such as hypermotility (leading to cramps and
chronic diarrhea) and hyperemesis (uncontrolled vomiting, usually due ei-
ther to cancer chemotherapy or as a complication of pregnancy). They
conclude that results on all these disorders are clearly positive but need
more research. They emphasize the point—which is true of both applica-
tion of hypnosis to psychotherapy discussed earlier in this volume and to
its role in medicine—that there is great promise for its use with many ill-
nesses and conditions. However, for hypnosis to be better accepted, it is
imperative that researchers in the field update older studies with ones that
pay more attention to current norms of “empirically validated treatments”
and integrate promising strategies from related research such as the mind-
fulness meditation discussed in Volume 1, Chapter 3. Then this powerful
technique will begin to be applied to many disorders in a way that it is
currently only utilized routinely for pain control, anxiety, and smoking
cessation.
NOTES
1. Griffith, F. I. & Herbert Thompson (Eds.) (1974) The Leyden Papyrus:
An Egyptian Magical Book. New York: Dover Publications.
2. Hart, Gerald (2000) Asclepius: The God of Medicine. London: Royal
Society of Medicine Press.
Chapter 1
The Hypnotic Deactivation of

Self-Conscious Source Monitoring
Robert G. Kunzendorf
In clinical cases throughout the nineteenth century, hypnosis was associated

with spontaneous manifestations of hysteria (Ellenberger, 1970), and in
specific cases throughout the twentieth century, it has been associated with
spontaneous occurrences of age regression (Gill, 1948), hallucination
(Schneck, 1950), dissociation (Bliss, 1986), posthypnotic amnesia (Erickson &
Rossi, 1974), and hypermnesia (Gruzelier, 2000). However, ever since
twentieth-century behaviorists began measuring “hypnotic suggestibility”
with experimentally controlled suggestions of regression, hallucination, dis-
sociation, and amnesia (Barber & Calverley, 1963; Barry, Mackinnon, &
Murray, 1931; Hull, 1933; Weitzenhoffer & Hilgard, 1959), the spontane-
ous or suggestion-free aspects of hypnosis have been overlooked in most
research and omitted from most theorizing. Moreover, the behaviorists’
“controlled” suggestions introduced demand characteristics that produce
cooperative faking rather than, or in addition to, genuine hypnotic
responding. This chapter presents research that investigates the suggestion-
free potentials of genuine hypnosis, as well as a theory that integrates both
its suggestion-free potentials and its suggestion-based effects. This integra-
tive theory—that hypnosis deactivates self-conscious source monitoring, or
reality testing, much the way sleep does—is introduced and developed in
the next section of this chapter. Subsequently, the theory is considered in
the context of research on positive hallucinations, both spontaneous hal-
lucinations and suggested ones. Next, the theory is discussed in the con-
text of research on dissociative phenomena: negative hallucinations, with
or without a “hidden observer,” and posthypnotic amnesias, including ir-
reversible source amnesia. Then, it is considered in the context of investi-
gations into hypnotic access to subconsciously encoded memories and
2 Hypnosis and Hypnotherapy
percepts. Finally, its implications for both the hypnotic recovery of trau-
matic memory and the hypnotic creation of traumatic pseudo-memory are
addressed.
SLEEP, HYPNOSIS, AND THE DEACTIVATION OF

SELF-CONSCIOUS SOURCE MONITORING
Somnambulistic phenomena during sleep and during hypnosis were
described by Janet (1901, 1910) as phenomena entailing conscious sensa-
tion without self-consciousness. Following Janet’s lead in the case of sleep,
Kunzendorf (1987–1988) has observed that
during both the wakeful image and the dream image of a blue sky,
the excitation of certain brain states results in the sensory quality of
blueness. And during the wakeful image but not the dream image,
the simultaneous excitation of other brain states results in the sensa-
tionless or “tacit” quality of waking self-consciousness. (p. 5)
Similarly, in the case of hypnosis, Prince (1925) made the following

observation:
Now, given an hysteric of a certain type with absolute anesthesia of

the skin, no tactile stimulus is felt, much less perceived, no matter
how intensely the attention is concentrated on the stimulated area. . . .
Now put that hysteric into another state of mind, [the sleep-like state
of] hypnosis, and he recalls, first, that there did actually occur the sensa-
tion of a “prick” or a “touch;” and, second, that when it occurred he
was unaware of it. He further insists that it was a veritable sensation-
in-being. (p. 177)
The introspective testimony of my dissociated subjects, who in that

[hypnotic] condition recalled vividly and precisely these subconscious
experiences, has been unanimous that these experiences were without
self-consciousness. . . . The perceptions, feelings, etc., were not synthe-
sized into a self or personality. The conscious events were just sensa-
tions. (p. 182)
The theoretical issue of interest here is what purpose self-consciousness

serves when it accompanies conscious sensations during normal wakefulness.
Self-consciousness, according to Kunzendorf (2000), is a tacit or sensa-
tionless quality that subjectively parallels the neural process of monitoring
whether sensations have a centrally “imaged” source or a peripherally
“perceived” source. Thus, self-consciousness that one is “imaging” is the
The Hypnotic Deactivation of Self-Conscious Source Monitoring 3
subjective quality of a neural process monitoring the central innervation of

sensations, and self-consciousness that one is “perceiving” sensations is the
subjective quality of the same process monitoring the peripheral innerva-
tion of sensations. It is noteworthy that the source-monitoring process itself
is not “conscious of” sensations or their source of innervation. Rather, this
neural process physically monitors the source of particular sensations, and
such physical monitoring is paralleled subjectively by a sensationless dispo-
sition to treat those sensations either as “imaginally generated by the self ”
or as “perceptually given to the self.” Present in either instance of source
monitoring is the generic self-consciousness that one is “having” sensations—
in the absence of any Cartesian subject actually “having” sensations or
being “conscious of” them.
It is also noteworthy that, during self-conscious source monitoring, “I am
not aware of my self as a content of consciousness . . . but of my thoughts as
mine” (Cavell, 1987, p. 60). Indeed, failing to distinguish between the
awareness of “self as a content of consciousness” and the illusion of “self as
a self-conscious subject of consciousness” has led some researchers to the
incorrect view that lucid dreams are self-consciously monitored, rather than
the correct view that lucid dreams, like pseudo-hallucinations, are inferred
to be imaginary on account of their contents (Kunzendorf, Treantafel,
Taing, Flete, Savoie, Agersea, & Williams, 2006–2007). Let us now con-
sider how the current theory advances our understanding of hypnotic
hallucinating.
SPONTANEOUS AND SUGGESTED HALLUCINATING

The current theory attributes hypnotically hallucinated sensations to
the attenuated monitoring of their non-perceptual source, whereas Barber
(1979, 1984) and Wilson and Barber (1982) attributed hypnotically hal-
lucinated images to the percept-like vividness of such images. Consis-
tent with the former attribution, and contrary to Barber’s, research by
Kunzendorf (1985–1986) indicates that the sleeplike state of hypnosis
deactivates source monitoring and that images generated during inacti-
vated monitoring, whether they be vivid or faint, spontaneous or sug-
gested, are hallucinatory images.
In Kunzendorf’s (1985–1986) research, the ability of 30 subjects to discrim-
inate perceptual sensations from imaginal sensations was measured initially
across 28 pre-hypnotic trials and then, without any suggestion of hallucinatory
imaging, across 28 hypnotic trials. On each of the pre-hypnotic and hypnotic
trials, an individually tested subject looked straight ahead while seeing an
object on one side and imaging it on the other. Then, after rating the vivid-
ness of the imaged object, the subject was queried as to which side the imaged
object (or the perceived object) was on, and the speed of his or her
discriminative response was measured to the nearest hundredth of a second. In

analyzing the subject’s 28 pre-hypnotic trials, each trial’s discrimination speed
was plotted over the trial’s image-vividness rating, as illustrated in Figure 1.1,
and the within-subject correlation between discrimination speed and image
vividness was calculated. Similarly, for the subject’s 28 hypnotic trials, the
within-subject correlation between discrimination speed and image vividness was
calculated.
Prior to hypnosis, the correlation between discrimination speed and
image vividness was negative on average, significantly so. In other words,
subjects prior to the induction of hypnosis discriminated percepts more
quickly from vivid images than from faint images, as Figure 1.1 illustrates.
Figure 1.1 An idealized 28-trial scattergram for a hypothetical subject prior to

hypnosis and for the same subject during the hypnotic deactivation of self-conscious
source monitoring.
This seemingly paradoxical result—that percepts during normal wakeful-

ness are most quickly discriminated from those images with the most
percept-like vividness and most percept-like detail in their sensations—is
not only explained but anticipated by source-monitoring theory; because
the number of centrally innervated sensations increases as a mental image
becomes more vivid and more detailed, the centrally “imaged” source of
a more vivid image is more reliably and more quickly registered by the
neural process that monitors the source of sensations.
Following the induction of hypnosis, however, the correlation
between discrimination speed and image vividness became significantly
more positive for some subjects—those who, post-induction, exhibited
greater hypnotic depth on Morgan and Hilgard’s (1978–1979) Stanford
Hypnotic Clinical Scale. That is, as Figure 1.1 illustrates, deeply hypno-
tized subjects discriminated percepts less quickly from vivid images than
from faint images. Because direct monitoring of the centrally innervated
source of imaged sensations is deactivated by hypnosis, the deeply hyp-
notized subjects in Kunzendorf ’s (1986) study were forced to make indi-
rect inferences, based primarily on image vividness, and were able most
quickly to infer that faintly imaged sensations were not vivid enough to
be perceived sensations. But as Hilgard (1981) notes, a “diaphanous
[or faintly imaged] hallucination, while distinguishable from ordinary
physical reality, still has perceptual reality” (p. 14), because it could
have been inferred to be the extraordinary percept of a “ghost or wraith”
(p. 14).
Accordingly, any image generated during the hypnotic deactivation of
source monitoring is a hallucinatory image, whether it be vivid or faint,
spontaneous or suggested. Remembrance of a suggestion to hallucinate can
enable a subject to infer that a hallucinatory image is imaginary, just as atten-
tion to a hallucinatory image’s faintness can, but such an image can never be
known directly to be “imaginal” in source. Indeed, such an unmonitored
image can always be inferred to be either “imaginal” or “perceptual,” depend-
ing on the attended context and the assumed possibilities.
DISSOCIATED PERCEIVING WITH OR WITHOUT

A “HIDDEN OBSERVER”
One consequence of the spontaneous inactivation of source monitoring
following hypnotic inductions is the inability to discern immediately and
directly that imaged sensations are “imaginal” in source. Another conse-
quence is the inability to discern that perceived sensations are “perceptual”
in source.
This latter inability, according to Kunzendorf and Boisvert (1996),
explains the evocation of hypnotic deafness and hypnotic blindness and
hypnotic analgesia—three dramatic cases of dissociated perceiving—in
response to hypnotic suggestions. By this account, because hypnotized

subjects are not certain that their perceived sensations are “perceptual” in
source, appropriate suggestions can convince such subjects that their
auditory sensations during suggested deafness are either “subconsciously
perceived” (by a “hidden observer”) or “imagined,” rather than “per-
ceived.” Accordingly, Hilgard (1977) reported that half of his hypnotically
deafened subjects subconsciously manifested a “hidden observer” who, dur-
ing deafness, subconsciously heard every word and subsequently, during
“automatic writing,” subconsciously wrote down every “unheard” word. In
explaining Hilgard’s data without reifying the “hidden observer,” Kunzendorf
and Boisvert (1996) showed that four hypnotically deafened subjects who
could write down every “unheard” word, when told that their “hidden
observer” would “automatically” do so, also could write down every “un-
heard” word when told simply to write down every word that they imagined
hearing during deafness.
Both in Hilgard’s research and in Kunzendorf and Boisvert’s research, hyp-
notic deafness was suggested. However, given that self-conscious monitoring
of the “perceptual” source of perceived sounds is spontaneously inactivated
following the induction of hypnosis, hypnotized persons could conceivably
convince themselves that they are unable to hear their auditory sensations,
without deafness being suggested by a hypnosis researcher or a hypnothera-
pist. Indeed, if Bliss (1986) and Prince (1925) are correct in attributing
pathologically dissociated personalities to self-hypnotic states, then Wall’s
(1991) patient exhibiting a host personality with normal hearing and an
alternate personality with total deafness may be someone who, for defensive
purposes, hypnotized herself and convinced herself that none of her hypnoti-
cally “unmonitored” auditory sensations were real.
In a line of research testing for spontaneously dissociated percepts,
Kunzendorf, Beltz, and Tymowicz’s (1991–1992) 36 individually tested
subjects—9 deeply hypnotized subjects, 9 unhypnotized control subjects,
9 hypnosis-simulating control subjects, and 9 autistic subjects with visuo-
spatially deficient self-concepts—were told to use a televised mirror-image
to move their hands together until their fingertips touched, but were not
told that they were actually seeing a pre-recorded tape of their hands strug-
gling unsuccessfully to touch. When queried immediately upon their
fingertips touching, 8 of the autistic subjects and all 18 of the unhypno-
tized control subjects confirmed that their fingertips were touching,
whereas 5 of the deeply hypnotized subjects denied that their fingertips
were touching and the other 4 asserted that they didn’t know whether or
not their fingertips were actually touching. Based on this finding, Kunzendorf,
Beltz, and Tymowicz concluded that deeply hypnotized subjects’ hand-
touching sensations, without any suggestion, are spontaneously “dissociated
from the immediate and incontrovertible self-consciousness that one is
perceiving the hands touching” (p. 129).
POSTHYPNOTIC AMNESIA
Hilgard and Cooper (1965) found that greater responsiveness to hypnotic
suggestions is statistically associated with suggested posthypnotic amnesia,
but not with spontaneous posthypnotic amnesia. Confirming and extending
this finding, Kunzendorf and Benoit (1985–1986) found that greater respon-
siveness to hypnotic suggestions is associated with suggested posthypnotic
recovery from amnesia as well as suggested posthypnotic amnesia itself, but
is not associated with recovery from spontaneous posthypnotic amnesia
through re-hypnosis or with spontaneous posthypnotic amnesia itself. One
possibility raised by such findings is that all hypnotic suggestions, including
suggestions of posthypnotic amnesia and recovery, are contaminated by
demand characteristics and cooperative responding and are not measuring
the more genuine, more spontaneous manifestations of hypnosis.
Consonant with this possibility, Kunzendorf (1989–1990) has concluded
that genuine posthypnotic amnesia is a suggestion-free manifestation of
the hypnotic deactivation of self-conscious source monitoring. He initially
came to this conclusion when he and Michelle Benoit encountered a sub-
ject who, during spontaneous posthypnotic amnesia, confessed that she did
remember her hypnotic experiences but did not want to report them
because she was not sure which of her experiences were suggested by the
hypnotist and which ones were simply imagined by her. Her spontaneous
posthypnotic amnesia, in other words, was really spontaneous posthypnotic
source amnesia. And to the extent that the induction of hypnosis sponta-
neously deactivates the source-monitoring process, as argued in this chap-
ter, posthypnotic amnesia for the source of a hypnotically experienced
image or percept should be, first and foremost, spontaneous—and, in addi-
tion, irreversible.
Kunzendorf (1989–1990) proceeded to test for the possibility that
all posthypnotic amnesias—recall amnesia and source amnesia, suggested
amnesia and spontaneous amnesia—are posthypnotic manifestations of
the hypnotic deactivation of self-conscious source monitoring. For the
24 deeply hypnotized subjects in the first of two studies by Kunzendorf
(1989–1990), the suggested effect of posthypnotic amnesia for 14 words
“seen” during hypnosis was successfully reversed by posthypnotic cuing
with a prearranged signal, but the spontaneous effect of posthypnotic
source amnesia for whether the 14 words were simultaneously “heard” or
auditorily “imaged” during their hypnotic viewing was not reversed by such
cuing. This first finding serves to confirm that deep hypnosis spontaneously
and irreversibly attenuates self-conscious source monitoring for whether
sensory experiences are “perceived” or “imaged.” Kunzendorf’s (1989–
1990) second study serves to show how suggested posthypnotic recall amnesia
and prearranged reversal cuing are attributable to irreversible posthypnotic
source amnesia.
After subjects in Kunzendorf’s second study were tested for suggested

posthypnotic amnesia, they heard one of the following three instructions:
1. Control instruction
Sometimes it’s hard to remember hypnotic events. In a moment, I want
you to try to recall some more hypnotic events, as many of the remain-
ing events as you can. For the next two minutes, write down as many of
the remaining events as you can.
2. Try Hard instruction
Sometimes it’s hard to remember hypnotic events, because it takes so
much effort to recall them. In a moment, I want you to try to recall
some more hypnotic events, as many of the remaining events as you
can. But this time, try harder to remember the events. Don’t be discour-
aged if it seems to take a lot of effort. Just try as hard as you can to
remember, and, for the next two minutes, write down as many of the
remaining events as you can.
3. Trust Imagination instruction
Sometimes it’s hard to remember hypnotic events, because you are not
sure whether you are just imagining events or whether you are actually
remembering them. In a moment, I want you to try to recall some more
hypnotic events, as many of the remaining events as you can. But this
time, use your imagination to conjure up the hypnotic events. Don’t
worry if you feel like you are not using your memory. Just trust your
imagination, and, for the next two minutes, write down as many of the
remaining events as you can.
Next, the 76 amnesic subjects in this study—the 23 amnesic subjects

who heard the Control instruction, the 25 amnesic subjects who heard the
Try Hard instruction, and the 28 amnesic subjects who heard the Trust
Imagination instruction—were cued with the prearranged signal for revers-
ing posthypnotic amnesia, and were given two more minutes of recall time.
The results of this second study revealed that, prior to reversal cuing, post-
hypnotic recall amnesia was breached by the Trust Imagination instruc-
tion, but not by the Try Hard instruction. And when subjects who heard
the Trust Imagination instruction used their imagination to recall events,
they correctly recalled events for which they were posthypnotically amne-
sic and did not incorrectly imagine events.
Based on this second finding, Kunzendorf (1989–1990) concludes that,
when given either the Trust Imagination instruction or the prearranged
reversal cue, amnesic subjects shift their recall criteria—from a criterion
rejecting “possibly imaginary” or “sourceless” memories, to a criterion accept-
ing “sourceless” but “familiar” memories. In other words, because posthyp-
notic source amnesia is spontaneous and irreversible (as Kunzendorf’s first
study shows), all hypnotically perceived and posthypnotically remembered
events are immediately experienced only as “familiar” events, not as “per-

ceived” events. So in the second study, because the suggestion of posthyp-
notic amnesia for all hypnotic suggestions discourages subjects from reporting
any suggestion not remembered as “perceived,” subjects tend not to report
any suggestion remembered as “familiar” until they are encouraged to shift
their recall criterion from “perceived” to “familiar.” Thus, suggested posthyp-
notic recall amnesia and cued or instructed recovery are ultimately attributa-
ble to the hypnotic deactivation of self-conscious source monitoring.
HYPNOTIC HYPERMNESIA FOR SUBCONSCIOUS PERCEPTS

Fechner (1860/1966) defined “subliminal” percepts as conscious sensations
below the threshold (the limen) for self-consciousness that one is perceiving sen-
sations. Following Fechner’s lead, Kunzendorf (1984–1985) and Kunzendorf
and Butler (1992) showed that when subliminally perceived sensations
bypass self-conscious source monitoring on account of their brevity or their
faintness, the sensations are experienced consciously, but are interpreted as
“possibly imagined”—not as “definitely perceived”—and are memorially con-
fused with mentally imaged sensations. Pushing further, Kunzendorf and
McGlinchey-Berroth (1997–1998) discovered that 45 subjects could recog-
nize subliminally viewed words when instructed to discriminate “the recently
experienced” word (“the imaged or perceived” word) from an unfamiliar dis-
tracter, even though they could not recognize subliminally viewed words
when instructed to discriminate “the recently perceived” word from an unfa-
miliar distracter. The latter finding leads one to predict that the hypnotized
subject—whose self-conscious source monitoring is too attenuated for him
or her to encode the subliminal as “not definitely perceived”—should sponta-
neously encode subliminal sensations as “experienced (without any source)”
and should report those sensations rather than edit them out of his or her
reporting.
In a test of this prediction, Kunzendorf and Montisanti (1989–1990)
found that, unlike 24 control subjects, 6 out of 8 deeply hypnotized subjects
who were given a suggestion to close their eyes upon seeing a cue word did
so when the cue word was subliminally presented and, afterwards, remem-
bered consciously experiencing the cue word. Indeed, 2 of these 6 hypnotic
virtuosos spontaneously read aloud the cue word as it flashed subliminally!
Moreover, the hypnotic attenuation of source monitoring enhances not
only the immediate experience of subliminal stimuli presented during hypno-
sis, as Kunzendorf and Montisanti found, but also the memory of subliminal
stimuli experienced prior to hypnosis, as Kunzendorf, Lacourse, and Lynch
(1986–1987) discovered. Specifically, the latter authors discovered that pre-
hypnotic pictorial stimuli only 10 milliseconds in duration were recognized at
chance levels before and after hypnosis, but, across 85 subjects in Experiment
1 and 60 subjects in Experiment 2, were recognized significantly better than
chance during hypnotic testing. Apparently, then, subliminal stimuli that

have been experienced previously or just recently and have been encoded as
sourceless sensations are, during the hypnotic deactivation of source monitor-
ing and source editing, less likely to be edited out either as “not previously
perceived” or as “not just perceived.”
HYPNOTIC RECOVERY OF DISSOCIATED MEMORIES AND

HYPNOTIC CREATION OF FALSE MEMORIES
The hypnotic deactivation of self-conscious source monitoring, as mani-
fested in the experimental phenomena described earlier, has important impli-
cations for the “recovered memory” versus “false memory” dispute that has
for decades divided psychological researchers, in general, and hypnosis
researchers, in particular. On one side of the divide, psychodynamic research-
ers like David Spiegel and Richard Kluft defend the position that hypnosis
facilitates the accurate recovery of dissociated memories (Butler & Spiegel,
1997; Gleaves, Smith, Butler, & Spiegel, 2004; Kluft, 1998; Kluft, 1999). On
the other side, cognitively oriented researchers like Elizabeth Loftus and
Steven Lynn suggest that hypnosis facilitates the construction and the
encoding of false memories (Loftus, 2000; Lynn, Knox, Fassler, Lilienfeld, &
Loftus, 2004). On the current account, hypnotic memory recovery and hyp-
notic memory construction are equally legitimate phenomena, both of which
are caused by the same process—the hypnotic deactivation of source moni-
toring. Accordingly, the current position straddles the divide and holds out
the possibility of linking together the two sides.
The theoretical assumption that allows such linkage is source-monitoring
theory’s reinterpretation of amnesia (Kunzendorf & Moran, 1993–1994;
Kunzendorf, 2006). Psychogenic amnesia is classically defined as a process of
active repression from consciousness by a Freudian censor or some other psy-
chodynamic mechanism—a process that is supported by no scientific evidence.
But according to Kunzendorf and Moran’s (1993–1994) reinterpretation of
amnesia, dissociation-prone individuals respond to trauma by defensively shut-
ting down their self-conscious source monitoring—immediately encoding the
trauma not as “definitely perceived,” but as “possibly imagined” or “possibly
dreamed,” and later experiencing not total amnesia due to active repression,
but source amnesia manifesting sometimes as unbidden traumatic imaginings.
In other words, dissociation-prone individuals respond to trauma by hypnotiz-
ing themselves, thereby inducing many of the effects discussed in this chapter.
In empirical concordance with source-monitoring theory’s reinterpreta-
tion of amnesia, Kunzendorf and Karpen’s (1996–1997) study of 141 college
students showed that the real-time deactivation of source monitoring (as
measured in Figure 1.1 by positive slope) is statistically associated with
scoring high on the Dissociation/Amnesia factor of Bernstein and Putnam’s
(1986) Dissociative Experiences Scale. In related research, Heaps and

Nash’s (1999) study of 55 students and Hyman and Billings’s (1998) study
of 44 students showed that attenuated memory for source is statistically
associated with greater dissociation, as well as greater hypnotizability. And
in research with 251 psychiatric outpatients, Kunzendorf, Hulihan, Simpson,
Pritykina, and Williams (1997–1998) found that dissociative diagnoses
are associated conjointly with a history of abuse and with a high score on
Tellegen and Atkinson’s (1974) measure of the hypnotizable personality—a
measure which Rader, Kunzendorf, and Carrabino (1996) found to be
predictive of unstable source monitoring. Finally, in Kunzendorf and
Moran’s critical experiment (1993–1994), 148 students who were exposed to
Rosenzweig’s (1938, 1943) mildly traumatic procedure for making them
repress the clue words to unsolvable anagrams were much less adept than the
73 control subjects at recognizing the source of “perceived” clue words (given
“imaged” distracters), but were not less adept at recognizing the familiarity of
“perceived” clue words (given new distracters).
Thus, scientific evidence for deactivated source monitoring is discover-
able in the context of post-traumatic amnesia, just as it is discoverable in
the context of posthypnotic amnesia and other hypnotic phenomena.
Based on the source-monitoring interpretation of amnesia for trauma,
then, there is reason to suppose that hypnosis can facilitate recovery from
post-traumatic source amnesia, just as it can facilitate recovery from post-
hypnotic source amnesia. As previously noted, the research subject’s post-
hypnotic tendency to remember hypnotically perceived events as “possibly
imagined,” and to edit them out accordingly, gives way to remembering
them as “familiar” when he or she is put back into a hypnotic state with
little source monitoring and less source editing (Kunzendorf & Benoit,
1985–1986). So, to the extent that a dissociatively disordered patient with
post-traumatic source amnesia is experiencing his or her traumatic memo-
ries as “possibly imagined” and is editing them out, hypnotizing such a
patient should similarly attenuate both source monitoring and source edit-
ing and should give way to the memory of his or her trauma as sourceless
but “familiar.” The problem is that, on account of attenuated source moni-
toring, the hypnotized patient could generate a spontaneous or suggested
hallucination of fictitious trauma that would be encoded and remembered
in the same manner as the real trauma.
This sobering predicament—that the recovered memory of a dissocia-
tively disordered patient’s real trauma is subjectively indistinguishable from
the recovered memory of a dissociatively disordered patient’s confabulated
trauma—should give pause to extremists on both sides of the “recovered
memory” versus “false memory” divide. From the standpoint of source-
monitoring theory, this divide is not theoretically sustainable—because
both sides are substantially correct.
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Rosenzweig, S. (1943). An experimental study of “repression” with special refer-
ence to need-persistive and ego-defensive reactions to frustration. Journal of
Experimental Psychology, 32, 64–74.
Schneck, J. M. (1950). A note on spontaneous hallucinations during hypnosis.
Psychiatric Quarterly, 24, 492–494.
Tellegen, A., & Atkinson, G. (1974). Openness to absorbing and self-altering
experiences (“absorption”), a trait related to hypnotic susceptibility. Journal
of Abnormal Psychology, 83, 268–277.
Wall, S. G. (1991). Treatment of a deaf multiple personality disorder. American
Weitzenhoffer, A. M., & Hilgard, E. R. (1959). Stanford hypnotic susceptibility scale.
Palo Alto, CA: Consulting Psychologists Press.
Wilson, S. C., & Barber, T. X. (1982). The fantasy-prone personality: Implications
for understanding imagery, hypnosis, and parapsychological phenomena. PSI
Research, 1, 94–116.
Chapter 2
Dissociaters, Fantasizers, and Their

Relation to Hypnotizability
Deirdre Barrett
The most common misconception about hypnosis is that trance, hallucina-

tory imagery, the will to carry out suggestions—indeed all the phenomena of
hypnosis—emanate from the hypnotist. In fact, it is the subject who produces
these. Very few people cannot be hypnotized at all, but the number is simi-
larly small who can experience the deepest hypnotic phenomena–eyes open
hallucinations, negative hallucinations (failing to perceive something right
in front of oneself), suggested amnesia and analgesia sufficient for surgery.
Hypnotizability is not a present/absent dichotomy but a continuum. Many
traits historically were believed to determine hypnotizability such as hysteric
personality, passivity, “weak will,” and “need to please.” However, these
actually bear little or no correlation when subjected to modern research anal-
yses (see Spanos and Barber, 1972, review for a good outline of what doesn’t
correlate with hypnotizability). This chapter summarizes the cluster of traits
that do predict response to hypnotic induction.
Through the late twentieth century, studies on what did correlate with
hypnotizability began to converge on a trait—or group of closely linked
traits—that was essentially like a preexisting disposition to informal
trance: vividness of imagination, absorption in imagination, and ability to
block out external stimuli. Josephine Hilgard (1970, 1979) found the
childhood histories of her deep trance subjects were more likely than less
hypnotizable subjects to involve imaginary playmates, parental encourage-
ment of fantasy play, and a hearty appetite for fiction. Many high suscepti-
bles also recalled being punished harshly and utilizing their fantasy ability
to tune out the punishment while it was occurring or to engage in self-
soothing later. As adults, the high susceptibles were more likely than
others to be avid consumers of drama, film, and fiction, to daydream more,
and to be more creative.
Hypnotic susceptibility also correlates with Tellegan and Atkinson’s

(1974) scale of absorption in imaginative activity, containing questions
about vividness of imagery, intensity of emotional involvement in fantasy,
tendency to tune out external stimuli when imaging, and experiences of syn-
esthesia. Absorption has also been found by multiple regression analyses to
account for factors such as positive attitudes toward hypnosis, which in turn
have been linked to hypnotic susceptibility (Spanos & McPeake, 1975).
Wilson and Barber (1981, 1983) studied 27 women, representing about
the 4 percent most hypnotically responsive, and reported that all but one
of them were distinguished by a constellation of fantasy-related character-
istics: (1) They spent much of their waking time engaged in fantasy; most
said they fantasized at least 90 percent of their waking time simultaneous
with carrying on real-life activities. (2) They reported their imagery to be
every bit as vivid as their perceptions of reality; 65 percent said this was
the case with their eyes open; 35 percent had to close their eyes for the
visual component of their imagery to look completely real. (3) They expe-
rienced physiologic responses to their images such as needing a blanket to
watch Dr. Zhivago on TV in a warm room, vomiting when they (mistak-
enly) thought they had eaten spoiled food, and being able to reach orgasm
through fantasy with no physical stimulation. The majority of their female
subjects had experienced physiological symptoms of false pregnancy at
least once when they had reason to suspect they might be pregnant. (4)
They had unusually early ages for their first memory, many dating back
to infancy. Only one of Wilson and Barber’s high hypnotizable subjects
did not display this constellation of fantasy-related characteristics, and
only a small minority of their low and medium susceptible subjects dis-
played any of them.
Their study used both traditional and nontraditional scales (Barber &
Wilson, 1978) in selecting the best hypnotic subjects including the rather
idiosyncratic variable of the ability to go into a trance instantly or quickly
as one of their criteria. This is not a criterion for any of the most widely
used scales of hypnotic susceptibility, which typically give the subjects
about fifteen minutes of induction before beginning the specific suggestions
whose responses will be scored for hypnotizability.
Several other studies examined the relationship between fantasy and
hypnotizability—all finding a positive correlation but to varying degrees.
Lynn and Rhue (1986) developed a “fantasy-proneness” scale based closely
on the characteristics Wilson and Barber had described. They found that
80 percent of fantasy-prone subjects scored as highly hypnotizable, while
only about 35 percent of the non-fantasizers did so. Lynn and Rhue (1988)
and Huff and Council (1987) found that high and medium fantasizers did
not differ on hypnotic responsiveness, while low fantasizers were less hyp-
notically susceptible. Spanos (1989) found an even lower degree of correla-
tion between fantasy proneness and hypnotic susceptibility.
Dissociaters, Fantasizers, and Their Relation to Hypnotizability 17
Several dreamlike qualities have been suggested to be more characteristic

of daydreams in high hypnotizable subjects than of those in low hypnotiz-
ables. In one of my own studies (Barrett, 1990), I found highly hypnotizable
subjects to be likelier than medium hypnotizables to have daydreams con-
taining magical or surreal content, abrupt transitions of scenes, sense of wak-
ening with a start at their conclusions, and occasional amnesia for content.
Hartmann (1984) has described frequent nightmare sufferers as having
“thinner boundaries” in many senses including those between sleeping and
waking. He reported that the concept “daymare” was a meaningful one to
nightmare sufferers only; they reported their fantasies could take on very
terrifying turns of content and be difficult for them to terminate. Frequency
of nightmares correlates with hypnotic depth (Belicki & Belicki, 1984) as
does Hartmann’s measure for thinness of boundaries (Barrett, 1989).
Other categories of dreams that research has found to correlate with hyp-
notizability include dreams that the dreamers believed to be precognitive
and dreams in which the dreamer experiences himself or herself as outside
their body (Zamore & Barrett, 1989). The same study found Tellegan’s
Absorption Scale to correlate with dream recall, ability to dream on a cho-
sen topic, reports of conflict resolution in dreams, creative ideas occurring
in dreams, amount of color in dreams, pleasantness of dreams, bizarreness of
dreams, flying dreams, and precognitive dreams.
In two further studies that I describe in detail in this chapter, I exam-
ined to what extent other highly hypnotizable people resembled Wilson
and Barber’s fantasizers and what traits might characterize deep trance sub-
jects who were not extreme fantasizers. As being able to enter a trance
instantly was the most idiosyncratic of Barber and Wilson’s criteria, it was
hypothesized that this might distinguish fantasizers from other deep trance
subjects. In addition to exploring the replicability of Wilson and Barber’s
findings about fantasy activity among high hypnotizables, other points of
interest were characteristics of hypnotic experience and how these interact
with a person’s waking fantasy style.
For the first of these studies, 34 extremely hypnotizable subjects were
selected from among approximately 1,200 undergraduate subject volunteers
who had been hypnotized in the course of other research projects and dem-
onstrations in classroom and dormitory settings over a several year period.
They were selected using two standard scales: The Harvard Group Scale of
Hypnotic Susceptibility, Form A (Shor & Orne, 1962); and The Stanford
Scale of Hypnotic Susceptibility, Form C (Weitzenhoffer & Hilgard, 1962).
All subjects scored either 11 or 12 on both scales. This constituted a very
similar criterion for hypnotic susceptibility to Wilson and Barber’s with the
exception of not requiring instant or rapid hypnotic induction.
Subjects were hypnotized a total of three to four times, depending on
what the protocol in the screening project had been. Their hypnotic expe-
riences included both ones in which an amnesia suggestion and removal
cue were given and ones in which they were not, age regression sugges-
tions, a hypnotic hallucination of a candle that they were asked to blow
out, a post-hypnotic hallucination of a person they knew arriving at the ex-
perimental room to talk with them, and an attempted instant re-hypnosis
followed by several measures of trance depth.
For that first study, these high-hypnotizable subjects were interviewed
from two and a half to four hours and were asked about the fantasy-related
phenomena that Wilson and Barber and J. Hilgard reported. They were
also asked about the “dreamlike” qualities of surrealism, abrupt transitions
within daydreams, startling out of them, and occasional amnesia for con-
tent that my earlier research had found (Barrett 1979, 1990). They were
then asked about the “daymare” phenomena that Hartmann (1984) found
among nightmare sufferers. They were also asked about how real and/or
involuntary the hypnotic phenomena they experienced felt and about how
much hypnosis was like other experiences.
FANTASIZERS
The first subgroup of deep trance subjects was selected by their ability to
enter trance instantly, since Wilson and Barber had used this as a criteria
TABLE 2.1 Waking Imagery and Hypnotic Characteristics of Fantasizers

Compared with Dissociaters
Fantasizers Dissociaters
(12 Women, 7 Men) (10 Women, 5 Men) Chi Square
df = 1
Characteristic Yes No Yes No X=
Waking image less 3 16 15 0 20.05**
than real
Daydream amnesia 3 16 14 1 15.22**
Earliest memory > 3 0 19 11 4 14.44**
Absorption score low 0 19 7 8 6.19**
Need time to reach 0 19 15 0 30.06**
deep trance
Spontaneous amnesia 0 1 9 6 11.61**
for trance details
Suggested amnesia 5 14 15 0 15.06**
total
Hypnosis very differ- 2 17 15 0 22.99**
ent from other
experiences
Field score high 11 8 15 0 6.08*
*p < .02
**p < .001
for the group they characterized. These 19 people, 7 male and 12 female, also
had a number of other characteristics that distinguished them from subjects
who did not achieve their deep trances immediately. Most of these character-
istics clustered around vividness of fantasy processes, so they are referred to
for the rest of this chapter by Wilson and Barber’s term fantasizers.
Vivid Imagery and Fantasies

Fantasizers scored extremely high on Tellegen and Atkinson’s Absorp-
tion Scale: 32–37 of 37 items, with a mean of 34. During their interviews,
they described five related characteristics of fantasy-proneness that Wilson
and Barber found most characteristic of their group: extensive history of
childhood fantasy play, majority of adult time devoted to fantasizing, hal-
lucinatory vividness of imagery, physiological effects from their imaging,
and a variety of “psychic” experiences.
They all described rich fantasy life as children. They had at least one,
most many, imaginary companions. These included a real playmate who
had moved out of state, a princess, an entire herd of wild horses, and space
aliens among others. The fantasizers greatly enjoyed stories, movies, and
drama; they tended to prolong their experience of these by incorporating
them into their fantasy lives, providing another source of imaginary com-
panions. For example, one subject described that, after seeing the movie
Camelot, he had spent two years engaging daily in an elaborate scenario in
which he was the son of Arthur and Guinevere and commanded the king’s
court. Periodically he would appoint new knights of his own invention to
the Roundtable. His real-life brother was cast in the role of Mordred, but
all the other characters were either from the film, or completely from his
own imagination. The fantasizers described these imaginary companions as
every bit as vivid as real persons. In addition to ongoing fantasies, these
subjects described a wide variety of brief fantasy as children, such as
watching a friend blow soap bubbles and suddenly developing a fantasy
about there being a fairy that lived inside one of the bubbles. Seventeen of
them found this changing of realities at will so compelling that before
encountering its formal philosophical discussions they had formulated their
own versions of the famous musings of Chuang-tzu: “One night, I dreamed
I was a butterfly, fluttering here and there, content with my lot. Suddenly
I awoke and was Chuang-tzu again. Who am I in reality: A butterfly
dreaming that I am Chuang-tzu, or Chuang-tzu dreaming that I was a
butterfly?” (trans. 1970)
Parents of fifteen of the fantasizers were remembered as explicitly
encouraging their fantasy. On a rainy day when one boy was bored, his
mother would begin play suggestions with, “You could pretend to be . . .”
Another said her parents’ formula response to her requests for expensive
toys was, “You could take this . . . (household object) and with a little
imagination, it would look just like . . . (that $200-whatever-Susie-just-

got).” And she reported, “this worked for me—although Susie couldn’t
quite always see it.” One mother very specifically trained hypnotic ability
by reading trance exercises about age regression, being an animal, speeding
up time, and so forth to her son from the book Mind Games (Masters &
Houston, 1972).
Their adult fantasy continued to occupy the majority of their waking
hours. They all fantasized throughout the performance of routine tasks and
during any unoccupied time. Six of them said they did not “fantasize” or
“daydream” when dealing with the most demanding tasks but still contin-
ued to have vivid images in response to any sensory words. The other thir-
teen said they continued to have elaborate ongoing fantasy scenarios.
Some experienced them superimposed and intertwined with the ongoing
tasks: “I’m listening to my boss’s directions carefully, but I’m seeing the
Saturday Night Live character ‘Mockman’ next to him mocking all his
gestures.” Others experienced the fantasies as simultaneous or separate,
happening “on a side state,” as one subject described it: “somehow I’m see-
ing the real world and experiencing my fantasy one at the same time.”
Fantasizers also continued to have momentary vivid fantasies inspired
by ongoing events. One young man had come to the interview directly
from an archery class where he described that as he shot arrows at a target
and watched others do so, he would briefly experience himself as the arrow
being hurled by the force of the string through the air and felt himself
piercing the fiberboard target. Another described that while passing up
chocolate cake at lunch because of a diet, she momentarily “became” a
microbe burrowing through the cake, tasting and smelling it as she dev-
oured it, and feeling it squish around her body. She reported experiencing
a sense of satiation with this fantasy indulgence.
All of these subjects described some of the dreamlike, surreal content,
sudden transitions, and surprise that two earlier studies had reported for
deep trance subjects’ daydreams (Barrett, 1979, 1990). When asked
whether they “startled” out of daydreams that they could not recall, four
said they experienced this occasionally, although usually they had a “tip of
the tongue” feeling about the fantasy and its memory would “come back”
to them shortly. Seven of them reported that they occasionally had fright-
ening content that seemed not to be under their control as in the
“daymares” reported by Hartmann’s nightmare sufferers.
Like Wilson and Barber’s subjects, they experienced physical effects from
their imagery. Seven of the twelve female fantasizers had experienced false
pregnancy symptoms. Even more of Wilson’s subjects had experienced some
such symptoms and full-blown cases (so to speak) presenting for treatment
have been linked to high hypnotic susceptibility (Barrett, 1989). All of the
fantasizers, male and female, described sometimes experiencing physical
sensations to visual stimuli, such as shivering when seeing a painting of the
Alps; feeling hot, dry, and impulsively getting something to drink in

response to looking at desert photos; and getting nauseated from motion
sickness at a film set on a tossing submarine. Ten of them said they tried to
avoid either fictional depictions or real newsreel footage of violence and
injuries because they experienced pain akin to real injuries. For four of
them, this might precipitate ill feelings for hours or days. One such subject
who had long ago learned to avoid television news, described several weeks
previously that she had been watching a nationally televised swim meet in
which a diver had unexpectedly been injured. As she described the scene,
she clutched herself tightly, grimaced as if in pain, tears came to her eyes,
and she described this as minimal compared to her reaction when watching
the scene that had left her shaken and physically aching for hours.
Fourteen of the fantasizers could experience orgasm through fantasy in the
absence of any physical stimulation, and all of them reported frequent, vivid,
and varied sexual fantasies. Although most of them tended to have fairly
active and varied sex lives, all of them had fantasies of many more variations
than they actually engaged in. Seventeen of this group were exclusively heter-
osexual, and two males were predominantly homosexual with a bit of hetero-
sexual experience. However, all of the women and two of the heterosexual
men mentioned homosexual fantasies. Other fantasy partners included ani-
mals, children, statues, and a variety of suggestively shaped inanimate objects.
Wilson and Barber reported that their subjects often obtained greater
enjoyment from their fantasized sex than their actual sexual relationships.
When our group was queried, they said this was not a meaningful compari-
son as their two categories of sexual experience were fantasy only versus
fantasy superimposed on real activity, of which the latter was often pre-
ferred. Real partners were heard to utter imaginary sexy comments, were
dressed in hallucinatory erotic attire, had movie stars’ faces (and occasion-
ally other parts) superimposed onto theirs, were joined by additional imagi-
nary partners, and were transformed into science-fiction creatures and
circus animals. Only two subjects (one male, one female) said they tried
not to fantasize during real sex, and both of them said they often failed.
Fantasizers all had some experiences that they considered “psychic”: 14 had
premonitions about events that were going to happen, 12 said that they could
sometimes sense what significant others were thinking or feeling at a distance,
9 had dreams that came true, 13 had out-of-body experiences, and 8 had seen
ghosts. Fifteen firmly believed these experiences were real paranormal phe-
nomena, and the remaining four said they were undecided about their reality.
Early Memories and Parental Discipline

The earliest memories of the fantasizers were all identified as being
before the age of three, and before the age of two for eleven subjects. For
the purposes of this study, subjectively believed age and detail of first
memories were compared. This study was not set up to definitely check
whether the ages were accurate or whether indeed the memory was
directly recalled rather than fantasized from stories told by parents. For
randomly selected college students, the average of subjectively recalled first
memory is about three and a half and two to six is the usual range (Barrett,
1980, 1983). The youngest memory that had a specific time estimate was
of age eight months. This subject remembered two scenes: one in which
he was being carried by his father down a hospital corridor and another in
which he was lying on his back with one green-gowned man prodding his
stomach while another pressed a plastic mask over his nose and mouth. He
remembered excruciating pain in both scenes. He was quite convinced
that these were memories of an appendectomy he had undergone at eight
months, and that he had remembered details of this, which surprised his
parents the first time they discussed it with him.
More typically, the incidents were too minor to be remembered by
parents or to be tied to an exact date but sounded like those of a preverbal
or early verbal child—for example, one incident that the subject estimated
as before age two: “I remember being in my crib, which was pushed against
a wall with a window above it. I was looking up at the window and it must
have been raining outside because water drops were running down the out-
side of it. I was fascinated because I’d never noticed the window doing this
before. This was a stage when I would point at things and ask ‘whah?’ and
my mother would say the name for it. I pointed at the water drops and said
‘shah?’ and my mother said ‘window.’ I already knew this word so I frustrat-
edly pointed again at the glass with the drops on the outside and repeated
‘whah?’ I guess she thought I meant the pane of glass—or maybe she even
said ‘rain’ and I misunderstood—because what I heard her say was ‘pain.’
I thought I recognized the word for when I hurt myself and I realized that
the drops were like the tears that ran down my face at those times.
I watched amazed that the window could cry with pain like me. I think it
was a long time before I corrected this impression and came to connect
the drops with the ‘rain’ that fell when I was outside and that could also
run down the window’s ‘pane.’ ”
Several of this group’s earliest memories were of surreal events, most
likely memories of fantasies or dreams such as this one: “I remember wak-
ing up in the middle of the night. In the air over me there were these big
neon letters of the alphabet, maybe eight inches tall dancing around. They
looked so wonderful. I recognized an ‘A’ and a ‘D’ because I knew the first
few letters, but most of them were shapes I didn’t know from later in the
alphabet. They seemed to be floating into my room from the hall. I got
out of bed and went into the hall where there were more neon letters in a
line coming from my parents’ room. I followed the line into my parents’
bedroom. They were coming out of the drain on the floor; one by one they
would pop up out of the drain and dance out of the room. I watched them
there for a while and then I went back to my room and watched them in
bed until I fell asleep again. I remember thinking I must tell my parents
about this in the morning, but I don’t know if I did. I must have been
about to turn three because I could say the alphabet by three years old.”
When asked about how their parents had disciplined them, eleven of
the subjects said that their parent had disciplined them solely by some
combination of two strategies: (1) rewards or withholding of rewards, and
(2) reasoning with them, often emphasizing empathy: “One time I’d gotten
in a fight at nursery school with another little girl because there was this
doll there that was her favorite or regular toy to play with. I’d gotten it
first that day; she tried to take it away from me and I pushed her down.
The teacher called my mother and told her about it. Mother told me
I should think about what she had felt like when she fell down, and it
became like I really was her hitting the floor scraping one knee, and cry-
ing. I could also feel her desperation and thinking it really was her doll
(even though it was the school’s); she had named it and everything. After
that I wouldn’t have done that again.”
Eight of this group reported discipline that they experienced as harsh
such as spankings, being locked in their rooms for extended periods, and
verbal belittling. They typically used fantasy and imaginary companions to
restore self-esteem after these incidents. Wilson and Barber (1978) reported
that their subjects’ fantasies in these situations did not revolve around
retaliation except indirectly toward other objects. In the present sample,
more than half of these fantasies were of retaliation against parents, albeit
tempered by leniency on the part of the offended child. One child fanta-
sized producing electric shocks to repel spankings. More typically, some
other powerful being intervened against the parent sometimes because of
punishing the child, sometimes for some other reason. Parents were kid-
napped by aliens, chained in King Arthur’s dungeon, arrested by the police,
or sent back to grade school. In most cases, however, the next step was that
the child intervened on the parents’ behalf and the parents were released
feeling repentant and/or indebted.
Fantasizers’ Experience of Hypnosis

Despite being such deep trance subjects, these 19 people scored only
just above average (mean ¼ 18) on the Field Inventory and very low on
the subgroup of Field Items that reported surprise at hypnotic phenomena.
Nine of the 19 described hypnosis as not different than what they experi-
enced in their waking fantasy activity, and the remaining ten found hyp-
nosis mildly different by being somewhat more intense in some aspect but
still similar to their other imagery experiences. These differences included
hypnotic imagery being more consistently hallucinatory for six subjects,
and two saying they felt much more subjective time had gone by in
hypnosis than it would if they were fantasizing for a similar amount of real
time. One drama major said, “Hypnosis is a lot like what I do with method
acting only you can get more into it. When I’m doing an acting exercise, I
can only get so far into the experience because some part of me has to
keep watching that I don’t become the character so much that I’d just
walk out of the class if he was mad, but with the hypnosis you don’t have
to watch that sort of thing at all. During the age regression I could leave
my adult self behind completely.”
These subjects were all quite aware that what they experienced during
hypnosis were phenomena they produced themselves. None of them con-
ceptualized it at all in terms of something the hypnotist was doing to
them. “Hypnosis was a lot like what I do when I’m daydreaming or experi-
encing something from the past except it’s even easier because your voice
conjures up the images automatically,” said one subject. The fantasizers
generally seemed proud of their ability at hypnosis. All of them enjoyed
the hypnotic experiences, although several remarked that the lengthy
interviews about fantasy and memory were more personally significant to
them. “Seeing the things you described in hypnosis is nice but pretty much
like my daydreaming all the time, but talking about what my daydreams
are like and how big a part of my life they are isn’t something I’ve ever
gotten to do before in this much detail.”
Fantasizers experienced hypnotic amnesia only when it was specifically
suggested—and not always absolutely then. Six of the eight fantasizers scor-
ing 11 rather than 12 on the HGSHS-A had the amnesia suggestion as their
only failed item. Some had partial recall although they had formally passed
it. Others described that it seemed not as completely real an effect as the
other hypnotic phenomena, citing working to keep items out of conscious-
ness or being very aware they could counter the suggestion if they chose.
The fantasizers were also likely to know hypnotic hallucinations were
not real without needing to be told this. When asked how they were sure
they knew there had not been a real candle lit in the room for instance,
fourteen of them cited some cognitive strategy that they had long practiced
for differentiating the hallucinations of their waking fantasies from reality.
Nine of them also usually retained the knowledge that the hypnotist had
given verbal suggestions to hallucinate what they then experienced, which
made the deduction simple. In response to the HGSHS-A suggestion about
hallucinating a fly during his first group induction, one subject had the fol-
lowing experience: “When you told us there was a fly buzzing around us,
one appeared circling my head. Then I realized you had suggested it to
everyone, and I saw and heard fifty of them circling around each student in
unison. At the same time, the rock group Kansas’ song The Gnat Attack
began to play as if there was a stereo in the room. I thought all this was
delightful and very funny. As soon as you said we could shoo the flies away,
the music stopped too.”
This group showed a moderate degree of muscular relaxation during hypno-

sis akin to what an average person might look like awake but at rest. There
was not a dramatic loss of muscle tone, all of them remained seated in their
chair without problem, and most shifted position occasionally during the
trance. They only moved easily when asked to do so for candle-blowing and
for tasks while age regressed. When asked to, they also talked readily in trance,
some of them with a bit softer or more monotone voice than awake, but no
one in the group was difficult to understand. All subjects in this subgroup
woke from the trance immediately alert. Some began talking about their
trance experience before the experimenter asked questions. The most immedi-
ate response upon awakening from hypnosis for the fantasizers was a big smile.
DISSOCIATION GROUP
The other subgroup of fifteen subjects was selected for scoring as very
highly hypnotizable on standard measures of hypnosis (scores of 11 or 12
on the HGSHS-A and SSHS-C) but not meeting Wilson and Barber’s
additional criteria of being able to enter a trance instantly. They scored
about average (range 16–33, mean ¼ 26) on the Absorption Scale and did
not display many of Wilson and Barber’s fantasizers’ characteristics.
In fact, the most distinctive quality to this subgroup’s descriptions of fanta-
sizing was the amnesia that had been noted for some subjects in a previous
study (Barrett, 1989). The majority of them said their fantasizing was often
characterized by inability to remember some or all of the content. Six of
them said the only reason they knew they just daydream was that they were
often startled to be spoken to, or otherwise have their attention summoned
to the real world, with a sense that their mind had been occupied elsewhere.
The reports of this group were quite dissimilar to most characterizations of
“fantasy proneness” and “high absorption.” They had so much more in com-
mon with the dissociative phenomena emphasized in Ernest Hilgard’s (1977)
neodissociation theory of hypnotic susceptibility that this subgroup is referred
to as the dissociaters for the remainder of this discussion.
Fantasies, Early Memory, and Parental Discipline

The fantasies that the dissociaters did recall from both childhood and
the present were more mundane than the other subgroup’s. They tended to
be pleasant, realistic scenarios about events they would like to happen in
the near future. None of them said these fantasies were as real in their sen-
sory imagery as their perception of reality. Dissociaters were somewhat
more like the fantasizers in how they reacted to external drama. They
described that as both children and adults, they could become so absorbed
in books, films, plays, and stories being told to them that they could lose
track of time, surroundings, or their usual sense of identity. Their lack of
equal vividness in self-directed fantasy seemed to stem partly from an

external locus of control. It just did not seem to them that vivid images
could be their own production, and so they tended to experience them
mainly in response to others’ lead as in hypnosis or in listening to stories.
Sometimes this absorption in external stimuli was intertwined with amnes-
tic phenomena; several subjects commented that they thought they got
very caught up in horror movies, but then could not remember their con-
tent shortly afterwards.
One of the most dramatic incidents of amnesia was recounted in answer
to a routine inquiry of one of the dissociaters as to whether she had ever been
hypnotized before. She answered “maybe” and described the following experi-
ence: “One time, my boyfriend and I were watching a police show on TV.
There was this scene where they were going to use hypnosis with a witness.
The detective began to swing a watch and tell the witness that he was going
to go into deep sleep. I don’t remember anything after that until I started
awake and said ‘what happened’ about twenty minutes later. My boyfriend
says the show continued with questions during the hypnosis, several scenes of
what other characters were doing, commercial break, and then came back to
the scene where the detective was waking the witness up. But I don’t remem-
ber any of that. I guess I was hypnotized by the watch.”
Other amnestic experiences seemed to be triggered by more personal
associations. One suggestion subjects were given in hypnosis was that they
would see a book “. . . with something important for you in it. You may
take it down from the bookshelf and open it.” One woman reported the
book she saw was Sybil. She had opened it in the trance but couldn’t recall
anything she had read then. She also said that in reality, she had bought
the book two years before and was sure she had read it but could not
remember anything about it. When asked if she could produce even a sin-
gle sentence about the main topic of the book, she insisted she had no
idea. The obvious diagnostic questions suggested by this will be discussed
later in the section on dissociative disorders.
The way in which the dissociaters appeared most like the fantasizers was
in the frequency of their dramatic psychophysiologic reactions. Five of the
ten women had experienced symptoms of false pregnancy. They reported
getting cold watching arctic scenes and becoming nauseated after eating
supposedly spoiled food that they later learned was fine. One developed a
rash after being told by a prankster friend that a vine she had handled was
poison ivy. Three of them also reported feeling pain when witnessing
others’ traumas. This might have been true of more of them, as six
remarked that they often could not remember moments around witnessing
injuries. After a swine flu vaccination (back in the scare of the 1970s), one
subject had a hysterical conversion-like episode of ascending paralysis that
mimicked Guillain-Barre syndrome, but which had remitted after a few
minutes of reassurance from her physician about the safety of the vaccine.
None of this group said they achieved orgasms solely from fantasy. All of
them reported sexual fantasies, but six subjects remarked that they some-
times couldn’t remember them afterward. The interview did not specifically
ask for examples of sexual fantasies. The fantasizer subgroup, as already
described, volunteered voluminous content in the course of answering ques-
tions about frequency and vividness of these fantasies. The dissociaters
rarely volunteered much detail, so less characterization was possible of their
fantasy content. Most of the ones that were mentioned were mundane. The
few who volunteered details consistently seemed to do so in the context of
wanting reassurance about their normality. One subject was worried that
she fantasized about anyone besides her boyfriend, and a male was bothered
by thoughts of his girlfriend’s attractive mother. A woman who in her early
teens had been a victim of sexual abuse, now in her early twenties, found
herself fantasizing about the abuse in an arousing manner during masturba-
tion and intercourse. She seemed reassured to hear that was not uncommon
among abuse and rape victims and that it did not invalidate her perception
that the sexual contact had been predominantly frightening and unwanted
at the time it occurred. Childhood sexual abuse may have been a common
event as will be discussed later in the section on abuse.
Fewer subjects in this subgroup believed they had psychic experiences,
and for nine of the eleven who did so, these experiences were confined solely
to altered states of consciousness—dreams most commonly for several of
them, automatic writing for two, and trance-like seance phenomena for two.
One subject reported that the spirit of her father, who had died when she
was nine, regularly appeared to her in dreams dressed in the uniform in
which he was buried and gave her advice on current problems. During hyp-
nosis, when she was told that she could open her eyes and “see someone that
you know and like” seated across from her, she had opened her eyes and seen
her father. She felt certain that her nocturnal visitations were real but was
not certain whether the hypnotic hallucination was her father’s spirit or not.
The earliest memories of the dissociaters were later than average (mean ¼ 5
and for six subjects between the ages of 6 and 8). This was the opposite
trend away from the general population mean than for the fantasizers.
When asked about parental discipline, seven of the fantasizers recalled
spankings and other corporal punishment, and 5 more of the others said
they could not recall. Abuse and other clearly traumatic incidents will be
discussed further in a subsequent section.
Dissociaters’ Experience of Hypnosis

This subgroup scored very high on the Field questionnaire, mean ¼ 33,
usually answering “true” to all six items that express surprise and amazement
at hypnotic phenomena. They were much likelier to conceptualize hypnotic
phenomena as due to some amazing talent of the hypnotist rather than as
produced by themselves. They were resistant to hearing that it was something

within their control, and in some sense this may really be less true for this
group, for them it is less consciously controlled. Six of them asked many
questions seeking reassurance that their hypnotic susceptibility was normal.
Two described hypnosis as partially unpleasant, not in terms of any specific
content being negative but they did not like the concept that they were hal-
lucinating. All described hypnosis as the more striking and interesting part of
the experimental process; much of the interview about fantasy and imagery
was not of great personal relevance. These subjects frequently experienced
spontaneous amnesia for hypnotic events. Amnesia was consistent and total
for them whenever it was suggested, and it sometimes persisted even once re-
moval cues had been given. Half of them experienced some degree of sponta-
neous amnesia for trance events when it had not been suggested.
Dissociaters were often surprised at some of their hypnotic experiences,
especially hypnotic hallucinations. They were much likelier than fantasiz-
ers to believe their hypnotic hallucinations were real until told otherwise.
The few who realized they were not real distinguished them on the basis of
their implausibility rather than by any other method for telling hallucina-
tions from reality. They almost never remembered the verbal suggestions
for the hallucinations, and when they did, still ignored the association
with their perceptions. One subject remained convinced that, coinciden-
tally at the moment that I suggested the HGSHS-A fly hallucination to a
roomful of subjects, a real fly happened to begin buzzing around him.
The dissociaters exhibited an extreme loss of muscle tone during trance, of-
ten slumping; two needed to be propped up so they did not fall out of their
chairs. When asked to move or speak during the trance, their voices and
movements were markedly subdued; four were partially inaudible. Six reported
that their trance had to lighten for them to be able to move or speak at all.
When they were instructed to awaken, they would usually open their
eyes, but most blinked and looked confused at first. Four asked disoriented
questions such as “What happened?” or “Where was I?” They appeared to
need almost to struggle to talk, and were slow to begin to answer ques-
tions. All these behaviors were transient, and all subjects were fully alert
within a couple of minutes.
FOLLOW-UP: COMPARISON WITH HIDDEN OBSERVER

DISTINCTION, DREAM PHENOMENA, AND
DISSOCIATIVE DISORDERS
In a later follow-up study (Barrett, 1996) with 24 subjects who were still
geographically available (15 women, 9 men), they were hypnotized again,
given suggestions of hypnotic deafness before the first four lines of a recorded
nursery rhyme were played at a clear volume, and then tested for the
Hilgard’s hidden observer phenomena (Hilgard, 1979). These 24 were then
interviewed with detailed queries about childhood trauma, dream content,

and diagnostic questions for dissociative disorders. Chi square analyses were
employed where expected cell size allowed. For smaller subsamples, signifi-
cance was computed by Fisher’s exact probability test.
All of both groups still tested as highly hypnotizable. Two of the disso-
ciater group reported more-consciously controlled and better-recalled im-
agery than they had at the time of the first study. However, even these two
did not show the fantasizer trait of instant-trance-entry and no one in either
group had totally shifted group characteristics.
The hidden observer phenomenon was slightly more common in dissociat-
ers (see Table 2.2). Seven of nine dissociaters manifested a hidden observer,
while seven of fifteen fantasizers did What was much more clearly pro-
nounced was the difference in content of hidden observers for dissociaters
versus fantasizers. All dissociaters who manifested a hidden observer gave
accurate descriptions of the stimulus. Four recited it flawlessly, two first
named it or said “nursery rhyme,” and when asked for the complete rhyme
recited it with only minor mistakes. Three dissociaters gave hidden observer
responses in a flat monotone similar to all other requested vocalizations they
had ever made in trance. Two spoke in a more childlike voice than usually
characterized these waking or trance vocalizations.
The final dissociater with a hidden observer responded quite dramatically
to the suggestion: opening her eyes (not suggested), saying “Hi, I think I’m
who you want to talk to” in a much more aggressive demeanor than the sub-
ject’s usual waking or hypnotized style, reciting the rhyme in a sarcastic tone,
glaring for about 15 seconds, and then closing her eyes again. This response
will be discussed later in the section on dissociative diagnoses.
None of the 6 dissociaters remembered the rhyme or their hidden
observer responses upon awakening, nor did the 3 who failed to exhibit a
hidden observer recall the rhyme upon awakening.
TABLE 2.2 Hidden Observers, Nightmares, and Trauma of Fantasizers

Compared with Dissociaters
Fantasizers Dissociaters
(9 Women, 6 Men) (6 Women, 3 Men) Fischer Exact
Probability
Characteristic Yes No Yes No Test p <
Some hidden observer 7 8 7 2 .10
response
Hidden observer with 7 8 4 5 .85
detailed accuracy
Recurring nightmares 0 15 6 3 .005
Trauma known 2 13 5 4 .05
Trauma known or 2 13 9 0 .005
suspected
The four fantasizers who gave fairly realistic accounts also describe an
intentional strategy of “not listening.” A typical response was, “It was the
rhyme ‘Twinkle, Twinkle, Little Star.’ The voice was there but I kept tell-
ing myself I didn’t hear it.”
Three fantasizers said something additional in response to hidden ob-
server suggestions that did not contain the majority of the poem. All of
these contained some confabulated, visual, or dream-like content either
related or unrelated to the poem. One contained a star in the night sky,
one heard a “nursery rhyme” that they could not name or recite while expe-
riencing apparently unrelated rich visual imagery, and the third heard “. . .
something about diamonds; I know I could have heard more but I tried not
to listen.”
After awakening from hypnosis, all seven of the fantasizers had some
memory of the rhyme and their hidden observer responses. They appeared
integrated with the hidden observer identity although they could also still
recall the point in time at which they had been unable to recall the stimu-
lus. For them, the hidden observer seemed to have much the same effect
as a simple amnesia removal cue.
Dreams
When asked to recount the most recent dream that they could recall
clearly, 11 of the 15 fantasizers gave a dream from the previous night. All
others were from the previous four days. They were typically lengthy,
fantastic accounts.
There was one out-of-body account, one lucid dream, and a false awak-
ening. All of these are very rare categories, albeit ones that I had found to
correlate with hypnotizability in another study on a different sample
(Zamore & Barrett, 1986). Three of the dreams were sexual (another rare
category), most were pleasant, and none were nightmares. When asked if
they had nightmares, 4 fantasizers reported that they had at least one a
month. None of them reported any recurring nightmares.
In contrast, when dissociaters were asked to recount the most recent
dream they could recall, many had trouble thinking of one. Although two
recalled dreams from the previous night, several dated the last dream they
could recall as years before. One gave a recurring nightmare that had hap-
pened only a few times as the only dream she believed she had ever recalled
in her lifetime. Two more dissociaters gave a recurring nightmare as their
most recent well-recalled dream, and 3 others reported they experienced
recurring nightmares at least once a month. All of these subjects also
reported nonrecurring nightmares, and one additional dissociater reported
nonrecurring nightmares only. Three reported sexual content in their most
recent dreams, but these were all within the context of nightmares or other
unpleasant dreams. Their nightmares had even more obviously disturbing
content than those of the fantasizers including things such as suffocating,

the dreamer’s body coming apart, and horribly injured babies and children.
Trauma Histories
None of the 19 fantasizers reported any severe beatings or sexual abuse by
immediate family or caretakers. Two female subjects in this group did report
abusive sexual behavior on the part of other adults, in one case a social ac-
quaintance of the family, and in the other, a stranger. Fantasizers in this
study actually reported less physical and sexual abuse than the approximately
20 to 25 percent rate reported in general college populations (NIJ & CDC,
1998). Their higher-than-average recollection for early childhood events
would make it unlikely they are underreporting, although this finding is
inconsistent with Lynn and Rhue’s finding that a history of abuse correlates
with their fantasy-proneness questionnaire (Lynn & Rhue, 1988).
Four of the 15 dissociaters initially remembered abusive behavior. For
three of them this involved physical violence, and for two of them it
involved sexual abuse. In addition to these 4 with direct memories, 2 subjects
said they didn’t remember but had been told that they had been battered as
children (in one case, an older sibling remembered witnessing this; in
another case, a social worker had monitored the parents following a teacher’s
report of abuse). One additional subject in the group described a severe his-
tory of early childhood multiple fractures and burns for which his parents
presented improbable explanations to others—and which he did not recall
the origins of. Another subject experienced nausea and vomiting whenever
anyone touched a certain portion of her thigh. Six of the remaining 7 sub-
jects reported some signs such as the recurring nightmares outlined in the
previous section and the lack of recollections before the ages of 7 or 8
described earlier. These signs have been associated with an increased likeli-
hood of childhood abuse (Belicki & Cuddy, 1996; Barrett & Fine, 1980).
Two of the dissociaters reported regaining abuse memories in the four years
between the initial and follow-up interviews, which further suggests the rate
for this group may approach 100 percent.
In addition to this suggestion that between 6 and 14 of the dissociaters
had been abused by parents, 3 of them reported other major traumas in
childhood—in one case a very painful and extended medical condition,
and for 2 the deaths of a parent when they were under 10.
Dissociative Diagnoses and Post-Traumatic Stress Disorder

No fantasizer came close to meeting DSM3-R (revised) Dissociative Dis-
order or Post-Traumatic Stress Disorder, although 100 percent of the fanta-
sizers fit what would constitute Dissociative Disorder Not Otherwise
Specified: “trance states, i.e. altered states of consciousness with markedly
diminished or selectively focused responsiveness to environmental stimuli”

(APA 1987, p. 277). However, DSM defines mental disorders to be diag-
nosed as “A psychological syndrome with present distress or disability . . .
or increased risk of suffering” (APA 1987, p. xxii). The fantasizers do not
appear to be distressed by their ability for selectively focused responsiveness.
Although the interview did not include all diagnostic questions for every
other possible disorder less obviously related to content of the study, fanta-
sizers did not obviously meet any other diagnoses. Two fantasizers did
demonstrate some bipolar tendencies, and one some schizotypal ones; how-
ever, in no case did they exhibit enough of the criteria and/or the severity
of distress or impairment necessary for the formal diagnosis. Overall, the
fantasizers appeared to be a mentally healthy group of people. Four
dissociaters met Dissociative Disorder NOS criteria, one with features of
multiple personality—the person whose hidden observer exhibited such
autonomy and distinctness had other brief amnestic episodes of speaking as
a very different persona. A fifth dissociater met formal criteria for Psycho-
genic Amnesia. Again, most of the remaining dissociaters could be seen as
meeting the symptom criteria for this disorder by their daydream amnesia
alone except that they did not appear to experience distress or impairment
from their amnestic tendencies.
Even the 5 dissociaters with enough distress to qualify for dissociative
diagnoses were toward the mild level of impairment from these disorders.
Only one of them had sought long-term psychotherapy or therapy directed
at trauma and dissociative symptoms. One of the other four with diagnoses
and two others in this study have married abusive spouses, been unable to
hold a job, made serious suicide attempts, or been hospitalized in psychiat-
ric settings. However, all these events are common for other people with a
serious trauma history and/or dissociative disorders.
CONCLUSIONS
In summary, there seem to be two distinct subgroups of people who are
highly hypnotizable. Wilson and Barber’s concept of the majority of highly
hypnotizable people having vivid fantasy and imagery ability is sound.
However, it appears there is another, somewhat similar group characterized
by amnesia and dissociative phenomena, who do not achieve trance as rap-
idly but are nevertheless capable of eventually reaching as deep a trance as
do fantasizers. This distinction does not seem to be synonymous with the
one between hypnotic subjects who manifest Hilgard’s hidden observer
phenomena versus those who do not.
Although the two dissociaters who developed some fantasizer-type im-
agery suggest these people may have some of the same fantasy ability
masked by amnesia, for the most part these seem to be remarkably separate
groups. The present author and other clinicians have occasionally seen
patients who seem like hybrids of the two types—with dissociative disor-
ders but with vivid voluntary imagery (Schatzman, 1980; Barrett 1998)—
however, this seems to be rare. It seems most accurate to think of high
hypnotizables as composed of two groups whose life histories have special-
ized them primarily toward one of the major phenomena: hallucinatory
imagery or dissociative abilities.
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Chapter 3
Hypnosis, Mindfulness Meditation,

and Brain Imaging
David Spiegel, Matthew White,
and Lynn C. Waelde
INTRODUCTION
Hypnosis, begun as a therapeutic discipline in the eighteenth century, was the
first Western conception of a psychotherapy (Ellenberger 1970). Hypnosis is a
state of highly focused attention coupled with a suspension of peripheral
awareness (Spiegel & Spiegel, 2004). This ability to attend intensely while
reducing awareness of context allows one to alter the associational network
linking perception and cognition. The hypnotic narrowing of the focus of
attention (Spiegel, 1998) is analogous in consciousness to looking through a
telephoto lens rather than a wide-angle lens—one is aware of content more
than context. This can also facilitate reduced awareness of unwanted stimuli,
such as pain, or of problematic cognitions, such as depressive hopelessness
(Spiegel & Spiegel, 2004). Such a mental state enhances openness to input
from others—often called suggestibility—and can increase receptivity to ther-
apeutic instruction. In this chapter, we review research on effects of hypnosis
and related data on mindfulness meditation on peripheral and central nervous
system functioning, emphasizing studies utilizing brain imaging techniques.
Hypnotizability, the individual’s degree of responsiveness to suggestion
during hypnosis (Green et al., 2005), is a highly stable and measurable trait
(Spiegel & Spiegel, 2004). In one study, hypnotizability was found to have
a .7 test-retest correlation over a 25-year interval, making it a more stable trait
than IQ over such a long period of time (Piccione, Hilgard, & Zimbardo,
1989). The trait of hypnotizability is a crucial moderating variable in pain
treatment response, both that involving hypnosis directly (Hilgard & Hilgard,
1975), and in augmenting placebo response (McGlashan, Evans, & Orne,
1969).
There is widespread belief that mental state has an effect on health.

Healing ceremonies in many cultural traditions involve inducing an altera-
tion in mental state. Most mind/body techniques employed in the West
involve inducing a change in mental state coupled with instructions to
control symptoms such as pain or anxiety, or even to improve the course
of a disease. Yet, we know very little about the neurophysiological basis of
these mental state alterations.
There is considerable evidence that hypnosis affects clinically important
aspects of somatic functioning. The oldest and best established effect is on
pain, dating back to the pioneering work of Esdaile (Esdaile, 1846;
reprinted 1957). This finding has been replicated in numerous studies (Lang
et al., 2000; Spiegel & Bloom, 1983). A randomized controlled clinical trial
among 241 patients undergoing invasive radiological procedures demon-
strated that, compared to either routine care or structured attention, hyp-
nosis produced significant reductions in pain, anxiety, complications, and
procedure time, while requiring only half of the analgesic medication used
in the other groups (Lang et al., 2000). Hypnosis is also a highly effective
tool in treating various kinds of somatic dysfunction, such as irritable bowel
syndrome (Colgan, Faragher, & Whorwell, 1988). Hypnosis can cause sig-
nificant increases and decreases in gastric acid secretion (Klein & Spiegel,
1989). Hypnosis has been employed to diagnose and control nonepileptic
seizures as well (Barry, Atzman, & Morrell, 2000; Barry & Sanborn, 2001).
Studies have also shown that hypnosis can directly affect autonomic func-
tioning. For example, highly hypnotizable subjects show evidence of greater
vagal tone (DeBenedittis et al., 1994; Harris et al., 1993), which is associated
with the ability to self-soothe (Porges, 1995; Porges, Doussard-Roosevelt, &
Maiti, 1994). Furthermore, induction of the hypnotic state reduces sympathetic
and increases parasympathetic activity, as measured by the low-frequency/
high-frequency ratio using power spectral analysis of heart rate (DeBenedittis
et al., 1994). Hypnotic induction of emotional states also affects the secretion
of the stress hormones cortisol and prolactin (Sobrinho et al., 2003). Thus,
hypnosis has the potential to modulate neural and endocrine components of
the stress response.
Neuroimaging of Hypnosis
We have not yet identified a “brain signature” of the hypnotic state per
se. However, many studies have demonstrated that hypnotic alteration of
perception changes perceptual processing in the brain. Changing the word-
ing of a pain-directed hypnotic instruction from “you will feel cool, tingling
numbness more than pain” to “the pain will not bother you” shifts activa-
tion from the somatosensory cortex to the dACC (Rainville et al., 1997,
1999). Similarly, in a positron emission tomography (PET) study, Kosslyn
and collegues have shown that hypnotic suggestion can alter visual color
Hypnosis, Mindfulness Meditation, and Brain Imaging 39
perception and affect activation in color processing regions of the brain

(Kosslyn et al., 2000). They asked hypnotized subjects to see a gray-scale
pattern in color; under hypnosis, color areas in the ventral visual processing
stream were activated, whether they were shown colors or the gray-scale
stimulus. Believing was seeing.
Among the brain regions implicated in hypnosis, the best evidence to date
points to frontal attentional systems, especially the dACC and the DLPFC.
Along with the frontoinsular cortex (BA 47/12), activity in the dACC tends
to track with changes in autonomic tone occurring in the setting of cogni-
tively demanding or emotionally salient tasks (Critchley, 2005; Seeley et al.,
2007). Highly hypnotizable subjects performing a cognitive or perceptual task
under hypnosis tend to show altered activation in the dACC (Rainville
et al., 1999; Szechtman et al., 1998; Raz, Fan, & Posner, 2005). Raij et al.
found that DLPFC, dACC, and frontoinsular activation correlated with the
degree of pain experienced under hypnotic suggestion (Raij et al., 2009). Raz
et al. have found the dorsolateral prefrontal cortex (DPPFC) and dACC to
be instrumental in suggestive interpretation of bistable figures with two
opposing perceptual interpretations—like the vase/face drawing (Raz et al.,
2007). Using PET, Faymonville implicated many regions including the
dACC and DLPFC in hypnosis and hypnotic reduction in pain perception
(Faymonville et al., 2000). However, it is difficult to assess whether previ-
ously identified task-related differences in dACC and DLPFC activation are
a generalized signature of hypnotic trance or an associated effect of the spe-
cific hypnotic suggestion.
MINDFULNESS MEDITATION
Health Benefits of Meditation
There is reason to believe that there are many analogies between hypnosis
and mindfulness. Meditation has been practiced in many forms for health
and healing for thousands of years. Meditation is defined as a family of self-
regulation practices that focus on training attention and awareness (Walsh
& Shapiro, 2006). A recent operational definition of mindfulness meditation
(MM) emphasizes self-regulation of attention on immediate experience and
cultivating curiosity, openness, and acceptance of that experience. As such,
MM requires the ability to sustain attention on the breath and to switch the
attention back to the breath once thoughts, feelings, and sensations have
been detected and acknowledged, without further elaboration (Bishop et al.,
2004). Mindfulness-based stress reduction (MBSR) is a widely used skills-
based educational intervention that combines mindfulness with hatha yoga
exercises to enhance health and well-being (Kabat-Zinn, 2005).
MM has been investigated in a broad range of health conditions, includ-
ing pain, immunological, and dermatological conditions, and as supportive
therapy in cancer care. A meta-analysis found five controlled studies of

MM for physical health conditions that included the following diagnoses:
chronic pain, fibromyalgia, and coronary artery disease that had a mean
effect size of d ¼ 0.5 (Grossman et al., 2004). Effects of MM on pain were
demonstrated in a study of chronic musculoskeletal pain (Plews-Ogan
et al., 2005). A controlled study of MBSR for fibromyalgia patients found
pre/post and three-year follow-up reductions in visual analog pain, coping
with pain, and somatic complaints (Grossman et al., 2007). A randomized,
controlled trial of MBSR for psoriasis found that patients who used MBSR
during light treatments experienced more rapid skin clearing than those
with light treatments alone (Kabat-Zinn, 2005). A recent review concluded
that MM shows promise for cancer supportive care (Smith et al., 2005).
Beneficial effects of MBSR for endocrine, immune, and autonomic parame-
ters were demonstrated in a series of trials with early stage breast and prostate
cancer patients. Participants were assessed at pre- and post-intervention and
at 6- and 12-month follow-up. Over the course of follow-up, cortisol, Th1
(pro-inflammatory) cytokines, and systolic blood pressure decreased (Bishop
et al., 2004; Carlson et al., 2003, 2007).
Neuroimaging and Mindfulness Meditation

Neuroimaging studies of MM using structural magnetic resonance imag-
ing (MRI), functional magnetic resonance imaging (fMRI), and PET sug-
gest that MM, like hypnosis, involves regulation of regions associated with
attention and interoception, particularly the dACC, the DLPFC, and the
frontoinsular cortex.
Structural imaging studies of experienced meditators have demonstrated
increased grey matter in regions associated with experiential self-monitoring
and interoception, in particular the left temporal gyrus, right frontoinsular
cortex, and right hippocampus. Lazar (Lazar et al., 2005) compared twenty
Buddhist Insight practitioners to fifteen non-meditators and found increased
cortical thickness in right middle and superior frontal cortex, right frontoin-
sular cortex, and left superior temporal gyrus. Holzel et al. also reported
increased grey matter density of the left inferior temporal gyrus, right fron-
toinsular cortex, and right hippocampus in a voxel-based morphometry
(VBM) study (Holzel et al., 2008). Larger volumes in the left inferior tempo-
ral gyrus and right hippocampus were replicated by Luders (Holzel et al.,
2007), who utilized VBM to compare 22 long-term practitioners of diverse
forms of MM (Zazen, Vipassana, Samatha) to 22 age- and gender-matched
controls. They also found larger volumes for meditators in the right orbito-
frontal cortex and right thalamus, regions implicated in emotion regulation.
In terms of functional imaging, similar to the literature on hypnosis,
activations of the dACC and DLPFC are the most consistent findings in
experienced practitioners of MM. In a small fMRI study of five subjects,
Lazar found increased activation during MM in many regions including

DLPFC, dACC, and striatum, regions associated with attention and auto-
nomic control (Lazar et al., 2000). Holzel et al. found increased activation
during meditation (compared with mental arithmetic) in the dACC and
dorsal medial PFC in experienced Vipassana meditators compared with
controls (Holzel et al., 2007). Baron-Short et al. found no difference in
regional activation between longer term MM practitioners and controls
using standard whole-brain comparisons with stringent thresholds; how-
ever, using a region-of-interest (ROI) analysis, they found significantly
more sustained activation in the dACC and DLPFC, an effect that was
more pronounced for more experienced meditators (Baron-Short et al.,
2007).
Hypnotic Changes in Attention Systems

Thus we know that hypnosis involves neural mechanisms related to
arousal and attention, but is not simply the product of them, since arousal
and attention occur frequently unrelated to hypnosis. Activity in the frontal
lobes and the anterior attentional system (Posner and Petersen, 1990),
especially the anterior cingulate gyrus, seems to be involved. Posner and
colleagues (Posner and Petersen, 1990; Fan et al., 2002) describe three com-
ponents of attention: executive attention, alerting, and orienting. Executive
attention, modeled as target detection, is related by Posner to the anterior
cingulate gyrus. Based on their work, this attentional subsystem is a
“spotlight,” narrowing the focus of attention. The second component, alert-
ing, is a characteristic of the anterior attention system and is characterized by
rapid response with an increase in error rates. This component is tied to the
right medial aspect of the frontal lobe. The third and most posterior involves
orienting, and is located in the anterior occipital/posterior parietal region.
This area has strong connections from the superior colliculus and the thala-
mus. Lesions in these lower connections result in a difficulty in orienting, fo-
cusing attention on the target, and avoiding distraction. Furthermore, there
is a hemispheric difference in the type of orienting, with a right hemisphere
bias toward global processing and a left bias toward local processing.
Hypnotic concentration is more associated with activation of the anterior
as opposed to the posterior attention system, in Posner’s terms, especially the
executive attention function of the anterior cingulate gyrus. In Pribram’s
terms, this means activation rather than arousal (Pribram & McGuinness,
1975). Pribram’s earlier conceptualization, quite consistent with Posner’s,
links arousal to noradrenergic activity and parsing, which means activating
multiple systems, with emphasis on external perception. Activation, on the
other hand, is described by Pribram as largely dopaminergic, and involves
“chunking,” or reducing the number of parallel systems, and emphasizes an
inner rather than outer focus. There is evidence, in fact, that hypnotizability
is correlated with levels of homovanillic acid (HVA) in the cerebrospinal

fluid (Spiegel & King, 1992). HVA is a metabolite of dopamine, so this find-
ing provides evidence linking hypnosis to dopaminergic activity. Furthermore,
the hypnotizability of schizophrenics, who have abnormalities in dopamine
activity and the D2 receptor (Lidow & Goldman-Rakic, 1997), is substan-
tially lower than normal (Pettinati et al., 1990; Lavoie and Elie, 1985).
The anterior cingulate gyrus is rich in dopaminergic neurons (Williams &
Goldman-Rakic, 1998), providing converging evidence that the hypnotic
state, which involves both arousal and focusing, may be associated with activ-
ity in the anterior cingulate gyrus. This is consistent with Rainville’s PET
study showing involvement of the anterior cingulate during hypnotic analgesia
of the type that involves reducing discomfort rather than pain perception itself
(Rainville et al., 1997, 1999; Hofbauer et al., 2001). However, these studies
show hypnotic analgesia associated with decreased concern about the pain (as
opposed to decreased perception of the pain) is associated with decreased activ-
ity of the anterior cingulate. So based upon this evidence, hypnosis does not
simply involve turning “on” the anterior cingulate—indeed hypnotic analgesia
seems to work in part by turning it off.
RESTING STATE NETWORKS OF INTEREST IN HYPNOTIC

TRANCE AND MINDFULNESS MEDITATION
Convergent, multimodal data point to the dACC and DLPFC and the
frontoinsular cortex as critical regions of interest in both hypnotic trance and
MM. These regions do not operate in isolation, but rather constitute core
regions in two distributed brain networks that have undergone intensive
recent study by our group and others: the salience network and the executive
control network. A recent study by Farb et al. (Farb et al., 2007) suggests
that network approaches may be fruitful in studying MM and hypnosis. Using
a functional connectivity analysis of fMRI data during a self-referential task,
they found that experienced meditators reduced functional connectivity
between the frontoinsular cortex and the medial prefrontal cortex (MPFC), a
region implicated in self-referential cognition. The MPFC is a core region in
a third well-characterized network using resting state fMRI known as the
default-mode network (DMN) (Seeley et al., 2007).
RESTING STATE fMRI AND CANONICAL

BRAIN NETWORKS
Biswal and colleagues first demonstrated that spontaneous, low-frequency
blood oxygen level-dependent (BOLD) signal fluctuations measured in the
left motor cortex of a subject resting quietly in the scanner were strongly cor-
related with BOLD signal fluctuations in the contralateral motor cortex
(Biswal et al., 1995). This was the initial demonstration of within-subject
functional connectivity in the absence of an externally cued task. Resting-

state functional connectivity has since been demonstrated (and replicated) in
several additional resting-state networks (RSNs), each with distinct spatial
and temporal profiles that correspond to critical functions including vision,
audition, language, episodic memory, executive function, and salience detec-
tion among others (Seeley et al., 2007; Beckmann et al., 2005; Hampson
et al., 2002). Of these several canonical RSNs, we now wish to focus primar-
ily on the salience network, the executive control network, and the DMN. It
should be noted that connectivity in these RSNs is present in mild sedation
and the early stages of sleep and so is not considered to reflect conscious proc-
essing but rather basal connectivity required to maintain critical networks in
a primed state. As such, resting-state connectivity is often interpreted as
reflecting the functional architecture that supports trait characteristics rather
than real-time, state-based cognitive or sensory processing.
The DMN was initially described by Raichle and colleagues as a set of
brain regions whose activity consistently decreased during most cognitively
demanding tasks (Raichle et al.). We first confirmed his hypothesis that
these regions constituted a tonically active RSN by selecting the posterior
cingulate cortex as an ROI during a resting-state scan and showing func-
tional connectivity with the other DMN regions (Greicius et al., 2003).
Subsequent work from our group and others has shown that the DMN
likely mediates episodic memory and self-referential processing given that
it includes the hippocampus as a key node, is activated by episodic mem-
ory and self-referential tasks, and is disrupted by Alzheimer’s disease.
Unlike the DMN, which is typically deactivated by cognitive tasks, the
executive control and salience networks are typically activated during
tasks. Their frequent co-activation has led to the assumption that they
constitute a single, unitary network. Critchley and colleagues have argued
that the frontoinsular cortex and the dACC monitor and/or modulate au-
tonomic responses to salient stimuli encountered during task performance.
These functions should be separable from the cognitive processing func-
tions mediated by the dorsolateral prefrontal-lateral parietal network. To
disentangle these two networks that tend to be co-activated during stand-
ard task-activation analyses, we isolated two regions activated by the same
working memory task: one in the right frontoinsular cortex, and one in
the right DLPFC (Seeley et al., 2007). In a separate resting-state func-
tional connectivity analysis, we showed that the two regions yielded dis-
tinct RSNs. Further, connectivity within these RSNs showed a double
dissociation of function (as measured outside the scanner): the executive
control network (incorporating the DLPFC node) correlated with perform-
ance on an executive control task but not with subject anxiety level,
whereas the salience network (incorporating the frontoinsular node) corre-
lated with subject anxiety but not with executive task performance (Seeley
et al., 2007).
In sum, the executive control network includes the DLPFC and bilateral
superior parietal cortex and is critical for tasks that involve focused atten-
tion and working memory. The salience network, joining the dACC and
frontoinsular cortex to subcortical regions like the hypothalamus, has a role
in monitoring and adjusting the autonomic nervous system based on salient
internal or external stimuli. The DMN, consisting of the posterior cingulate
cortex (PCC), hippocampus, and MPFC, appears to mediate self-referential
processing and episodic memory retrieval. These networks are tonically
active and generally dissociable in resting-state fMRI. In task settings, these
networks interact such that the DMN and executive control network
appear to alternate during states of internally directed and externally
directed attention, respectively, with this toggling directed, perhaps, by the
salience network. They thus should have salience in the understanding of
both hypnosis and mindfulness, and help us understand how hypnosis can
affect peripheral autonomic function as well as CNS activity.
Hypnotic Effects on Automaticity

There is recent evidence that hypnosis can effectively decontextualize
lexical perception and eliminate the delay in reaction time seen in the
classical Stroop interference paradigm (Raz, Fan, & Posner, 2005; Raz et al.,
2002, 2006). This is surprising, since the Stroop color-word interference
task is one of the most robust phenomena in psychophysiology. In these
hypnosis experiments, high hypnotizables were instructed that the words
they would see were written in a foreign language and would have no
meaning, thereby attempting to bypass the automatic lexical processing of
the color meaning of the word (e.g., green written in red). This instruction
eliminated the standard lexical processing delay in naming the color of a
word that describes a different color. This finding is consistent with our
own that a hypnotic instruction to focus on just a portion of the letter
reduces Stroop interference (Nordby et al., 1999), and with earlier work
by Sheehan and colleagues (Sheehan, Donovan, & MacLeod, 1988). The
one contradictory finding (Dixon & Laurence, 1992) can be accounted for
by differences in hypnotic instruction. Dixon and Laurence tested
“strategic” versus “automatic” Stroop response, instructing subjects how to
predict which color would come next based on the previous one, while
assuming that a short interstimulus interval (ISI) would render the strate-
gic approach impossible. They thus gave instructions to alter anticipation
of the color, rather than perception of the word written in a contradictory
color. They found more Stroop interference for highs than lows during the
short ISIs, but in fact highs were better at reducing Stroop interference by
using the color prediction strategy at the longer ISIs than were lows. So
even in their hands, strategy trumped automaticity in the eyes of highs.
They were better than lows at reducing the presumably “automatic” lexical
Stroop interference. This is crucial for interpreting studies of hypnotic

effects, as we have seen in earlier studies of the effects of hypnotic sugges-
tion to change olfactory perception on olfactory event-related potentials
(Barabasz & Lonsdale, 1983).
These Stroop studies suggest that hypnosis can reduce the automaticity
of lexical processing. This may seem odd given that hypnotic performance
is typically seen as inducing automaticity, while in this case it reduces the au-
tomaticity associated with word reading. The key feature of hypnosis may
be its ability to alter automaticity rather than the prior notion that simply
increases it. What hypnosis may do is modulate the sense of agency. In hyp-
nosis one takes experiences that would ordinarily be tied to a sense of
agency, such as lifting one’s hand, and makes them seem automatic—the
hand seems to rise by itself because the subject has been given and is affili-
ating with the instruction that his hand will feel light and buoyant like a
balloon (Spiegel & Spiegel, 2004). The subject exerts control over percep-
tual processing that is unusual—enhancing agency over perception—while
the usual sense of control over motor function is reduced, because the
motor activity is driven by the perceptual alteration. Intentionality in
the brain is largely driven by the frontal lobes, and typically the portion of
the brain in front of the central gyrus is most associated with agency and
action—predominantly motor activity and speech. The posterior portion of
the cortex—post-central gyrus, temporal, and occipital lobes, are primarily
sensory and receptive—processing somatic sensation, hearing, and vision.
In hypnosis, there is greater potential to rearrange these relationships,
exerting agency, perhaps through altered activity of the frontal cortex and
anterior cingulate gyrus, on the perceptual portions of the brain, while
reducing perceived control over anterior regions, including motor cortex.
The anterior cingulate, which focuses attention, is a context generator, and
in hypnosis it may shift attention to manipulation of perceptions rather
than actions. Better understanding of the effects of hypnosis on functional
activities of these portions of the brain among high hypnotizables and dur-
ing hypnotic experience is an exciting opportunity for future research
designed to elucidate brain function in general and hypnosis in particular.
HYPNOTIC INVERSION OF AGENCY: RESPONDING

TO WORDS AND MANIPULATING IMAGES
Hypnosis seems to involve an inversion of our usual means of processing
words and images (Spiegel, 1998). In normal mental states we respond to
images and manipulate words, whereas in hypnosis we respond to words
and manipulate images. In a trance we accept verbal input relatively
uncritically (suggestibility), but are capable of transforming images and per-
ceptions to an unusual degree. Much of the power of the hypnotic state
involves the uncritical acceptance of the implausible, for example, being
able to reduce or eliminate pain despite the persistence of the same

unpleasant stimulus.
One can think of the brain as being divided into an anterior effector por-
tion involving thought and motor function—what one can do to the world—
and a posterior receptive portion—sensory information received from the
world. Autobiographical memory commences in the frontal lobes with a
search strategy and works its way posterior toward activation of images in the
occipital lobes. This is controlled, desired activity accompanied with willing—
invoking a sense of agency. By contrast, situations involving helplessness, such
as PTSD, seem to move from back to front, with unbidden intrusive images
that are experienced as uncontrolled and unwelcome (Horowitz, Field, &
Classen, 1993; Mueser & Butler, 1987). Brain imaging in PTSD (Rauch &
Shin, 1997) shows hyperactivation of hippocampus (memory), amygdala
(emotion), and occipital cortex (imagery), and hypoactivation of Broca’s area
(speech). Thus the deep and posterior portions of the brain are activated,
while the motor systems, especially speech, are inhibited, adding to the sense
of helplessness and involuntariness in PTSD. Such individuals feel they are
being retraumatized by their memories.
There would seem to be a paradox: agency would seem to be enhanced by
efferent activity rather than passive perception. Yet it is not uncommon that
people engaged in motor performance lack self-awareness, for example,
actors, athletes, and other people in “flow” states (Csikszentmihalyi, 1991).
Thus, agency does not uniformly accompany activity, even voluntary activ-
ity. One way to resolve this apparent paradox is to conceive of self-awareness
as a perception. Even if agency is best demonstrated by action, it may not be
perceived if there is some inhibition of perception, for example, if perceptual
processing is saturated with intrusive imagery, or redirected through hypnotic
instruction. Motor activity can occur in hypnosis without the perception of
agency. The well-established ability of hypnosis to alter perception may
account for its less-well understood ability to alter identity, memory, and
consciousness, which is really self-perception. Perception of motor activity is
complex—it involves expectation of a response to a motor act initiated. For
this reason, we cannot tickle ourselves. Thus altering perception has great
potential to alter the awareness of agency in regard to our own actions. It is
noteworthy that mindfulness and meditation practices have as their very aim
the reduction of the sense of agency.
Another way to think about the evidence is that systems are affected
that both respond to and manipulate perceptions. Typically, we respond to
perceptions and manipulate words. In hypnosis, by contrast, we seem to
respond to words and manipulate perceptions. The majority of Stroop stud-
ies reviewed herein indicate that words can be delexicalized by altering
perception, but this is done in response to verbal instructions that in some
ways do not make sense—the words are in English but they are perceived
as unreadable, and Stroop interference decreases (Raz, Fan, & Posner, 2005;
Raz et al., 2002, 2003, 2006). In fact, Raz found that reduced Stroop inter-
ference in hypnosis was associated with reduced activity in the anterior
cingulate gyrus, similar to Rainville’s observation involving the type of
analgesia that involves reduced distress rather than perception (Rainville
et al., 1999; Hofbauer et al., 2001).
CONCLUSION
We know that the states of hypnosis and meditation are associated with
important health-related aspects of somatic regulation, including pain percep-
tion, gastrointestinal function, immune function, endocrine function, and au-
tonomic function. We know far less about the brain regions intrinsic to
hypnotic attention and to mindfulness meditation. Previous attempts to
reveal the neural underpinnings of these states have been hampered by (a)
the reliance on block designs that have limited naturalistic validity, (b) small
sample sizes, and (c) a focus on specific brain regions rather than interactions
within and across brain networks. Both mindfulness and hypnosis are culti-
vated special states that must rest upon underlying neural capabilities. Clearly
hypnosis has powerful effects on neural structures involved in the processing
of perception. Ironically, the state often associated with loss of control is one
that provides means for enhancing control over physical and mental states
once thought to be beyond conscious neural control, such as pain, lexical per-
ception, and even gastro-intestinal function. Interactions among the prefron-
tal cortex, the anterior cingulate gyrus, and various sensory-processing regions
are clearly involved in hypnosis. Use of newer and more sophisticated func-
tional brain imaging techniques should help us to elucidate the brain net-
works involved in the hypnotic state and its effects on perception, identity,
memory, and consciousness.
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Chapter 4
Forensic Hypnosis: A Practical Approach

Melvin A. Gravitz
INTRODUCTION
For more than two centuries, the modality known today as hypnosis has been
applied effectively to the treatment of a wide array of psychological and med-
ical conditions that are described in other sections of this book and elsewhere
(Rhue, Lynn, & Kirsch, 1993). These clinical uses are based on the many
phenomena of hypnosis, especially hypermnesia, which refers to the increase
in memory that can be elicited through hypnosis. It is this aspect of the
modality that has been particularly helpful—and controversial—in the legal
field, as well as in psychotherapy, where retrieval of repressed memories is an
important treatment technique.
The term generally given to such application is forensic hypnosis,
although investigative hypnosis has sometimes been used (Reiser, 1980).
Both descriptors refer to essentially the same process.
For more than a century, scientific investigators and clinicians have noted
the potential for memory distortions associated with hypnosis. Moll, a noted
nineteenth-century authority, commented that “Retroactive hallucinations
are of great importance in law. They can be used to falsify testimony. People
can be made to believe that they have witnessed certain scenes, or even
crimes” (Moll 1889/1958, pp. 345–346). The pioneer hypnosis practitioner,
Bernheim, observed, “I have shown how a false memory can cause false testi-
mony given in good faith, and how examining magistrates can unwittingly
cause false testimony by suggestion” (Bernheim, 1891/1980, p. 92). Similar
findings have been observed by later legal commentators, as will be noted
the following discussion.
The first documented application of hypnosis in the investigation of a
crime in the United States was reported in 1945 when it was used to obtain
information from a witness concerning a theft (Gravitz, 1983). Another
case was published in 1848 and involved an interview with a witness in a

murder trial; the hypnotically obtained testimony was admitted by the
court without any issue (Anonymous, 1948). But it was not until July 25,
1976, that a sensational case in California made headlines throughout the
country and lent to forensic hypnosis a resurgence that has continued.
A busload of 26 school children and their adult driver was abducted off
a country road by three masked men near the farming community of
Chowchilla. The victims were then taken in several vans to a repositioned
enclosure that had been partially buried in a quarry. The driver and two of
the older boys eventually succeeded in digging their way out, and they
made their way to the nearby highway where they contacted the author-
ities. During the investigation that followed, the driver was hypnotized, as a
result of which he was able to identify a license plate on one of the vans.
With the exception of one transposed digit, this number was matched to
the vehicle of a man who, together with two accomplices, was subsequently
convicted and sentenced to life imprisonment (Kroger & Douce, 1979). In
my own experience, the correct retrieval of a license tag number is difficult
to obtain, probably because such a combination of letters and numbers is
usually non-meaningful information for all practical purposes; scientific
research has amply demonstrated that meaningful stimuli are learned faster,
retained better, and remembered in greater detail than that which is non-
meaningful (Council of Scientific Affairs, 1985).
VARIETIES OF FORENSIC HYPNOSIS

There are a number of modern uses of hypnosis in the legal arena (Gravitz,
1980). Foremost of these is that it can be a helpful method to develop leads in
police investigations by interviewing witnesses and victims of crime (Johnson,
1981; Shaw, 1991). The modality has also been employed in the enhance-
ment of the memory of parties in civil actions (Hughes, 1991). While such
use does not assume the truth, the whole truth, and nothing but the truth,
important details about a case frequently can be recalled. Hypnosis is not a
“lie detector,” and in fact it is possible for a subject to dissemble. Another
application is to lift the veil of amnesia and thereby to aid in the preparation
of the defense of an accused whose recollections may be faulty, perhaps
because of the repressive impact of trauma. Hypnosis can also be utilized as an
aid in the evaluation of a person’s state of mind, specific intent, or mental
condition (mens rea, in the legal sense), as for example, in the differentiation
between malingering and the claim of multiple personality disorder. In every
application, it should just be recognized that hypnosis is not necessarily com-
plete or infallible, but then no psychological method is.
The forensic hypnotist may be called upon to perform other services.
As an expert in the field, he or she may be asked to comment on or testify
about hypnosis interviews conducted by someone else. In this instance, a
Forensic Hypnosis: A Practical Approach 55
recording or typescript would be reviewed, or the expert could listen to

testimony in court and then be examined on that.
Qualified forensic hypnotists may be asked to train law enforcement
officers and other professionals in the criminal justice system in the proper
utilization of the method. The training would not instruct in how to do
hypnosis, since that would be inappropriate, but rather how to work effec-
tively with the psychologist who performs the actual interview.
Another area of function is to advise others about the effects and the
implications of hypnosis. As an example, a psychologist was asked by an
attorney for an expert opinion on the possibility of harm being done to
someone listening to a television advertisement by a political candidate
who sought, as a public service, to hypnotize the audience to vote. The
psychologist reviewed the relevant scientific findings that addressed the
question and prepared a written statement, which the law firm then incor-
porated in its defense of a television station that had been sued for declin-
ing to sell air time for such purposes. The spurned candidate had accused
the station of infringing on his right to speak on his own behalf, and the
defendant’s defense was based on the possibility that a listener could expe-
rience an undue or even harmful reaction for which the station could then
be held liable. The responsible federal government regulatory agency
upheld the defendant’s position. The candidate lost the election.
MEMORY AND HYPNOSIS

At this point, it will be useful to consider the mechanisms of memory
and how hypnosis impacts them. While our modern understanding of these
mechanisms is incomplete and not fully understood, there is a theoretical
paradigm that provides a working frame of reference. This model assumes
that an individual acquires and processes incoming information from vari-
ous conscious and unconscious sensory sources, as well as certain prior
experiences that have been stored in a bioelectrical memory bank. Based
on the needs of the individual, there is then a rapid preliminary sorting of
this information that results in short-term memory (STM). Some of these
STMs are personally meaningful and are therefore retained (“coded”) in
the form of a memory trace in long-term memory (LTM). But some of the
incoming information is not coded as personally significant and is there-
fore not retained—it is permanently forgotten and cannot ever be
retrieved, either by hypnosis or other means. These experiences that are
stored in LTM, however, may be retrieved by a variety of means including
hypnosis, provided there has been no organic deterioration. Thus, memory
is an active process of acquisition, retention, and retrieval. It is also a func-
tion of the needs and condition of the person at the time the original
event occurred—this memory is state dependent. The latter may include
mood, affect, stress, and biochemical factors, such as drugs and alcohol.
In the process of recollection, there is a restructuring of the memory

traces for LTM; therefore, memory is more or less naturally imperfect, and
perfect reproduction cannot be assured. There may also be gaps in mem-
ory, and these are subject to confabulation, which refers to the process
whereby one fills in the gaps based on one’s needs and past experience.
Memory is not a photograph-like or film/tape recorder-like exactness, even
though some who use hypnosis may erroneously claim that is so.
The enhancement of memory by hypnosis, then, may produce a
melange of fact and fancy in proportions that cannot be determined or
separated either by the subject or an observer. These recollections may
have the force of truth for the subject, as well. Accordingly, hypnotically
facilitated memories should be corroborated so independent verification
may be obtained. While many police officers have been impressed by hyp-
nosis because they have observed firsthand how useful it can be in certain
cases, jurors tend to be skeptical (Greene, Wilson, & Loftus, 1989; Labelle,
Lamarche, & Laurence, 1990).
Certain inaccuracies of memory that may occur in whole or in part, includ-
ing non-hypnotic recollections that are found to be invalid, however, may
lead in turn to the uncovering of new and valid information and evidence.
Since it has been observed that individuals are capable of simulating or
faking hypnosis and of making willful false statements while hypnotized,
care must be exercised in attesting that a subject is “in” hypnosis or not.
While some in the field question the very existence of hypnosis as an
altered state, others seem to consider virtually any human behavior as evi-
dence of the condition (Lynn & Rhue, 1991). A more reasoned approach
was offered by a study panel convened by the American Medical Associa-
tion (Council for Scientific Affairs, 1985), which concluded that hypnosis
“can be recognized by administering a series of different test suggestions of
varying degrees of known difficulty, typically involving alterations of per-
ception, motor control, or memory. The degree to which these suggestions
were followed and experienced as real and involuntary indicates the extent
to which hypnosis has taken place” (p. 1919). Accordingly, in forensic
cases it is important to consider any information that may be developed as
a lead, which must then be subject to further investigation. In this regard,
the forensic hypnotist is not an appropriate investigative officer.
Labelle, Lamarche, and Laurence (1990) and others have found that
hypnotized witnesses display greater confidence in the validity of their rec-
ollections than do control subjects, regardless of accuracy; and the effect of
confidence is greater in highly hypnotizable persons. Since not all research
has disclosed a difference between normal and hypnotized subjects in their
level of confidence, it appears that this effect is a potential and into a per
se accompaniment of hypnosis.
Complicating the acceptance of hypnotically obtained reports as valid
is the fact that confabulation appears to be a normal component of human
memory. The hypnotized subject may incorporate these confabulated

recollections as part of his or her memory and then tend to accept such
recollections with confidence and as the truth. Even when such memories
are in fact false, hypnosis may produce a greater degree of confidence or
belief that they are real (Dywan & Bowers, 1983).
LABORATORY EXPERIMENTS
There are a number of laboratory investigations that have been
designed to study the nature and effectiveness of hypnotically influenced
memory. These have been reviewed by Pettinati (1988) and Smith (1983).
In general, these research studies have been based on contrived, analogue
methodologies using uninvolved laboratory volunteer subjects and not
real-life events and people who were personally involved, as in a crime.
The laboratory experiments have tended to show limited and even nega-
tive results from the use of hypnosis.
REAL-LIFE STUDIES
There is a relative paucity of published reports of hypnotic efficacy based
on real-life cases, which may be explained in part by the fact that practi-
tioners as a group do not publish their clinical findings as frequently as do
their academic colleagues. Even so, a number of such reports are available.
In a review of experiences in the Los Angeles Police Department, Reiser
(1980) reported more than 90 percent verification of the additional infor-
mation obtained by hypnosis. In one sample of 67 interviews, new investi-
gative leads were obtained in 78 percent of these cases, and the solutions of
16 percent of these cases were directly attributable to the hypnosis. In
another series of 348 cases, 79 percent yielded additional information not
previously known.
In further comment on the hypnosis program in the Los Angeles Police
Department, Reiser and Nielson (1980) revealed that in some 374 interviews,
92 percent of subjects reached a light to deep hypnotic depth; 85 percent
improved recollections from a slight to significant degree; and 80 percent
produced additional information with hypnosis, two-thirds of which was con-
sidered important to the case. Where corroboration was possible, 91 percent
was found to be accurate and seven percent was determined to be inaccurate.
Hypnosis was considered a significant factor in the resolution of 65 percent of
these cases. Another finding was that no subject experienced ill effects from
the interview, while 40 percent felt emotional relief or benefit. Similar
psychological benefit is frequently reported by others.
Yuille and Kim (1987) reported results of a Canadian study of 41 cases.
Hypnotic interviews nearly tripled the amount of total information
obtained, and every subject displayed an increase. Accuracy was found in
82 percent of the recollections. They also noted that 80 percent “Of the
information provided in the initial (i.e., nonhypnotic) interviews was
repeated in the hypnotic interviews. This repeated information constituted
only 32.1 percent of the facts recalled under hypnosis, which means that
67.9 percent of the facts from the hypnosis interview were new. Of the in-
formation that was comparable between the two interviews, 94.1 percent
was consistent” (p. 424).
Kleinhauz, Horowitz, and Tobin (1977) described a series of Israeli
police cases in which hypnosis was instrumental in increasing recollections
in 24 of 40 instances. Sixteen of these 24 cases were further studied to
ascertain the accuracy of the memories, and of these, 14 showed a signifi-
cant increase.
In a symposium presentation at the 1992 annual meeting of the Society
for Clinical and Experimental Hypnosis, Gravitz, Ault, Gelles, and Hibler
(1992) reported on efficacy outcomes in investigative hypnosis interviews
conducted by several law enforcement agencies. Successful results were
found in 10–75 percent of the cases.
It is evident that hypnotic interviews in real-life cases can be a useful
technique in assisting the resolution of police cases that, typically, were at
a dead end in their investigation.
LEGAL ISSUES
There are several principal areas of legal concern that pertain to the
admissibility of hypnotically based testimony in a court of law (Worthington,
1979). These include the general acceptance by the scientific community
involved that such evidence is reliable (the Frye Rule), the allegation that
the use of hypnosis denies an accused the constitutional right of confronta-
tion and cross-examination, the possible denial of due process since the hyp-
notized subject is said to be vulnerable to suggestion, and the legal theory
that material evidence in the form of a memory “trace” may be either negli-
gently or deliberately damaged or destroyed. While the first of these concerns
is the one that is most often raised, the others could be introduced, and the
expert witness must be prepared to confront them.
A number of landmark legal decisions have shaped developments in the
field (Worthington, 1979). If a court rules that the testimony of a witness
who has been hypnotized was not admissible, then judicial and law
enforcement authorities understandably would be averse to utilizing the
method, as that could then prevent victims and witnesses from testifying
and could thereby negatively impact their case. While various courts over
the past hundred years have ruled for and against hypnosis, there has been
a mitigating trend especially over the past quarter century toward greater
acceptance, since the California Supreme Court in People v. Ebanks (1897)
ruled that all testimony by a hypnotist was excludable because “the law of
the United States does not recognize hypnotism” (p. 1053) in the matter
of a defendant who, while hypnotized, had denied his guilt. Following that
early decision, there have been a series of cases that either supported or
were critical of the use of hypnosis in assisting recollection. In Leyra v.
Denno (1954), confessions obtained by hypnosis were rejected on the
grounds that such statements were per se involuntarily given, a belief con-
sistent with the contemporary understanding of hypnosis. Likewise, the
claim that hypnosis renders all statements true has also been consistently
rejected (People vs. Blair, 1979). In People v. Quaglino (1977), a California
trial court permitted and the Court of Appeals upheld a conviction for
murder, in part because the defense had failed to object to the use of hyp-
nosis. In State v. McQueen (1978), a North Carolina court held hypnotic
testimony to be admissible and left it to the jury to determine the weight
to be assigned to the evidence. In that decision, the court ruled that hyp-
notically refreshed memory did not render the witness incompetent to
testify regarding present recollections. Hypnotic regression as an uncover-
ing technique was upheld in the civil case of Wyler v. Fairchild Hiller Corp.
(1974), although here too the court held that it was up to the jury to
determine the credibility and reliability of the testimony.
In the Maryland case of Harding v. State (1968), the court permitted
the testimony of a rape victim who had remembered important details fol-
lowing hypnosis. The appeals court ruled that the admissibility of expert
testimony is basically a matter for the hearing judge to determine, and it
emphasized the importance of the professional credentials and expertise of
the psychologist who had administered the hypnosis.
In State v. Jorgenson (1971), an Oregon court held that hypnosis of a
prosecution witness was admissible provided that an adequate cross exami-
nation was possible by the defense. In the civil suit of Kline v. Ford Motor
Company (1975), an accident victim who had sustained head trauma and
amnesia recalled in full the events leading up to the injury. Although the
trial court excluded this testimony on the grounds that hypnosis per se
made the subject incompetent to testify to the facts recalled after hypnosis,
the appellate court found this ruling to be erroneous.
In Cornell v. Superior Court (1959), the court upheld the position that
an accused’s rights to counsel included the right to be hypnotized in order
to aid in the preparation of his defense, and the sheriff was ordered to
provide appropriate facilities for the interview.
In a highly unusual case (State v. Nebb, 1962), a defendant testified
while in hypnosis in the courtroom. As a result of the disclosures made in
that testimony, the prosecution reduced the charges against him. In this
instance, the court ruled that hypnotically obtained evidence would be
excludable if it incriminated the witness.
In the landmark case of State v. Hurd (1981), the New Jersey Supreme
Court recognized the risks of confabulation and suggestibility, but it sought
to minimize or negate these problems by requiring procedural guidelines.

The facts in this important case were that the sole prosecution witness,
who had been the victim of a knife attack during the night in her home,
was “unable or unwilling” to identify her assailant. At the initiative of the
prosecutor, the victim was hypnotized to refresh her memory, and during
an emotional revivication she identified her attacker as the defendant, her
former husband. Although she later expressed some doubts about her
retrieved recollections, she reaffirmed her identification and the defendant
was indicted. On appeal, the New Jersey Supreme Court found that the
purpose of hypnosis was “not to obtain truth, as a polygraph . . . is sup-
posed to do,” but rather to overcome amnesia and restore the memory of a
witness (State v. Hurd, 1981, p. 92). Furthermore, “Hypnosis can be con-
sidered reliable if it is able to yield recollections as accurate as those of
an ordinary witness, which likewise are often historically inaccurate”
(p. 92). That was a critical point, since all human memory and non-
hypnotic witness testimony in general is inherently non-literal, reconstruc-
tive, and therefore subject to distortion (Loftus, 1979). In a thoughtful
and well-researched opinion, the Hurd court concluded that hypnosis was
admissible if it was conducted properly, in support of which it adopted six
procedural guidelines. These were that: the hypnosis should be conducted
by a psychologist or psychiatrist trained in hypnosis; the qualified professio-
nal should be independent of the prosecutor, defense, or investigator;
information provided to the professional should be in a written form; the
professional should obtain from the subject a pre-hypnosis account of the
facts as they are remembered; all contacts between the professional and
the subject should be properly recorded; and only the professional and the
subject should be present during any phase of the hypnotic session. The
court also noted the importance of independent verification of hypnoti-
cally induced recollections. Many other courts subsequently adopted
the Hurd rules, or similar steps, as these procedural requirements have
been called.
The 1982 California case of People v. Shirley (1982) was particularly im-
portant and instructive in its time. A woman claimed that she had been
raped, and the night before the trial she was hypnotized to refresh her
memory, after which she modified important aspects of her story. Heavily
basing its decision on a critical law review article (Diamond, 1980), which
claimed that hypnosis per se rendered an individual inherently unreliable
and vulnerable to influence, the state Supreme Court not only excluded
hypnotic testimony in that matter but also ruled that no witness or victim
who had been hypnotized could testify in the future.
Shirley has been faulted for a number of reasons. During the situation
in question, the alleged victim admitted that she had been intoxicated to
the point of blackout. She also had sat nude in the company of the defend-
ant in her apartment, where the alleged crime had occurred, after the
alleged rape and during the interval when he had left the premises to buy
more beer. Despite the opportunity provided by his absence, the plaintiff
did not then contact authorities but, instead, did so only after a friend had
encouraged her to file a complaint. Furthermore, the hypnotist was a law-
yer who possessed no professional qualifications in hypnosis but was him-
self a member of the state’s prosecutorial team and therefore not a
disinterested party to the legal proceedings.
Several months after its initial ruling on Shirley, the California
Supreme Court issued a modification of opinion in 1982 in which it held
that “When it is the defendant himself—not merely a defense witness—
who submits to pre-trial hypnosis, the experience will not render his testi-
mony inadmissible if he elects to take the stand” (People v. Shirley, 1982,
p. 3). This change was adopted in order to uphold the constitutional right
of an accused to defend oneself.
The modification of Shirley and its emphasis on the right of a defendant
to testify on his own behalf was soon followed by the Rock case. Vicki
Rock, an Arkansas resident, was accused of killing her husband during an
argument. She claimed that the shooting was an accident and that she had
not had deliberate intent. To aide her defense, she was twice hypnotized
by a psychologist, and as a result she was then able to recall that her finder
had not been on the trigger when the weapon discharged but that the gun
had fired after her husband grabbed her arm. As a consequence of that
recollection, an expert on guns examined the weapon in question and
determined that it had a defective trigger mechanism that was apt to
fire when struck even slightly, as during the altercation that had preceded
the shooting. Reflecting the influence of Shirley, a lower court in that
state had ruled that the gun expert could not testify as to his findings
because they arose as a result of hypnosis, which was allegedly inherently
unreliable, and Vicki Rock was convicted. That decision was upheld by
the Arkansas Supreme Court. The case was eventually brought to the U.S.
Supreme Court, and in a split decision, the highest tribunal ruled that the
defendant’s right under the constitution to testify in her own behalf had
been violated by the previous per se exclusion of hypnotically derived
testimony. This decision turned to the Fifth Amendment, which guaran-
tees the right of an accused to call witnesses in one’s behalf and the Fourth
Amendment, which pertains to the applicability of the Sixth Amendment
to the states as well as to the federal government (Rock v. Arkansas, 1987;
Udolf, 1990).
Although limited in certain respects, the Rock decision helped pave the
way for a more enlightened and careful use of forensic hypnosis, and the
frequency of applications increased together with a greater acceptance of
hypnotic-based testimony.
In the federal courts, guidance had been provided by a set of procedural
standards established by the Federal Bureau of Investigation and approved
by the United States Department of Justice. This has been termed the
Federal Model and has been used since 1968 with virtually no controversy
(Ault, 1980; Hibler, 1984a, 1984b). Investigators, known as coordinators, are
present during the interview and are responsible for making the arrangements
for the procedures. Also, hypnosis can be used with special cases and then
only after approval by higher administrative and legal authorities, the session
must be recorded, the induction and interview itself are conducted by a psy-
chologist or psychiatrist with special qualifications in hypnosis, and the
records are maintained in a chain of custody. A complete description of these
Federal Model requirements is available in Ault (1980).
The previous discussion is not intended to be an exhaustive compilation
of relevant case law. That is available in Hughes (1991) who has analyzed
civil cases, Shaw (1991), and Warner (1979) who has considered issues of
admissibility in criminal matters.
In summary, various courts have advanced three positions regarding
hypnotically facilitated memory (Udolf, 1983). Some jurisdictions have
treated hypnosis like any other method of memory refreshment and have
relied on the trier of fact (judge and/or jury) to determine its reliability
and the amount of weight that it should be given. Other courts have
admitted hypnotic testimony provided that certain specified preconditions
or procedural rules were followed to minimize the potential for error, and
yet other courts have regarded all testimony of a previously hypnotized
witness as inherently unreliable and therefore inadmissible.
The practice of forensic hypnosis is advanced by adherence to a set of
procedures that the courts will accept, for unless the testimony enabled by
hypnosis is admissible, then there could be a negative impact on a case.
Since the Hurd Rules and the Federal Model present certain practical prob-
lems, the following are recommended as meeting the essentials of both, as
well as incorporating changes that enhance application and admissibility in
the event the case progresses to that point.
Conducting the Interview

The following procedures are recommended for the conduct of a foren-
sic hypnosis interview. They are based on experience and are within the
context of the relevant legal rulings discussed previously.
While it is preferable to have the referral for forensic hypnosis submit-
ted in written form, this may not be practical since the initial contact with
the professional is usually accomplished by a telephone call. At that time,
the availability of the clinician is established and a brief outline of the
purpose of the interview is described. Appropriate records must be made
and maintained from the first contact.
The forensic hypnotist should be well qualified as a mental health profes-
sional and should therefore be either a clinical psychologist or psychiatrist
with special training and experience in hypnosis; most forensic hypnosis is

presently being performed by psychologists (Gravitz, Ault, Gelles, &
Hibler, 1992). Possession of a specialty diploma awarded by either the
American Board of Psychological Hypnosis or the American Board of
Medical Hypnosis is highly desirable, as are other indications of achieve-
ment recognized by professional peers. The interviewer should be qualified
to intervene and manage any undue emotional expression, such as cathar-
sis, on the part of the subject. Such credentials serve to underscore the
professional and legal qualifications of the clinician as an expert.
The location of the interview should preferably be on neutral ground,
such as the professional’s office. In certain circumstances, use of otherwise
appropriate facilities elsewhere may be used. Furniture, such as chairs,
should be comfortable, and lighting should not be glaring. Noise level
should be minimal.
The clinician should not be an agent of either the prosecution, defense,
or investigating authority, even though the fee for services may be paid by
any of these parties. Most of all, the professional should have no vested
interest in the outcome of the investigation.
Preferably only the subject and the hypnotist should be present in the
room when the hypnosis is undertaken. For practical reasons, however,
other personnel might include an investigative officer who has background
information about the event in question, a video camera technician, or a
police artist. In certain cases, the subject’s legal counsel may attend to pro-
tect a client’s rights (see the following case). Since distraction is to be as
limited as possible, the video camera is optimally used through a one-way
screen; this would remove the requirement for the presence of a camera
technician. Other involved parties could observe the process through the
one-way screen or on a video monitor in another room.
The entire interview with the subject should be recorded, preferably by
video, and the recording may be retained in the custody of the clinician in
order to safeguard the chain of evidence. The interviewer may make notes
during the session, and these should be made part of the case record. It is
best not to undertake the interview if the subject is hungry, tired, or has to
use the lavatory facilities. Inquiry prior to the hypnosis should clarify this
possibility.
The psychologist or psychiatrist should assure that the subject is aware
of the purpose of the interview and is otherwise in good mental condition.
Persons who are not of sound mind, in the legal sense, or are otherwise
unduly stressed, should not be hypnotically interviewed, although situa-
tional anxiety is not infrequently observed at the onset. Such discomfort
generally fades as the interview progresses. Unwilling subjects should also
not be hypnotized, until and unless their reluctance is resolved.
The subject should be asked to sign a release for the procedure based on
informed consent. The release should also note that a report of the results of
the interview will be communicated to the appropriate law enforcement

agency or other referral source, as indicated. In the case of a minor, the
release may be executed by a parent or legal guardian. Obtaining a release is
not intended to convey that hypnosis is a dangerous procedure, but is rather
meant to ensure that the subject is a willing and informed participant.
The subject should be asked for his or her understanding of a possible
experience with hypnosis. Misconceptions should be clarified, and if there
has been prior experience, the induction techniques used previously may
be utilized in the forensic interview. Any questions posed by the subject
should be answered as fully and candidly as possible.
The subject should be asked for a non-hypnotic statement of the event
in question prior to induction of hypnosis. Later, when the pre-hypnotic
account is compared with that obtained in hypnosis, the extent of the
information obtained by hypnosis can be ascertained.
The induction of hypnosis then flows. When this is completed, the sub-
ject is asked for his or her account of the event being investigated. There
are a variety of techniques that may be used, which have previously been
discussed, and are illustrated in the several cases that are presented in a
later discussion.
Hypnosis should not be undertaken as a routine procedure but should
be reserved for use in cases where traditional investigative procedures have
already been attempted.
Forensic Hypnosis Techniques

There are a number of methods that are useful in hypnotic memory retrieval.
Primary among these is the development at the onset of rapport with the sub-
ject, since a positive relationship is a prerequisite for success. Generally, a help-
ing and supportive attitude on the part of the forensic hypnotist is indicated;
however, in working with certain personality types, a different approach may be
more effective. For example, a passive-dependent man was unable to recall
details of an event until he was strongly directed to do so by the hypnotist.
I also employ what may be termed “contextual positioning,” which
refers to aiding the subject to perceive externally the peripheral circum-
stances of time, place, person, and other conditions as they existed at the
time the situation to be retrieved had originally occurred. The recall of
context variables surrounding an event facilitates memory. These include
the time of day, temperature, physical characteristics of the surroundings,
how the subject felt, preceding events, and so on. In addition, Bower
(1981) has found that reinstatement of the original mood that accompa-
nied an event aids the subsequent recall of that event. These set the stage
for the original experience and assist greater recollection of information.
In beginning a forensic hypnosis interview, a nondirective, free-recall
approach is generally best, with inquiry for more specific information
introduced as the interview progresses. Thus, one starts with a broad outline
and then gradually spirals down to greater detail.
Not only is the encouragement of imagery helpful in contextual posi-
tioning, but it is useful in helping the subject to retrieve details of the par-
ticular circumstances that are being sought. Such instructions to the
hypnotized subject as, “look around and describe what you see and hear,”
can be facilitative.
Time regression, sometimes called age regression, is another important tech-
nique. This refers to the process whereby the subject is asked to re-experience
an event by mentally returning to it. This does not necessarily guarantee accu-
racy, as with a reconstructed memory, confabulation and fantasy could result.
Typically the regression proceeds better the less time has elapsed between the
original situation and the hypnosis interview, but I have had successful valid
recollections retrieved as long as ten years post-incident. Since forensic hypno-
sis tends to be a method of last resort, after more traditional techniques have
been tried, it is not unusual for an interview to be conducted several months
after an original event occurred.
Revivification is related to regression but is fundamentally different.
This refers to the re-experiencing or re-living of the effect attached to a
traumatic incident. Memory regression may occur without revivification
and vice versa; it is best if both can be facilitated simultaneously. Because
the retrieval of repressed feelings can be disruptive to an individual’s emo-
tional equilibrium, the forensic hypnotist should be prepared to encounter
and to help the subject cope with any undue psychological expressions that
may arise when and if traumatic feelings are released. (See the case of the
state trooper discussed later.) For this reason and others, forensic hypno-
tists should be qualified mental health professionals with experience in the
assessment and treatment of emotional problems. Police officers, attorneys,
and other lay persons do not possess these qualifications.
The affect bridge is a technique that can help the subject trace current
feelings back to their origins (Watkins, 1971). It is not unusual to
observe that an individual has certain emotions that are not consciously
attached in the present to their past origins, and the affect bridge
method aids in establishing such connections. When affect is attached to
memory, more vivid, veridical, and greater amounts of information can
be elicited.
Releasing the subject prior to the request for information reduces the
level of anxiety and thereby lowers the defenses against the retrieval of
painful detail about an event that was traumatic at the time it occurred.
Verbal encouragement and support are related useful methods: “You’re safe
now, and it’s all right to tell me what happened.”
Ideomotor signals and automatic writing can also be employed to
circumvent the defenses against traumatic pain that an individual tends to
erect (Gravitz, 1985a).
Free association under hypnosis can also be an effective method to lead

the subject from one detail to another, from relatively superficial and less
important to deeper and more important information.
There are other techniques that can be applied. Several of these are
metaphorically modeled after the functions of a camera lens. A subject
can be asked to zoom onto a portion of a scene, such as a face or vehicle,
or to widen the angle of the image. Action can be slowed down or rolled
back. Volume of sound, such as spoken words, can be turned up and
made more audible, while the lighting of a scene can be made brighter.
In turn, distracting peripheral noise can be reduced. Using metaphors
such as “stopping the tape” and “rolling back the action” is not meant to
imply that this is the manner in which memory is organized. All memory
by its very nature is reconstructed and thereby inexact and in a sense
distorted. Yet, certain subjects will feel more secure and consequently
do better in their recall if there is distance between themselves and the
recollection of a traumatic event. For such persons, asking them to visu-
alize the incident unfolding on a television or cinema screen can help
them do better.
The use of such metaphors as these is not meant to infer that memories
themselves are stored as in a tape recorder or videotape. This theory of
memory as a static phenomenon was formulated by Penfield (1975) and is
accepted today by few workers in the field. It proposes that past experien-
ces are somehow stored in the mind in their entirety. Hypnosis, according
to this theory, enables these memories to be reproduced as an exact copy
of the original experience. The “tape recorder” model of a machine-like
memory not only lacks scientific validity, but it may mislead triers of fact
and other responsible forensic agencies.
In contrast to this static concept of memory as an exact mechanical
device, it is best to conceptualize it as selective, reconstructive, incomplete,
and subject to distortion. Scientific research has demonstrated that in
hypnosis there is an increase in the quantity of both valid and fantasized
recollections (Pettinati, 1988). One’s confidence in the accuracy of recol-
lections does not necessarily reflect literal accuracy, a point that was made
by Bartlett (1932) more than fifty years ago. Thus, a hypnotized person
cannot always distinguish between real and confabulated memories.
It has been found that recollection can also be enhanced without hyp-
nosis: encouragement, personal needs, free association, conscious effort,
and prolonged concentration can all aid in the retrieval of forgotten expe-
riences (Pettinati, 1988).
THERAPEUTIC SERENDIPITY
While forensic hypnosis is not intended to be a therapeutic method, the
professional using such techniques must be capable of intervening and
managing the unexpected and undue emotional reactions that may result,
since hypnosis can be a powerful tool for accessing the repressed recollec-
tions and feelings of a victim or witness (Putnam, 1992). Requiring that
the hypnotist be a qualified mental health professional lessens the risk
to the subject that emotions that had been psychologically controlled prior
to the interview could be brought to surface expression with possibly
deleterious effects on well-being. An example follows:
A 38-year-old state trooper was among a group of law enforcement
officers who were taking a seminar designed to acquaint them with the
applications of hypnosis in their work within the context of the model
used by federal agencies (Gravitz, Ault, Gelles, & Hibler, 1992). The par-
ticipants were not learning how to administer hypnosis but instead how to
work with the psychological professional who did. In seeking to demon-
strate the induction process, the course leader who was a clinical psycholo-
gist asked for a volunteer from the audience, and the trooper agreed to
serve in that role. He proved to be a good subject, and induction pro-
ceeded uneventfully. The psychologist then sought only to elicit the mem-
ory of a prior experience and asked the hypnotized trooper to “go back to
an earlier time that was important to you.” After a brief pause, the subject
began to display overt signs of distress, including tears, sobbing, clenching
of both fists, and overall bodily tension. At that time, he was on routine
patrol in his vehicle on a state highway when he received a radio message
directing him to assist with the management of an automobile accident.
Upon arriving at the scene, he observed a passenger car on fire and was
told by onlookers that the driver of the vehicle was unconscious and
unable to exit. When the officer rushed to the car to remove the driver,
he found that the doors were either jammed or locked and could not be
opened. Consequently, he had to watch helplessly and in horror as the
vehicle became engulfed in flames and the passenger burned to death.
Evidently, the subject repressed the memory and effect of that situation,
for over the following years he had no conscious recollection of it. Only
when he was hypnotized in the relative security of a classroom and in the
presence of a psychologist was he able to surface the extreme frustration,
fear, and guilt feelings that he had had at the time of the original experi-
ence. The demonstration was of course terminated, and the subject was
provided with the private opportunity to discuss—finally—his reactions
at the scene of the fatal accident. He was also referred to the Employee
Assistance Program of his unit for further counseling.
RESISTANCE
Despite expressions of positive motivation, desire to cooperate, and the
fact that nearly all persons may be regarded as hypnotizable (Hilgard,
1965), subjects may display resistance in the forensic hypnosis situation.
There are a number of determinants for such behavior (Gravitz, 1985b),

including the following:
1. Distraction in the environment. This includes such factors as noise

inside and external to the location where the hypnotic interview is
conducted, temperature that may be uncomfortable, inappropriate light-
ing, and even furnishings and decor. In general, the fewer individuals in
the office where hypnosis is being done, the less will be the distraction
and the better will the interview progress. All evident sources of dis-
traction should be avoided or removed.
2. Inappropriate methods of induction. Certain imagery may stimulate
negative associations in the subject; for example, suggesting a usually
relaxing image of a warm and sunny beach may prove counterproduc-
tive to an individual who is phobic of swimming. In such instances, the
utilization of more appropriate imagery content or other methods of
induction is indicated.
3. Negative transference. If a subject has negative feelings, such as fear of
or hostility toward authority figures, these may be transferred to the hyp-
notist. Preliminary inquiry can be useful in uncovering such dynamics.
4. Shame and embarrassment. A victim of crime may be reluctant to dis-
cuss openly certain experiences because of their personal implications.
For example, a female rape victim may resist describing her experience
with a male interviewer. In that event, using a hypnotist of the same
gender could facilitate the process.
5. Obsessive personality traits. There are some persons who are so con-
cerned with making a perfect and non-mistaken identification that they
block in recall. It would be helpful in such cases to ask the subject to
begin their account in a general way and only subsequently to become
more specific about particulars.
6. Misconceptions about hypnosis. Resistance may arise when there is the
belief that hypnosis is a form of “mind control” or mental coercion.
There may also be a concern about inadvertently slipping back into a
“past life” or that there will be an inability to be alert when the inter-
view is concluded. Reluctance to proceed because of such factors can
be managed by preliminary noting that it is the subject who basically
controls the hypnotic situation (Gravitz, 1971).
7. Fear. This can arise from several sources. Some witnesses or victims
may have been threatened with physical harm to themselves or others
if they identify a perpetrator. Other subjects may seek to maintain con-
trol over the expression of underlying emotional expression, and they
may be reluctant to display powerful affect.
8. Religious belief. A few denominations teach their adherents that hypnosis
is a satanic scheme and that it deprives one of self-determination. While
such misconceptions have no scientific basis, if clarifying explanations are
unsuccessful, then other means of eliciting information may have to be

considered, since the forensic hypnotist should be respectful of a subject’s
personal beliefs.
9. Culpability. In general, suspects in a criminal matter are not considered
appropriate for forensic hypnosis because of Fifth Amendment concerns.
However, if they willingly and knowingly agree to such a stipulated
interview, it may be undertaken because the retrieval of information
could serve to clear a suspect of personal involvement (Mutter, 1990).
In summary, there are a variety of both conscious and unconscious
reasons why a subject may be resistant. In such situations, resistance should
be recognized as a defense mechanism, and resolution of such difficulty
should be attempted.
ILLUSTRATIVE CASES
There are many cases that can be cited to illustrate the effectiveness of
forensic hypnosis. Most of these typically concern the description of an
alleged perpetrator, vehicle, crime scene, or other circumstances surround-
ing an event under investigation by law enforcement authorities (Gravitz,
1985a). Other cases, however, are not so typical.
Case A
An attorney asked a psychologist if hypnosis could help his client, a
28-year-old woman, to refresh her memory in order to obtain additional
information about an incident that had resulted in her arrest and convic-
tion of murder in the first degree. The attorney was preparing an appeal
but could find no circumstances that had not been brought out in the orig-
inal trial. The original police report showed that several months previously
the client had been involved in an altercation with another younger
woman whom she confessed to having stabbed to death with a knife.
While this appeared to be another instance of impulsive-driven street
crime, there was no motive, no witness had come forward, and the client
was unable to recall more than that she had become lost in a strange part
of the city while on her way to visit a relative, and “before I knew it” she
and the victim, who was unknown to her, had begun to fight. The client
did not deny having killed the victim, but she could not identify the knife
used as belonging to her. The conviction was based mainly on circumstan-
tial evidence and the client’s ready confession to the authorities.
The subject was interviewed in the psychologist’s office, and the pro-
ceedings were videotaped. In hypnosis using a time-regression approach,
the subject was asked to return to where she had been prior to finding her-
self in the strange neighborhood. Using the present tense, she then related
that she was taking a bus to visit a relative who lived across town. She
mistakenly got off the bus at what she believed was her transfer point, but
instead found herself lost in an unfamiliar locale. Seeking to phone her rel-
ative for directions, she found that she had no change in her purse, so she
went to the door of a nearby apartment building intending to ask if she
could use someone’s phone. On entering the building’s lobby, she encoun-
tered several teenage girls who rushed her and attempted to snatch her
purse. In panic, the client fled with the teenagers in pursuit. The subject
in hypnosis voiced her fear as she ran that she would be robbed or worse.
She managed to outrun all but one of the girls, and as the latter caught up
with her, the two of them collided and both fell to the pavement. As the
client struggled to disengage herself, her pursuer drew a knife from her
coat. At that point in the interview, the client screamed out that she was
going to be killed, and she made motions indicating that she was pushing
her assailant’s hand away. It was then that the subject apparently turned
the knife against her pursuer. A passing police cruiser arrested her as she
fled still clutching the knife with which the victim had been stabbed.
After the psychologist’s report, including the videotape, was made avail-
able to the trial judge, he reduced the charge to involuntary manslaughter
and the sentence to time served. The client was then released.
Case B
In a civil action, two parties to a collision of automobiles early one
morning were suing each other for damages, each alleging the responsibil-
ity of the other. There were no immediate witnesses to the accident. The
two damaged vehicles were both situated on the painted median strip, and
both drivers were found unconscious. One of the parties asked to be hyp-
notized in order to retrieve her memory for the incident. She proved to be
a good subject, responding to classical induction procedures. Time regres-
sion was the investigative method employed, and the subject was able to
report considerable detail concerning her automobile’s progress prior to
and up to the time of the collision. No new information was initially
obtained, however, and although she faulted the other driver, this could
be construed as self-serving. The subject was then asked to repeat her
account of the events, and she was told to look about even more, bearing
in mind that prodding a subject may lead to confabulation. At that point,
the client remarked that a second car was being driven behind the other
across the street, a report that she had not previously made. She was asked
to describe the second vehicle, which she did, and she also noted that it
had a windshield sticker of a variety used for parking purposes at a local
hospital, which was nearby. She also revealed that the driver was “a white
blur.” With the aid of the description of the second car and its driver,
an investigator was able to identify a nurse at that local hospital who
admitted that she had witnessed the accident while on her way home that
morning after working the night shift and still wearing her white uniform.
She was tired and hungry and did not want to become involved, so she
had not stopped at the time. When interviewed further by the investigator,
the nurse reported that she had observed that the car in front of her had
swerved into the path of the client. The trial judge, a federal jurist since
the hearing took place in the District of Columbia, heard the new testi-
mony and then ruled in favor of the subject, awarding her a considerable
sum for damages.
Case C
In another case, the attorneys for a public figure requested hypnosis to
aid in the retrieval of information concerning the disposition of a large
sum of money. The Internal Revenue Service had alleged that their client
had received the funds seven years previously, and the government was
seeking back income tax, interest, and penalties on that amount. The gov-
ernment was agreeable to dropping its charges if the client could prove, as
he claimed but could not recall, that he had disbursed the money that he
acknowledged receiving to various other individuals for certain services
performed by them. When the client arrived at the psychologist’s office,
he was accompanied by his two attorneys, who asked that they be present
during the interview to ensure that their client made no self-incriminating
statements and otherwise to protect his rights under law. This was a legiti-
mate request, and they were permitted to remain in the room but out of
sight of both the client and the clinician. Each of the two attorneys oper-
ated a hand-held audio recorder.
The subject was an excellent hypnotic subject, who responded quickly
to an optical-fixation mode of induction. Soon after his eyes closed, how-
ever, he spontaneously opened them, but when the interviewer asked if he
was hypnotized, the client replied in the affirmative, so the interview con-
tinued. Direct questioning of the client proved to be nonproductive, so
another strategy was undertaken.
The subject was hypnotically regressed back to the office that he had
occupied at the time seven years previously when he had admittedly
received the funds. The interviewer then identified himself as and played
the role of the subject’s secretary. In that role, the client was told that the
“secretary” was preparing a budget based upon the amounts of money dis-
bursed to whom and for what purposes. The client immediately rose to his
feet from the chair where he had been sitting and began to pace the floor
with his eyes open. He then “dictated” at length and in good detail the
“budgetary” items to the “secretary” and was successful in accounting
for the bulk of the information required by the Internal Revenue Service.
After he had completed the listing, he was asked by the interviewer to
return to the seat and close his eyes, which he did. The subject was then
gradually and uneventfully alerted by a numerical count-up method, and
he was then asked how he felt. His first words were an apology for not hav-
ing been able to be hypnotized, and it quickly became apparent that the
subject was posthypnotically amnestic for what had transpired, including
the dictation of the “budget.” While the entire interview covered two
hours, the subject after alerting gave the estimated time interval as
10 minutes. The lawyers who were present laughed and one of them par-
tially played back his tape recording of the interview. Expressing astonish-
ment, the subject then acknowledged that he must have indeed been
hypnotized. There was no further contact with the subject, but several
months later a newspaper story reported that the Internal Revenue Service
had accepted his accounting and had closed its claim against him.
In other cases, subjects have been assisted in recalling conversations by
asking them to “turn up the volume,” words painted on the backs of trucks
have been retrieved to identify vehicles, and events occurring in dim light
have been “brightened for greater clarity.”
While most forensic hypnosis interviews have been administered to
adults, it is also feasible to apply the method to appropriate children. As
Hilgard (1965) has shown, children tend to be good hypnosis subjects, per-
haps even better than older persons. In my experience, a child as young as
four years old was able to “draw” the picture of a man whom she had seen
in the company of her mother shortly before the latter was found murdered.
An investigative officer recognized certain facial features on the drawing as
those of someone he knew, who was subsequently identified as the mother’s
assailant. In another case, a five-year-old boy was able to describe in suffi-
cient terms the man who had abducted him from his home in the middle of
the night and whose identity was previously undetermined.
At times, a retrieved forgotten memory may be valid but irrelevant. As an
example, a 32-year-old woman who was a Latin American immigrant briefly
overheard, and then observed, the automobile of a male who was suspected
by the police of a series of assaults on children in the neighborhood. During
hypnosis, she was able to recall what she described as the vehicle tag of the
suspect’s car. Upon investigation, the tag number was found to be that of her
own husband’s car, which had been sold two years previously and which she
had forgotten. As is common in many forensic hypnosis cases, however, a
seemingly minor peripheral finding during this interview proved to fit a sus-
pect who was later apprehended for the offenses—she was able to identify
the Spanish-accented English of the man whom she had overheard as that of
one who came from a certain country in South America.
ETHICAL CONSIDERATIONS
The ethical issues associated with the practice of forensic hypnosis have
been discussed by Gravitz, Mallet, Munyon, and Gerton (1982) and Meyer
(1992). These are based upon the overall guidelines established by the
practitioner’s own profession and the major hypnosis societies that have
formulated their own standards (International Society of Hypnosis, 1979;
Society for Clinical and Experimental Hypnosis, 1979). Where the con-
tents of a case, including notes, recordings, reports, and expert testimony,
may later become a matter before the courts, the clinician should inform
the client of this possibility and its implications. As noted elsewhere in
this chapter, a written release based upon informed consent should be
obtained from the subject early in the process. Legal advice should not be
provided by the interviewer, but instead such questions should be referred
to the client’s counsel.
The practitioner must be knowledgeable of the relevant research, especially
that which pertains to the potential distortions of memory. In that regard,
there should be awareness that the mere wording of a question must also rec-
ognize the possibility of subtle and unintentional communication to the sub-
ject by verbal or other cues. In addition, there must be sensitivity to the fact
that the subject matter involved in a forensic hypnosis interview frequently
involves traumatic past experiences, certain of which may be unresolved.
Consequently, the “need to know” must be carefully balanced against the
needs of the individual with respect to the events under investigation.
Because the practice of hypnosis is virtually unregulated by statute, the
field is open to infiltration by persons with less than thorough qualifica-
tions, the latter including education, training, experience, competence, and
integrity. This makes it all the more necessary for the ethical professional
in forensic hypnosis, and indeed all professionals who use hypnosis, to per-
form their services in the most circumspect manner with full regard for the
rights and well-being of the individual with whom they are working,
SUMMARY
This chapter has presented an overview of the applications of forensic
hypnosis from a practice-oriented viewpoint. Its early origins in the nine-
teenth century and its resurgence in the 1970s are discussed, together with
landmark legal decisions that have shaped the development of the field.
Based on the psychology of memory and its operations as they are under-
stood today, the phenomenon of hypermnesia is reviewed together with
such possible consequences as confabulation, selective reconstruction, and
enhanced level of confidence. Areas of application and specific techniques
are described. Experimental analogue research from the laboratory on hyp-
notically facilitated recall is cited, as are the results reported by a number
of law enforcement agencies that have been derived from real-life cases
with personally involved witnesses and victims. The differences in outcome
between these two methods of research are noted. A set of procedures for
the conduct of forensic hypnosis interviews is described, and these have
been designed to mesh with and be acceptable to the requirements
established in important legal decisions, notably the Shirley, Hurd, and

Rock cases in recent years. A number of cases illustrating the techniques
and experiences are presented, along with comments on resistance and the
ethical implications of the method.
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Chapter 5
Hypnosis in Popular Media

Deirdre Barrett
Hypnosis has a dark and lascivious history in literature, film, and even
song. For the past two centuries, fictional mesmerists have swung watches,
twirled spiral discs, and transfixed the unsuspecting with their piercing
gaze. Maidens surrendered their virtue and good men staggered away,
glassy-eyed, to steal and kill—while those of us familiar with real hypnosis
convulsed with laughter or indignation. This chapter chronicles the nega-
tive stereotypes of hypnosis in novels, film, television, the visual arts and
even music, and examines the handful of positive exceptions. I will com-
pare this to the more positive portrayal of psychotherapy and dreams in
the arts and explore why there’s such a contrast in portrayals of these simi-
lar realms.
George du Maurier’s Trilby (1894) has been the most influential proto-
type for both literary and film hypnosis. The novel topped British and
American bestseller lists at the advent of cinematography. It describes
mesmerist Svengali seducing naive young Trilby while endowing her with
an unearthly singing voice. At least eight versions have been filmed—most
titled Svengali rather than Trilby, signifying how powerfully the hypnotist
captured the popular imagination. These ranged from a 1911 silent melo-
drama to a 1983 made-for-TV movie with Jodie Foster as Trilby (Svengali
1911; Kolm & Fleck, 1912, 1914; Righelli & Grund, 1927; Mayo, 1931;
Langley, 1955; Svengali, 1981; Harvey, 1983).
The most successful was the 1931 version with John Barrymore in the
title role. Numerous films featured similar plots of malevolent males using
hypnosis to seduce and control hapless heroines including The Hypnotic
Eye (Blair, 1947) and Hipnosis (Martin, 1963). Later films starring Barry-
more, such as Rasputin and the Empress (Boleslavsky, 1932) and Dr. Jekyll
and Mr. Hyde (Robertson, 1920), showed gratuitous hypnosis scenes that
were not in the original material because this had become such a quintes-
sential aspect of his film persona.
The second most popular application of hypnosis in film has been to com-
pel innocents—male or female—to commit murder. In the classic silent film,
The Cabinet of Dr. Caligari (Weine, 1919), the title character has a carnival
act in which he controls a “somnambulist” for the audience’s amusement. By
night, he sends the somnambulist to murder sleeping men and women. At
the end of the film, the whole scenario is revealed to be a delusion of a man
who expects to be the next victim—Dr. Caligari is actually his psychiatrist.
Cabinet was so successful that Fear in the Night (Shane, 1947), Nightmare
(Shane, 1956), Hipnosis (Martin, 1963), and Mask of Dijon (Landers, 1946;
Mask, 1993) all featured variants of this plot, usually with the hypnotic mur-
ders treated as real. Whirlpool (Preminger, 1949) introduced self-hypnosis
when villain Jose Ferrer applied the technique immediately after major sur-
gery, endowing himself with supernatural powers of recovery so he could
leave his bed and commit murder without falling under suspicion.
Sometimes, instead of requiring murder, the cinematic hypnotist com-
pels his subject to harm himself or herself. In Orson Welles’s Black Magic
(1949), Count Cagliostro learns hypnosis from Mesmer, and then uses it to
force his enemies to suicide during the rule of Louis the XIV and Marie
Antoinette. In The Hypnotic Eye (Blair, 1947), a stage hypnotist selects
attractive young women from the audience, brings them on stage for
innocuous antics, and then gives them secret suggestions to return home
and mutilate themselves. He, in turn, is under the hypnotic control of a
once beautiful performer who has suffered disfiguring burns. . . . Eye makes
overt what is an implied premise of much of the hypnosis-for-murder
genre: the hypnotist is a bitter person who would be ineffectual without
this extraordinary skill. Eye was the most popular hypnotic film of all time,
with the exception of Cabinet. Eye was subtitled or dubbed into twenty
languages, and the depiction of hypnosis as light entertainment masking
dark destruction was disseminated around the world.
Hypnosis is also a subplot in much horror and science fiction. It is utilized
by villain Fu Manchu in several films bearing his name in their titles. In the
original Bram Stoker novel Dracula (1897), the only episode of hypnosis is
by heroic Doctor von Helsing when he hypnotizes bite-victim Lucy to get
her to reveal Dracula’s daytime refuge. However, in all but one of the film
versions, this scene is omitted, and, instead, Dracula is the one practicing
hypnosis (Browning, 1931; Melford 1931; Hillyer, 1936; Siodmak, 1943). In
multiple Flash Gordon films (Stephani, 1936; Beebe & Taylor, 1938, 1940),
Flash’s love, Dale, is hypnotized by the villain. With typical fifties restraint,
marriage is always the ultimate nefarious goal. Flash inevitably shows up just
in time, carrying Dale from the wedding stiff as a board in one film, and limp
in another. Two unabashedly sensational spoofs of the genre, Invasion of the
Space Preachers (Boyd, 1990) and I was a Zombie for the FBI (Penczner, 1982)
featured, respectively, aliens and spies utilizing hypnosis to achieve criminal
manipulation of crowds.
Hypnosis in Popular Media 79
The villainous use of hypnosis to commit crimes also shows up in main-

stream comedies such as Abbott and Costello films (Barton, 1948, 1949,
1951), and most recently in Woody Allen’s Curse of the Jade Scorpion
(2001) in which Allen volunteers for a turbaned stage hypnotist and ends
up compelled to commit a series of jewelry thefts.
INDUCTIONS IN FILM
When murder and other asexual malfeasance was the goal, the induc-
tion was usually accomplished by “magnetic passes” of the hypnotist’s
hands close to the subject’s body—much like those Mesmer employed—
sometimes elaborated to resemble a puppeteer’s control of a marionette.
Sleepwalking was the model for the subject—closed or glassy eyes, automa-
ton movements. Caligari, The Bells (Apfel, 1913; The Bells, 1914; Warde,
1918; Young, 1918) and The Mask of Dijon (Landers, 1946) are all exam-
ples of this style of hypnosis.
In the “Svengali” genre where the hypnotist is invariably male and the
subject a nubile female, the induction features an intense stare by the hypno-
tist that is indistinguishable from what Eibl-Eibesfeldt (1989) termed the
“copulatory gaze.” Ethologists have observed that when any two animals,
including humans, stare at each other unblinkingly for more than three sec-
onds, they are invariably—to quote one behavioral coding system—about to
either “fight or f—k.” On the silver screen, a third alternative is that one is
about to fall into a deep hypnotic trance controlled by the other. Films occa-
sionally employ the primal applications of the stare: in 1940s Westerns, cow-
boys froze and locked eyes just before the shootout and Rudolph Valentino’s
reputation as the “Great Lover” was built partly on his trademark smoldering
gaze. More often, however, film reserved unbridled murderous or sexual eye
contact—or an ambiguous combination of the two—for the mesmerist.
Eibl-Eibesfeldt (1989) noted that during the copulatory gaze, the pupils
dilate. To mimic this for the mesmerist, filmmakers lined their eyes with
black pencil. The metaphoric sense of energy radiating from the eyes was
concretized with lighting effects. In Svengali, (Mayo, 1931) there is a glow
around the eyes of the mesmerist. In animated films, rays emanate from
the eyes of the hypnotist while those of the subject spiral or go white. The
films also borrow from folk traditions about the “evil eye.” The Hypnotic
Eye’s performer holds a glass one on, and the buffoonish villain in Abbott
and Costello Meet the Killer (Barton, 1949) hypnotizes the heroine with a
pair of rings mounted with glass eyes. The hypnotic stare has become so
much of a cliche that the 1979 comedy Love at First Bite featured dueling
hypnotists commanding, “Look into my eyes.” “No, you look into my eyes.”
“No.”
There is usually a verbal induction—shorter than any in real practice
but containing components of standard authoritarian ones. Hypnosis is
depicted as irresistible and absolute in its power over the subject. The only
exceptions come late in the films when a hapless protagonist may learn
how to resist and fake hypnosis—or to turn it on the villain. Road to Rio
(McLeod, 1947) features one of the odder versions of this resolution. Hero-
ine Dorothy Lamour has been under the life-long hypnotic control of her
evil aunt—who wields a pendulum, also a popular hypnosis prop. When
Lamour falls in love with Bing Crosby, the aunt hypnotizes her into hating
him. His buddy Bob Hope observes this, steals the aunt’s pendulum, and
uses the same hypnotic induction to get her to leave the aunt and marry
him. Significantly, this is the only film in which Hope rather than Crosby
got the girl in their Road to series. Several films of the 1930s–1960s have a
young woman ending up with a man she’s been hypnotized to desire. This
is depicted as an appropriate happy ending as long as it’s a likeable protag-
onist who performed the hypnosis himself, as in Eternally Yours (Garnett,
1939), How to be Very, Very Popular (Johnson, 1955), and The Pirate (Min-
nelli, 1948), or benefited from a third party’s suggestions, as in Don’t Go
Breaking My Heart (Patterson, 1999) and Ein Ausgekochter Junge (Schon-
felder, 1931).
STEREOTYPES OF HYPNOSIS
Even when hypnosis is depicted as having beneficial effects, it is still por-
trayed as terrifyingly powerful, and many false stereotypes are perpetuated.
The Search for Bridey Murphy (Bernstein, 1956), a book about a real-life sus-
pected reincarnation case, was made into a highly successful film of the same
name (Langley, 1956). Several fictional versions followed including The Devil
Rides Out (Fisher, 1967), On a Clear Day You Can See Forever (Minnelli,
1970), Audrey Rose (Wise, 1977)—and most recently, Dead Again (Branagh,
1991). The message is that unsuspecting people may seek hypnosis for enter-
tainment (Murphy) or smoking cessation (Clear Day) and end up reliving
dramatic experiences from their earlier incarnations. An absolute postulate
of these films is that material recalled under hypnosis is unerringly accurate
no matter how farfetched. She Creature (Corman, 1956) took the premise
into the realm of the cult classic when a beautiful woman discovered under
hypnosis that her past life was as a huge-breasted prehistoric monster and she
began to revert to this state unpredictably.
A similar age regression occurs in the recent K-Pax (Softley, 2001)
when Kevin Spacey is hypnotized to determine why he believes himself to
be an alien. Though the film leaves some ambiguity as to the answer, the
hypnotic recall of a traumatic event is taken as absolute; the only lingering
question is whether trauma caused Spacey to develop a dissociative belief
that an alien had taken over his body or whether a helpful extraterrestrial
really did intervene. In Purple Storm (Chan, 1999), police hypnotists are
able not only to extract real memories from a major terrorist’s son, but also
to implant elaborate false ones that make him believe he’s a police agent
working against his father.
In Shallow Hal (Farrelly & Farrelly, 2001), the title character wants to date
only physically perfect women until he is stuck on an elevator with self-help
guru Tony Robbins. Robbins hypnotizes him with an induction beginning
“Demons be gone!” and tells Hal he will now see a woman’s inner beauty
manifested concretely. This film—which overtly preaches that one shouldn’t
judge people by their weight or appearance—serves partially as a vehicle for
two hours of fat jokes. Hypnosis is again all powerful. One saving grace is
that it does attempt—however perfunctorily and unrealistically—to portray
the subjective effects of hypnotic suggestions rather than just the observer’s
perspective. Hal hallucinates his massively obese girlfriend as looking like
Gwyneth Paltrow.
Hypnosis has also been featured in pornographic films—almost always
with the theme only implied in Svengali or Flash Gordon: women are com-
pelled to satisfy the hypnotist’s every kinky whim. She Did What He
Wanted (n.d.), Suggestive Behavior (n.d.), Hypnotic Passions (n.d.), Stripno-
tized (n.d.), and Hypnotic Hookers I and II (n.d.) all follow this formula.
This theme has been reversed at least once for masochistic male viewers in
Wanda the Sadistic Hypnotist (Corarito, 1969).
Almost every genre has ventured into hypnosis. The children’s cat-and-
mouse cartoons eventually produced Svengali’s Cat (Donnelly, 1946). A
Caligari-like clown, Dr. Bozo, attempted evil in a Scoobie-Doo (1982)
episode.
HYPNOSIS AND TELEVISION

Television has been equally harsh on hypnosis; it’s used most often by
the villain of the week in crime dramas. Several episodes of Hart to Hart
(1979), including the pilot, solved a murder by finding out the apparent
perpetrator had been—hypnotized. In a sophisticated variation, one
Columbo (1975) episode depicts the rumpled detective becoming suspicious
when he learns that a suicide took off her watch and shoes before diving
off a building; she’d been hypnotized to see a swimming pool in front of
her. When the hero’s the target, the hypnotically suggested murder is
foiled at the last minute. Emma Peel almost kills Steel after being hypno-
tized in one Avengers episode. A co-ed almost kills Hawaii Five-O (1968)’s
McGarrett after her psychology professor (!!) hypnotizes her to do so.
Television, like film, perpetuates the myth that trance memories are
infallible. One Perry Mason (1957) episode depicts hypnotic memory
recovery from a witness—performed by the defense attorney live before
the court. Under his all-powerful suggestion, she recollects witnessing a
murder that clears Mason’s client. Hypnosis was also used by comedic vil-
lains in shows including Dukes of Hazard (Amateau & Asher, 1979) and
Gilligan’s Island (Amateau & Arnold, 1964) and has been popular in
horror/science fiction shows such as the cult-classic daytime soap opera
Dark Shadows (Curtis, 1966) to the recent X-Files (1993).
HYPNOSIS IN SONG AND MUSICAL THEATER

In 1893, J.M. Barrie (who had yet to write Peter Pan) and Arthur
Conan Doyle (already wildly famous for Sherlock Holmes) collaborated on
the libretto for an opera at the Savoy Theatre. Who contributed which
part has been lost to posterity. Barrie’s biographers assume the hypnosis
theme was contributed by him as he had a longstanding interest in the
subject.1 In any case, the result, Jane Annie,2 tells the story of a young
woman who has the “hypnotic eye” from childhood and later uses it to
seduce beaus into proposing and schoolmasters into providing money and
aid for an elopement. The pivotal song’s lyrics are:
JANE ANNIE.
When I was a little piccaninny,
Only about so high,
I’d a baby’s bib and a baby’s pinny
And a queer little gimlet eye.
They couldn’t tell why that tiny eye
Would make them writhe and twist,
They found it so, but how could they know
That the babe was a hypnotist?
ALL.
Now think of that! this tiny bray
Was a bit of a hypnotist!
JANE A.
And as I grew my power grew too,
For we were one, you see,
And what I willed the folk would do
At a wave or a glance from me.
I could “suggest” what pleased me best,
And still can, when I list,
And Madam Card will find it hard
To beat this hypnotist!
ALL.
Oh, think of it! This little chit
Is a mighty mesmerist!
American “Tin Pan Alley” songs at the turn of the century often featured
hypnosis in seduction mode. “Hypnotizing Man” practices the copulatory
gaze on unsuspecting women, “Oh those wonderful eyes, how they seem to
tantalize. When that feeling o’er you does creep, your eyes are open but
you’re fast asleep . . . ’til eventually, I must obey, I hear him say, ‘You are
mine today’ ” (Brown & von Tilzer, 1911). This song enjoyed a cult revival
in the 1970s when Tiny Tim recorded a goofy version of it with his trade-
mark ukulele and tinny falsetto.
In “Hip Hip Hypnotize Me” the young woman plays a less innocent
role: “A Hypnotist once in a Vaudeville Show was admired by a maid in
the very front row . . . she said, ‘if you hypnotize me, then I won’t know
. . . I don’t care what you do; I’ll take my chances with you, if I’m hip, hip
hypnotized, hypnotized’ ” (Dillion & von Tilzer, 1910).
In “It Must Have Been Svengali in Disguise,” “Hypnotism is the force by
which the world is ruled. It heals the sick and by its use, the wisest men are
fooled.” Every imaginable achievement is attributed to it from making some-
one relinquish a bus seat to the act of Adam and Eve eating from the tree of
knowledge: “They say the snake had whiskers and knew how to hypnotize . . .
it must have been Svengali in disguise” (Bryan & von Tilzer, 1910).
Other media, when it depicts hypnosis, makes it either sinister and/or
the butt of jokes. Innumerable cartoons depict hypnotists able to bend
others to their will for ill purposes. In January 2007, the Atlantic Monthly
ran a cover story titled, “Why Presidents Lie.” An accompanying cartoon
showed an intensely staring George W. Bush swinging a gold pocket
watch—with no caption; obviously, hypnosis and lying were understood to
be synonymous.
REALISTIC CINEMA HYPNOSIS

Are there any positive or realistic depictions of hypnosis in film? Well,
yes—a very few. Cinema, probably just because of holding the most exam-
ples, tends to contain the occasional positive one. Mesmer (Spottiswoode,
1994) presented a sympathetic depiction of its protagonist and realistic infor-
mation about why his method worked and why his theory didn’t. The multi-
ple personality films Three Faces of Eve (Johnson, 1957), Sybil (Petrie, 1976),
and numerous obscure spin-offs have included hypnosis scenes in which it is
portrayed fairly realistically and positively. In Agnes of God (Jewison, 1985),
Meg Tilly plays a young nun who has apparently given birth to a baby and
murdered it. Psychiatrist Jane Fonda hypnotizes her to unlock the series of
events that led to this act. All of these films use inductions that are drama-
tized a bit for the camera and feature atypically neat solutions to unconscious
conflicts—but they stay closer to the truth than most.
Probably the best depiction of hypnotherapy is in Equus (Lumet, 1977).
Some atypical details are used for visual interest: there is an unusual induc-
tion with a rhythmically tapping pen and the patient is asked to act out
memories in age-regression. However, the initial explanation of hypnosis
by psychiatrist Richard Burton and his patient’s subsequent experience of

it are remarkably realistic. They elucidate the steps in the young man’s for-
mation of delusions about the all-seeing horse-god “Equus” to explain his
blinding a stable full of horses in the middle of the night.
One film that is quite negative about hypnosis but unusually realistic in
what it selects as its dangers is the very dark comedy Storytelling (Solondz,
2001). The neglected youngest son of a dysfunctional middle-class family
approaches his father after his favored older brother has been brain dam-
aged in a football accident. He asks if he can hypnotize him, and his dazed
father mutters, “Sure, whatever.” The boy begins a crude induction much
like what one would find in a pop book on the topic. The highly suggestible
and recently traumatized father goes rapidly into a trance. Storytelling plays
out the fantasies of parental favor and all the ice cream one can eat more
amusingly, but also more realistically, than an earlier film with virtually the
same plot, No Dessert, Dad, until You Mow the Lawn (McCain, 1994).
Even when the depiction of hypnosis is positive, the emphasis is virtually
always on it as a means to influence or control another person—depicted
from an observer’s vantage—not on the altered state of consciousness
from the subject’s perspective. Omitting the feeble attempt in Shallow Hal
(Farrelly & Farrelly, 2001), the one main effort at depicting the subject’s
experience is the film Stir of Echoes (Koepp, 1999). Though it eventually
spirals into a supernatural thriller, there’s a realistic early scene in which
Kevin Bacon argues about the reality of hypnosis with a lay hypnotherapist
and then agrees to try being hypnotized. During the induction, the hypno-
tist tells Bacon he’s in a theater. Viewers see Bacon’s imagery—a well lit
auditorium with red seats. The hypnotist says, “It is dark,” and the lights
dim, “The seats are black,” and their color changes. When Bacon wakes up
amnesic for some of the childhood embarrassments he’s relived and the pin
the hypnotist has stuck in his hand, his confused discomfort is palpable.
The film is unique in its vivid depiction of the subjective experience. When
he begins to receive supernatural impressions, Bacon learns that the hypno-
tist has given him a suggestion to “be more open”; the danger of an ambigu-
ous suggestion is quite realistic even if the specific outcome is preposterous.
One other filmmaker who brought the experience onto the screen was
Werner Herzog. Herzog was not concerned with overtly depicting hypno-
sis, however, but rather with using it to depict other issues. Before each
day’s filming for Heart of Glass (Herzog, 1976), he hypnotized all but one
of the cast members to influence their performances. They move with
excruciating slowness, eyes rolled up into their heads, which caused one
reviewer to describe it as the “most tedious film ever made with the possi-
ble exception of a couple of Andre Tarkovsky’s efforts” (Anonymous,
1999). Herzog wanted to begin the film with a clip in which he would hyp-
notize the audience and conclude it with one awakening them from
trance. His financial backers wisely vetoed this idea.
Lars von Trier begins a film, alternately circulated under the titles
Europa (von Trier, 1991) and Zentropa, with Max Von Sydow’s voice giv-
ing hypnotic relaxation suggestions and counting. Sydow then tells view-
ers, “You are in a train, in Germany . . .” and the film story unfolds in a
more traditional manner with only occasional voice-overs by the hypnotic
voice but ends with wake-up suggestions.
While a few highly susceptibles might go into a trace while viewing
Europa/Zentropa, others have been more serious about actually hypnotizing
viewers—1990s Russian television featured hypnotists doing mass hypnosis
of viewers. In the early 1970s, an obscure Georgia gubernatorial candidate
paid for late-night television time to hypnotize viewers and suggest they
vote for him.
Table 5.1 presents 230 films utilizing hypnosis and categorizes them in
terms of a few of the variables that have been discussed.
TABLE 5.1 Films Featuring Hypnosis1
Genre: C ¼ Comedy D ¼ Drama H ¼ Horror M ¼ Mystery P ¼ Pornography

SF = Science Fiction Coercive Influence: Cr ¼ Commit Crime Sed ¼ Seduction
Transformation: Mem ¼ Recover Memories Rein ¼ Past Life Regression
Sp ¼ Increase Sports Performance Th ¼ Psychotherapy Oth ¼ Other dramatic
gains in artistic, intellectual or physical abilities
Coercive
Title/Year Genre Influence Transformation
Abbott & Costello Meet Frankenstein
(1948) C Cr, Sed
Abbott & Costello Meet the Invisible
Man (1951) C
Abbott & Costello Meet the Killer (1949) C Cr
Agnes of God (1985) D Th, Mem
Allan Quartermain (1937) D Cr
Anastasia — The Story of Anna (1956) D Mem
Audrey Rose (1977) D Rein
Ein Ausgekochter Junge (1931) D Sed
The Bells (1913) M Mem
Bewitched (1945) M Mem
Bez Konca (1984) D
Big Trouble in Little China (1986) H Cr
Black Magic (1949) M Cr
Black Sunday (1961) H Cr
Blind Alley (1939) D Th
Blink of an Eye (1991) D Oth
(Continued)
TABLE 5.1 (Continued)
Coercive
Body of Influence (1992) D Th
Bostonians, The (1984) D
Broadway Danny Rose (1984) D Oth
Buford’s Beach Bunnies (1993) C Sed
Calling Dr. Death (1943) M Cr
Carefree (1938) C Th
The Case of Becky (1921) D Sed
Casino Royale (1967) C
Cat People (1943) H Th
Chandu the Magician (1932) H
Charlie Chan at Treasure Island (1939) M Mem
Charlie Chan in Rio (1941) M Cr
Charlie Chan: Meeting at Midnight
(1944) M Cr
The Climax (1944) Cr
Coach (1978) C Sp
Cold Turkey (1971) C Th
Condemned to Death (1932) M
The Court Jester (1956) C Oth
Cult Rescue (1994) D
Cure (1999) M Cr
Curse of the Jade Scorpion (2001) C Cr
Dark Tower (1942) D Sed
Daughter of the Dragon
(a Fu Manchu film) (1931) M Cr
Dead Again (1991) M Rein
Dead on Sight (1994) M Mem
Deadly Lives of the Ninja (undated) D Cr
Death Warmed Up (1985) M Cr
The Devil Doll (1964) H
The Devil’s Undead (1972) M
Dick Tracy (1937) M Cr
Divorce American Style (1967) C Sed
Don’t Go Breaking My Heart (1999) D Sed
Dr. Mabuse, the Gambler (1922) M Cr
Dr. Mabuse, The Testament of (1932) M Cr
Dracula (1931) H
Dracula (1931 Spanish) H
Dracula (1979) H
Dracula’s Daughter (1936) H
Dying to Remember (1993) M Rein
The Element of Crime (1984) M Mem
Equus (1977) D Th
Coercive
Escapement (1958) D
Eternally Yours (1939) C Sed
Europa (a.k.a. “Zentropa”) (1991) D
The Exorcist II: The Heretic (1977) H
Far Out, Man (1990) C Oth
Fear in the Night (1947) M Cr
Feast of the Devil (1987) D
Fingers at the Window (1942) M Cr
Flagpole Jitters (1956) C
Flash Gordon (1936) SF Sed
Flash Gordon (1980) SF
Flash Gordon Conquers the Universe
(1940) SF Sed
Flash Gordon’s Trip to Mars (1938) SF Sed
Foreign Tongues: Mesmerized (undated) P Sed
Freud (1962) D Th
Fright (aka “Spell of the
Hypnotist”)(1956) M
Frozen Ghost, The (1945) M Mem
The Garden Murder Case (1936) M Cr
Geisha Girl (1952) C Mem
Ghost Chasers (1951) C
Ghosts on the Loose (1943) C
Going Berserk (1983) C Cr
Goldy III, The Legend of the Golden
Bear (1994) C Oth
Guilt of Janet Ames (1947) M/D
Guilty of Treason (1949) D
Hannusen (1988) M Oth
Haunting Fear (1990) M Th
Heart of Glass (1976) D
Here Come the Co-eds (1945) C
High Anxiety (1977) C
Hipnosis (1963) M Cr
Hitz (1988) C Sed
Hocus Pocus (short: 1949) C
Hold that Hypnotist (1957) C
Horrors of the Black Museum (1959) H
The Hot Rock (1977) C Cr
Hot Under the Collar (1991) C Sed
Houdini (1953) D Oth
How to be Very, Very Popular (1955) C Sed
How to Make a Monster (1958) C Cr
(Continued)
Coercive
Hypnosis (1963) H
The Hypnotic Eye (1960) H Cr
The Hypnotic Monkey (1915) H Cr
Hypnotic Murders (1998) M Cr
Hypnotic Passions (1993) P Sed
Hypnotic Power (1914) H Cr
Hypnotic Sensations (1985) P Sed
The Hypnotic Violinist (1914) H Oth
The Hypnotic Wife (1909) D Sed
Hypnotism (1910) D Cr
The Hypnotist (1957) D Cr
I Was a Zombie for the FBI (1982) C Cr
I’m From the City (1938) D
In Like Flint (1967) M Cr Mem
In the Grip of a Charlatan (1913) M
Incredibly Strange Creatures That H Cr
Stopped Living and Became Mixed-Up
Zombies (1964)
Intruders (1992)
Invasion of the Space Preachers (1990) C Cr
The Invisible Ghost (1941) H Cr
The Ipcress File (1965) M Cr
Irma Vep (1997) D Cr
Jones’ Hypnotic Eye (1915) D Cr
Keeper (1975) M Cr
The Killing Jar (1996) M Th
Kiss the Girls (1997) M Mem
Let’s Do It Again (1975) C Sp
Let’s Kill Uncle (1966) C Cr
The Lightning Incident (1990) D Oth
Liquid Dreams (undated) P Sed
Lizzie (1957) D Th
London After Midnight (1927) H
Looker (1981) Cr
Lord Love a Duck (1966) C Oth
Lost in a Harem (1944) C
Love at First Bite (1979) C Cr Oth
The Magician (1926) D
The Magician (1959) D Sed
Le Magnetiseur (aka The Hypnotist at
Work (USA); aka While Under the
Hypnotists’ Influence) (UK) (1899) D Sed
The Maltese Bippy (1969) C Cr
Coercive
The Manchurian Candidate (1962) D Cr
The Mask of Diijon (1946) H Cr
The Mask of Diijon (1993 Spanish) H Cr
Maurice (1987) D Th
Max Hypnotize (1910) D
Mesmer (1994) D Th
Midnight Eye Golem (1964) D Cr
Misadventures of Merlin Jones (1964) C Cr
Mr. Hex (1946) C
The Mummy (1932) H
Murder in Mind (1997) M Cr
The Naked Gun (1988) C Cr
The Natural (1984) D Sp
Night of the Living Babes (1987) P Sed
The Night They Killed Rasputin (1962) D
Nightmare (1956) M Cr
Nights of Cabiria (1956) D
No Dessert, Dad, Until You Mow the
Lawn (1994) C
Office Space (1999) C Th
On a Clear Day, You Can See Forever
(1970) D
Palmy Days (1931) C Cr
The Peeper, The Hypnotist, and the
Model (1972) C Sed
The Pirate (1948) C Sed
Play It As It Lays (1972) C
Problem Child 2 (1991) C Cr
Promise to Carolyn (1996) M Th, Mem
Purple Storm (1999) D Th, Mem
Raising Cain (1992) D
Rasputin (1996) D
Rasputin and the Empress (1932) D
Rasputin: The Mad Monk (1966) D Cr
The Razor’s Edge (1984) D Oth
The Reanimator (1985) H
Remains to Be Seen (1953) D
The Resurrection Syndicate (aka Nothing
But the Night;aka The Devil’s Undead)
M Mem
(1972)
Return (1985) D Rein, Mem
The Return of Captain Invincible (1983) C Cr
(Continued)
Coercive
Rock and the Money Hungry Party Girls
(1989) C/P Sed
Running Wild (1927) C
Santa Sangre (1989) D
Savage (1973) D
Screwballs (1983) C Sed
The Search for Bridey Murphy D Rein
The Secret Diary of Sigmund Freud
(1984) C Th
Seventh Heaven (1998) D
Seventh Veil (1946) D
Sex Kittens go to College (1960) C/P Sed
Shallow Hal (2001) C Th
Shaman (1987) D
The She-Creature (1956/8) H Rein
She Did What He Wanted (undated) P Sed
Silent Conflict (1948) D Cr
Silly Scandals (1931) D
Sisters (1973) D Cr
Slave of a Foreign Will (1919) D Cr
Son of Dracula (1943) H
Spellbound (1945) M Th, Mem
Splitz (1984) P Sed
Spy Chasers (1955) C
Starship Invasions (1977) SF
Stir of Echoes (1999) D Oth
Strange Brew (1983) C Cr
Stripnotized (undated) P Sed
Sucker Money (1933) Cr
Suggestive Behavior (undated) P Th
Svengali (1911) D Cr, Sed
Svengali and Trilby (1983) D Cr, Sed
Swing Fever (1944) C Cr Sp
Tales of Hoffman (1951) D
Taste the Blood of Dracula (1970) H Cr
The Three Faces of Eve (1957) D Th
The Two-Souled Woman (1918) D Sed
The Undead (1958) H Rein
Up the Front (1972) C Oth
Coercive
Les Vampires (1915) M Cr
Wanda the Sadistic Hypnotist (1969) P
Whirlpool (1949) M
Whoops! Apocalyspe (1986) C
Will Any Gentleman? (1954) C Oth
A Wind from Wyoming (1994) C
The Woman in Green (1946) M
Zelig (1983) C
1
The author has watched the majority of these films. However, this table is
compiled most directly from synopses in two film reference books (Katz, 2000;
Matlin, 2005) and two Internet reference sites (The Internet Movie Database;
The Missing Link).
CONCLUSIONS AND IMPLICATIONS

It is clear that the main interest of film and television is in hypnosis as
absolute control over others. This obviously plays to popular fears and
fantasies. Most of us at least occasionally wish for greater influence upon
the behavior of others than we can effect with ordinary social skills. We
also fear undue control by others. When hypnosis is viewed as this meta-
phor for ultimate control, the filmmaker—and hence his (or occasionally
her) audience—wants to identify with the observer, not the subject of this
overwhelming phenomena.
Obviously there is something to the idea “They’re only movies”; film’s
purpose is to entertain and it’s not entirely realistic on any subject. But
the distortion and vilification of hypnosis go far beyond that of other
psychological phenomena. Dreams have suffered the indignities of the
Nightmare on Elm Street series (Craven, 1984, 1985, 1987, 1988, 1989,
1991, 1994). Psychotherapists are occasionally depicted as killing
patients—while cross-dressing as in Dressed to Kill (De Palma, 1980) or as
a prelude to cannibalism in Silence of the Lambs (Demme, 1991). However,
these films are offset by numerous others that depict positive aspects of
dreaming, such as Dreams (Kurosawa, 1990), or psychotherapy, as with
Ordinary People (Redford, 1980), and which portray the subjective experi-
ences of each richly (Barrett, 2001, 1991–2006; Gabbard & Gabbard,
1987; Petric, 1998). There are also films in which a character recounts a
dream in passing or a minor scene shows someone talking to their therapist—
we never see hypnosis depicted in this understated manner. Hypnosis is
always there for its metaphoric possibilities—larger than life and usually up to
no good. The most likely cause of this difference is that everyone dreams
and—in Hollywood at least—almost everyone is in psychotherapy.
There are two possible routes by which hypnosis in film might be rehabili-
tated. The first is if hypnosis ever became widespread enough that most every
director or screenwriter had used it for smoking cessation or headache relief.
If the press regularly ran factual, non-sensational articles about hypnosis, it
would likely develop a more realistic presence in film. We already see a hint
of this reflected in the fact that hypnosis films in the first half of the twenti-
eth century were unrelentingly negative, and all examples of positive and/or
realistic depictions come from the second half. However, the influence of real
life use of hypnosis upon cinema is not the direction in which we are most
interested. If hypnosis ever becomes completely recognized for all its poten-
tial benefits, we’d probably care little what liberties the cinema takes with it.
We’re more interested in how realistic depictions of hypnosis might educate
viewers and influence real-life attitudes toward hypnosis.
Hollywood’s raison d’être is box office success; the plots of hit movies
are recycled endlessly. If there was a successful film in which the protago-
nist benefited from hypnotherapy or one that depicted the trance state
with the appeal meditation regularly receives, more would follow. One
good screenplay or adaptable novel would go a long way toward changing
stereotypes. Half of all films are based on novels. However, most positive
hypnosis films have been based on nonfiction books (Dissociative Identity
Disorder case studies, Mesmer biographies, etc.) and the remainder on
stage plays (Equus; Agnes of God). There’s as great a dearth of novels that
are hypnosis friendly as of films. Short of beginning to pen screenplays and
fiction, hypnotherapists would do well to emphasize positive hypnosis
themes to people involved in these media. Herbert Spiegel served as con-
sultant to the film version of Equus, enhancing the authenticity of the
hypnosis that was already moderately realistic in the stage play. We might
all do well to take every opportunity to get involved in the popular depic-
tions. In trying to discourage false beliefs about hypnosis—discounting
stage hypnosis, past life, and alien abduction phenomena—we may, at
times, veer too far toward making hypnosis sound boring. Information on
actual dramatic developments within the field and descriptions of how
enjoyable and fascinating the experience of hypnosis can be may be more
effective at combating false images than is relentless debunking.
NOTES
1. Barrington, Rutland (1908). Rutland Barrington: A Record of 35 Years’ Ex-
perience on the English Stage. London: G. Richards. http://www.archive.org/
details/rutlandbarringto00barrrich. Preface by W. S. Gilbert.
2. http://math.boisestate.edu/GaS/other_savoy/jane_annie/jane_annie_home.
html.
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Chapter 6
Hypnotic-Like Procedures in Indigenous

Shamanism and Mediumship 1
Stanley Krippner and J€urgen W. Kremer
The term hypnosis was popularized by James Braid (1795–1860), an English

physician. Braid disliked the term mesmerism, which had been named after
its originator, Franz Anton Mesmer (1734–1815), an Austrian physician.
Braid concluded that Mesmer’s purported cures were not due to “animal
magnetism” as Mesmer had insisted, but to suggestion. He developed the
eye-fixation technique (also known as “Braidism”) of inducing relaxation.
Earlier French writers had called similar procedures hypnotisme (after
Hypnos, the Greek god of sleep) because they thought that these phenomena
were a form of sleep (Gravitz, 1984). Later, realizing this error, Braid tried to
change the name to monoeidism (meaning influence of a single idea), how-
ever, the original name stuck. In other words, semantics and social construc-
tion played an important role in the history of hypnosis and actually directed
the way that this modality was practiced and conceptualized.
Contemporary discussions and definitions can be found in the materials
of the Society of Psychological Hypnosis (Division 30 of the American
Psychological Association; see especially the 2004 statement of its Execu-
tive Committee). The Society defines hypnosis as a procedure involving
cognitive processes (such as imagination) in which a participant is guided
by a hypnotist to respond to suggestions for changes in sensations, percep-
tions, thoughts, feelings, and behaviors. Sometimes, people are trained in
self-hypnosis in which they learn to guide themselves through a hypnotic
procedure. (It is important to note that psychologists hold a wide variety
of opinions on how to define hypnosis and on why hypnosis works; psycho-
analytic, neo-dissociative, socio-cognitive, and transpersonal approaches
provide different theories and definitions.)
1
Several segments of this chapter appeared in S. Krippner (2004). Hypnotic-like procedures
used by indigenous healing practitioners. Hypnos, 31, 125–135. Used by permission.
The hypnotic procedure can be seen as consisting of two parts: (1)

induction, and (2) suggestions given. During the induction, the participant
(patient, client, or research volunteer) is guided to relax, concentrate, and/
or to focus his or her attention on some particular item. Some hypnotic
practitioners believe the purpose of the induction is to induce an “altered
state of consciousness,” while others believe the induction is a social cue
that prompts the participant to engage in hypnotic behaviors. The sugges-
tions given provide guidance to undergo changes in experience, such as to
experience a motor movement (ideomotor suggestions), or changes in sen-
sations, perceptions, thoughts, or feelings. “Challenge suggestions” may also
be given (e.g., subjects are told they will not be able to engage in some par-
ticular activity and then are asked to perform the prohibited activity).
Answers to the question whether people in hypnosis enter an “altered state”
remain contentious; however, research suggests that there is a trait that is
associated with an individual’s responsiveness to hypnotic procedures (e.g.,
Barber, 1969). The use of hypnotic procedures in a clinical setting is gener-
ally confined to verbal instructions in an office or similar venue.
By contrast, indigenous shamanic practices commonly involve a very dif-
ferent setting with inductions and suggestions proceeding in a multiplicity
of dimensions. These practices reach back to tribal rituals directed by native
shamans, those socially designated practitioners who voluntarily shift their
attentional states to obtain information not available to other members of
their community (Krippner, 2000). Agogino (1965) stated, “The history of
hypnotism may be as old as the practice of shamanism” (p. 31), and
described hypnotic-like procedures used in the court of Pharaoh Khufu in
3766 BCE. Agogino added that priests in the healing temples of Asclepius
(commencing in the 4th century BCE) induced their clients into “temple
sleep” by “hypnosis and auto-suggestion,” while the ancient Druids chanted
over their clients until the desired effect was obtained (p. 32). Vogel (1970/
1990) noted that herbs were used to enhance verbal suggestion by native
healers in pre-Columbian Central and South America (p. 177).
However, Krippner (2004, 2009) has suggested that the procedures
described by Agogino, Vogel, and others be referred to as “hypnotic-like”
because they differ considerably from procedures utilized in standard hyp-
nosis. The setting for rituals or ceremonies may be outdoors or in tradi-
tional structures very different from the office of a counselor, psychiatrist,
or clinical psychologist, even though contemporary shamanic practitioners
may conduct healing ceremonies in hospitals or in nontraditional living
quarters. In addition to verbal instructions, singing or chanting, the use of
instruments (particularly percussion instruments), drama, movement,
body-painting, tactile, olfactory and/or gustatory stimulation, dietary prac-
tices (mind-altering herbs, emetics, fasting, etc.), shifts in waking and
sleeping cycles, and cleansing procedures (such as sweating and purging)
play an instrumental role. The use of a wide variety of implements or
Hypnotic-Like Procedures in Indigenous Shamanism and Mediumship 99
utensils is also common, for example, feathers, bundles, crystals, and in the
verbal dimension, storytelling (including joking and teasing), can all
play a significant role. In addition to specific suggestions provided by the
shaman or other indigenous practitioner, the cultural context (such as the
cosmology of the ritual venue or stories told or alluded to in songs) gives
guidance during the hypnotic-like procedures employed by shamans.
Language issues quickly arise when we move cross-culturally to investi-
gate hypnotic-like phenomena, especially given the diversity and complex-
ity of indigenous languages. While we are intent on using indigenous
peoples’ explanations of their own practices, we cannot help but resort to
concepts that have their own history in the English language. For example,
the word consciousness, like hypnosis, is a social construct, one that has
been defined and described differently by various groups and writers. When
it is translated into a non-English language, the problem intensifies, as
some languages have no exact counterpart to the term. From our perspec-
tive, the English noun consciousness can be defined as the pattern of per-
ception, cognition, and affect characterizing an organism at a particular
period of time. However, some definitions equate “consciousness” with
“awareness,” while other definitions focus on “intentionality,” “attention,”
or some other aspect of the phenomenon.
So-called “alterations” in consciousness or “altered states” of conscious-
ness (often described as observed or experienced changes in people’s usual
patterns of perception, cognition, and/or affect) have been of great interest
both to practitioners of hypnosis and to anthropologists. Rock and Krippner
(2007) have deconstructed the phrase “altered states of consciousness,”
claiming that it confuses consciousness with its content, especially if a
phrase such as “shamanic states of consciousness” is used. They prefer the
phrase “patterns of phenomenological properties” as it avoids what they call
the “consciousness/content fallacy,” and places the emphasis upon experi-
ence itself (p. 485). Regardless of the term used, various indigenous (i.e.,
native, traditional) people engage in practices that they claim facilitate
encounters with “divine entities” and contact with the “spirit world.” Many
Western observers have been reminded of hypnosis by some of these proce-
dures, especially those in which individuals have appeared to be highly sug-
gestible to the practitioner’s directions have seemed strongly motivated to
engage in imaginative activities and have become engaged in shifts in
attention, all of which are common to Western hypnotic practices.
In any event, these behaviors and experiences reflect expectations and
role enactments on the part of the individuals or a group. The practitioner
invites these individuals to attend to their own personal needs while
attending to the interpersonal or situational cues that shape their
responses. However, it is an oversimplification of a very complicated set of
variables to refer to the practices of shamans and other indigenous practi-
tioners as “hypnosis,” as many authors have done (e.g., Agogino, 1965).
Native practitioners and their societies have constructed an assortment of

terms to describe activities that, in some ways, appear to resemble what
Western practitioners refer to as “hypnosis.” To indiscriminately use the
term “hypnosis” to describe exorcisms, the laying-on of hands, dream incu-
bation, and similar procedures does an injustice to the varieties of cultural
experience and their historic roots.
“Hypnosis,” “the hypnotic trance,” and “the hypnotic state” have been rei-
fied too often, distracting the serious investigator from the cross-cultural uses
of human imagination, suggestion, and motivation that are worthy of study
using a native practitioner’s own terms (Krippner, 1993). It is important to
take account of the entire range of procedures that are part of shamanic prac-
tices (as well as those from folk mediumship) and to include indigenous defi-
nitions and accounts rather than to abstract them from culturally significant
understandings (Kremer, 1994). We agree with Gergen (1985) who observed
that the words by which the world is discussed and understood are social arti-
facts, “products of historically situated interchanges among people” (p. 267).
This caveat also applies to the word indigenous, a term for which there is no
universal definition (Kuper, 2007). We apply indigenous to descendents of
original inhabitants of a land, as well as to groups only partially related ge-
netically to those people but who have also suffered discrimination from a
society’s powerful elite.
HISTORICAL AND CROSS-CULTURAL ISSUES

We have explored practices found in North American shamanism
(Krippner and Kremer), Balinese folk customs (Krippner), contemporary
Sami traditions (Kremer), and African-Brazilian mediumship (Krippner),
and will use our data to illustrate the multisensory nature of indigenous
hypnotic-like procedures. A survey of these practices and others in the
social science literature indicates that there are elements of native healing
procedures that can be termed “hypnotic-like.” This is due, in part, to the
fact that so-called “alterations in consciousness” are not only sanctioned
but are also deliberately fostered by virtually all indigenous groups. For
example, Bourguignon and Evascu (1977) read ethnographic descriptions
of 488 different societies, finding that 89 percent were characterized by
socially approved “alterations of consciousness,” or if you will, “changed
patterns of phenomenological properties.” The use of different terms
throughout this chapter is an attempt to present the reification of such
appellations as “altered states of consciousness.”
The ubiquitous nature of hypnotic-like procedures in native healing also
demonstrates the ways in which human capacities—such as the capability to
strive toward a goal and the ability to imagine a suggested experience—can
be channeled and shaped, albeit differentially, by social interactions. Concepts
of sickness and of healing can be socially constructed and modeled in a num-

ber of ways. The models found in indigenous cultures frequently identify such
etiological factors in sickness as “soul loss” and “spirit possession,” each of
which are diagnosed (at least in part) by observable changes in the patient’s
behavior, mentation, or mood (Frank & Frank, 1991, ch. 5).
For example, there is no Western equivalent for wagamama, a Japanese
emotional disorder characterized by childish behavior, emotional outbursts,
apathy, and negativity. Nor is there a counterpart to kami, a condition
common in some Japanese communities that is thought to be caused by
spirit possession. Susto is a malaise common in Peru and several other parts
of Latin America and thought to be caused by a shock or fright, often con-
nected with breaking a spiritual taboo. It can lead to dire consequences
such as the “loss,” “injury,” or “wounding” of one’s “soul,” but there is no
equivalent concept in Western psychotherapy manuals.
Cross-cultural studies of native healing have only started to take seri-
ously the importance of understanding indigenous models of sickness and
their treatment, perhaps because of the prevalence of behavioral, psycho-
analytic, and allopathic medical models. None of these has been overly
sympathetic to the explanations offered by indigenous practitioners or to
the proposition that Western knowledge is only one of several viable rep-
resentations of nature (Gergen, 1985). Kleinman (1980) commented,
The habitual (and frequently unproductive) way researchers try to

make sense of healing, especially indigenous healing, is by speculating
about psychological and physiological mechanisms of therapeutic
action, which then are applied to case material in truly Procrustean
fashion that fits the particular instance to putative universal principles.
The latter are primarily derived from the concepts of biomedicine and
individual psychology. . . . By reducing healing to the language of biol-
ogy, the human aspects (i.e., psychosocial and cultural significance) are
removed, leaving behind something that can be expressed in biomedi-
cal terms, but that can hardly be called healing. Even reducing healing
to the language of behavior . . . leaves out the language of experience,
which . . . is a major aspect of healing. (pp. 363–364)
Similarly, Faris (1990) criticized attempts to fit indigenous beliefs and

practices “into some variety of universal schema—reducing its own rich logic
to but variation and fodder for a truth derived from Western arrogances—
even if their motivations are to elevate it” (p. 12). In using the terminology
of “hypnotic-like procedures” we have attempted to point to the importance
of the local construction of practices and their interpretations.
Most illnesses in a society are socially constructed, at least in part, and
alleged alterations of consciousness (or changed patterns of phenomeno-
logical properties) also reflect social construction. Because native models
of healing generally assume that practitioners, to be effective, must shift

their attention (e.g., “journeying to the upper world,” “traveling to the
lower world,” “incorporating spirit guides,” “conversing with power ani-
mals,” “retrieving lost souls”), the hypnosis literature can be instructive in
fathoming these concepts.
MULTI-SENSUAL PERSPECTIVES ON
HYPNOTIC-LIKE PROCEDURES
Observing hypnotic-like procedures closely we find that “induction” and
“suggestion” occur in ways notably different from the setting and proce-
dures of hypnosis in clinical settings. The following list highlights some of
the most obvious dimensions that are part of hypnotic-like ritual endeavor
(see Kremer, 2002a, for a more lengthy discussion).
Cultural Context
The application of hypnotic procedures in Western clinical settings
does not occur in the context of a shared cultural mythology or shared sto-
ries and ritual practices; it is specific to the individual. By contrast, indige-
nous ceremonies are enacted in a rich cultural context in which the
patient participates. These mythic stories (especially their understanding
of the healing process, the origin of symptoms, and the goal of health or
balance) provide a rich context that may or may not be verbalized or made
present during the ceremony, but is, nonetheless, the operative background
of hypnotic-like procedures.
Sacred Geography
Oftentimes healing rituals occur within a geography that is invoked, lit-
erally traveled to, or replicated in the place of ceremony (such as the Dine
hogan or the Sami lavvu); the macrocosm of the cultural sacred geography
is oftentimes mirrored in the sacred layout of the place of ceremony (as in
Dine sand paintings).
Storytelling
Stories are frequently used to invoke cultural context, to explain illness,
and to guide healing. They may also serve to shift attention, very much
like in the practice of Milton Erickson (Erickson, Rossi, & Rossi, 1976) or
in the adaptation of indigenous practices in counseling and psychotherapy
(see Krippner, Bova, Gray, & Kay, 2007; Krippner Bova, & Gray, 2007).
Verbal Instructions
In most situations, specific verbal instructions (e.g., as induction or sug-
gestion) form the smallest part of the proceedings.
Singing or Chanting
Songs or repetitive chanting as part of invocations, affirmations, or sug-
gestions both provide direction, invoke stories, spirits, or cosmologies, and
shift the participant’s attention.
Percussion and Other Musical Instruments

Research (e.g., Neher, 1961) has demonstrated that the repetitive use
of a percussion instrument, such as drumming, can lead to alterations in
phenomenological awareness. Such isolated use of an induction seems
extremely rare in indigenous practices. These powerful ways to shift atten-
tion (drumming, rattling, bullroarer, click sticks, whistles, etc.) are usually
only one aspect of a multisensory design of healing procedures.
Ritual Implements
These may include feathers, amulets, crystals, and wands, among many
others, all considered to have special powers or spiritual importance.
Olfaction
The most common event is probably the use of herbs as incense or
offering (such as sage), or the smoking of herbs (such as tobacco), as well
as the use of fire and its ensuing smoke.
Gustatory Stimulation and Dietary Practices

The ingestion of mind-altering plants or other herbal remedies with specific
alleged healing properties, as well as changes in diet (fasting, dry fasting, or other
restrictions) are an important aspect of many indigenous healing ceremonies.
Cleansing
This may involve such activities as ingesting emetics, washing (such as
with yucca suds), bathing, standing under a waterfall, and sweating (in a
sauna, Native American sweat lodge, etc.).
Tactile Stimulation
This may include various forms of massaging, stimulating pressure
points, slapping, simple touching, and related procedures.
Movement
Dance, particularly repetitive dance, is probably the most common use
of movement; however, there are various stylized postures and interactive
movements that fall into this category as well.
Body Painting
The patient and/or shamanic practitioner as well as other participants
may use temporary or permanent designs evocative of particular presences
or various mythological stories.
Drama
Dramatic enactments may be part of the invocation of story, notions of
health and balance, or the cosmology within which a hypnotic-like proce-
dure occurs.
Waking-Sleeping Cycles
Many ceremonies occur during the evening, late into the night, or
during the entire night. Wakefulness to ritual proceedings at a time when
participants usually sleep and dream also facilitates changes in attention.
In some traditions we may find many of these dimensions present during
native ceremonies, but in others only a few are effectively employed for
the sake of healing. The examples discussed next illustrate the range of
multidimensionality of hypnotic-like procedures in sample cultures.
PROCESSES OF HYPNOTIC-LIKE PROCEDURES

Clottes and Lewis-Williams (1998/1996) have proposed three stages of
what they call “shamanic consciousness” (see also Lewis-Williams, 2002).
This is consistent with Tart’s (1975) discussion of the process of altered states
and Winkelman’s (2000) discussion of the neuropsychological bases of rock
art. Figure 6.1 combines the work of Clottes and Lewis-Williams, Tart, and
Kremer (2002b). It illustrates the stages of “shamanic consciousness” during
hypnotic-like procedures using an abstract depiction, images from contempo-
rary Western processes, European Paleolithic cave art, San rock art, and Dine
rock art. The left column presents images of consensual, everyday reality,
Figure 6.1 (Chart assembled and drawn by J€urgen Kremer based on images and
inspiration from: Clottes, J. & Lewis-Williams, D. (1997). Schamanen. Sigmaringen,
Germany: Thorbecke; Tart, C. (1975). States of Consciousness. New York: Dutton; Grant,
C. (1978). Canyon de Chelly: Its People and Rock Art. Tucson, AZ: University of
Arizona Press.)
while the columns toward the right show increasing alteration of attention
and shifts in one’s pattern of phenomenological properties.
In Stage One, people move from alert consciousness to a “light” altera-
tion, beginning to experience geometric forms, meandering lines, and
other “phosphenes” or “form constants,” so named because they appear to
be hard wired into the central nervous system. For example, the Tukano
people of South America use a series of undulating lines of dots to repre-
sent the Milky Way (Reichel-Dolmatoff, 1971).
In Stage Two, people begin to attribute complex meanings to these
“constants.” Practitioners enter the next phase in several ways—by crossing a
bridge, going through a whirlpool, or entering a hole. In Stage Three, these
constants are combined with images of people, animals, spirits, and mythical
beings. Experients began to interact with these images, often feeling them-
selves to be transformed into animals, either completely or partially (e.g., the
celebrated prehistoric Les Trois Freres animal/human depiction); shamanic
journeys are generally felt to be more feasible in this form (Clottes & Lewis-
Williams, 1998/1996, p. 19). Various chambers of Upper Paleolithic caves
seem to have been restricted to advanced practitioners; some caves have spa-
cious chambers embellished with large, imposing images while elsewhere
there are often small, sparsely decorated diverticules into which only a few
people could congregate (p. 20).
From an epistemological perspective, the shaman gained knowledge from
his or her journeys into other realms of existence, and communicated the
results to members of the community (Flaherty, 1992, p. 185). Shamans
provided information from a database consisting of their dreams, visions,
and intuitions, as well as their keen observations of the natural and social
world. Sansonese (1994) suggested that there was “a degree of genetic pre-
disposition for falling into trance” and that this ability made a significant
contribution to social evolution (p. 30). For example, there was a succes-
sion of Indo-European shamans whose traditions included parent-to-child
transmissions of shamanic lore that, in turn, institutionalized extended-
family shamanic groups (Ibid.).
MULTIDIMENSIONALITY OF DIN E CHANTWAYS

Dine (Navajo) chantways represent a complex system of ceremonies that
can, in some sense, be seen as exemplars for the multidimensionality of
hypnotic-like procedures in indigenous traditions. Hataal in the Dine
language means chant and hataałii means medicine person, singer, or chan-
ter. There are about 60 distinct Dine names for various chantways and
chantway branches, many of them now considered extinct (Young &
Morgan, 1987). The chants are usually grouped into four basic categories:
Blessing Way, Holy Way, Night Way, and Evil Way. The specific names of
chants are indicative of a particular mythology, symptom, or intervention,
ranging from Red Ant Way, Raven Way, Game Way, and Big Star Way to
Hand Trembling Way and Prostitution Way. Ceremonies typically last sev-
eral days, with the longest lasting up to nine days. The performance of a
hataal is expected to be carried out following the precise instructions and
special procedures in order to counteract any errors that have occurred.
This gives them a flavor that is liturgical rather than improvised, inspired,
or spontaneous as in other indigenous shamanic practices (although cere-
monies connected with the oldest layer of the Navajo traditions, such as
those involving crystal gazing and hand trembling, belong in the latter cat-
egory (see Luckert, 1975). Faris (1990), in discussing the Night Way,
stresses that these “healing procedures which order, harmonize and re-
establish and situate social relations—are in local knowledge prior to other
concerns. And it is only in careful attention to local beliefs and local knowl-
edge that Navajo conceptions of order and beauty can be understood” (p. 3;
italics in original).
The Coyote Way (ma ˛ ’iijı hataal) has been documented in great detail,
including an extensive photographic record, by Luckert (1979). It is worth
exploring this example in some detail to exemplify the intricate multidi-
mensionality of hypnotic-like procedures that exist in certain cultural
practices. Coyote Way is a nine-day ceremony that involves Unraveling

Ceremonies (so named because during the first four evenings and nights,
bundles of herbs and other ingredients are unraveled to loosen the illness),
Fire Ceremonies (occupying the first four mornings and noon), Basket-
Drum Ceremonies (occupying the second four evenings and nights), Sand
Painting Ceremonies with one or more god impersonators or ye’ii (occur-
ring on the second four mornings and noon), and a final Basket Drum
Ceremony on the ninth night. Coyote Way involves 161 chants and pray-
ers (including repetitions) and two different sand paintings (at least in the
ceremony documented by Luckert, 1979).
Like other chantways, Coyote Way is “traceable in history, possibly, to
a point in time when several formerly shamanic traditions became amalga-
mated into the conglomerate healing ceremonials of later priestly hataałii
or singers” (Luckert, 1979, p. 3). Communication with spirits in an altered
state is now replaced by learned liturgy of the poetic chantway; discussion
of altered states or spirits is not part of the proceedings. In fact, it might
be seen as problematic if a participant were to report the sighting of a spi-
rit (Faris, 1988, personal communication). Many of the specific procedures
used, based on extant research, can be seen as conducive to changes of
various aspects of consciousness (such as rattling or repetitive chanting or
the shift in waking cylce) or they can be interpreted as social cues that
prompt the patient to engage in appropriate behavior (with no apparent
signs of alterations in one’s patterns of phenomenological properties).
The origin myth of Coyote Way, however, clearly indicates the inspired
or shamanic origins of the now highly structured priestly performance and
can be seen as the account of an earlier shamanic visionary experience
(see Winkelman, 2000, for a differentiation of shamans and priests). The
beginning of one version of the story talks about the origin of chantways
in dreams. It describes a journey through the sacred landscape of the Dine
people. A boy has exhausted his hunting luck and follows coyote tracks in
hopes that they might lead him to some game. He arrives at a frozen pond
and follows the tracks down a ladder. In this underworld, he receives
detailed instructions on how to perform Coyote Way, and the ceremony is
performed over him. He then teaches the Earth People the ceremony
before returning to the Coyote People. This myth exemplifies a four-year-
long shamanic underworld journey, as the story goes (analogous to the pro-
longed initiations during “shamanic illness” among Siberian tribes;
Vasilevic, 1968) and sets the cultural context for the ritual. It should be
noted that the Great Coyote previously had much more positive connota-
tions as a trickster and hunter than it has today.
Coyote illness originates with the Great Coyote beyond the East and is
brought to humans via predators from Sun and Moon. The basic symptoms
seem to be mania, nervous malfunctions, and rabies, with such sympto-
matic behavior as twisted mouth, cross-eyed vision, weakened eyesight,
loss of memory, and fainting. Faris (1990) has extensively argued for the
importance of situating ceremonial practices and reliance on the authority
of practitioners of local knowledge (as opposed to the use of Jungian or
other perspectives alien to Dine cultural practices).
The absence of a formal induction does not prevent the client from
becoming receptive to a suggestion and motivated to follow it, just as
most, if not all, hypnotic phenomena can be evoked without hypnotic
induction (Kirsch, 1990, p. 129). Contributing to this procedure is the
multimodal approach that characterizes Navajo chants, as well as their
repetitive nature and the mythic content of the words, which are easily
deciphered by those clients well versed in tribal mythology. Sandner
(1979) described how the visual images of the sand paintings and the body
paintings, the audible recitation of prayers and songs, the touch of the
prayer sticks and the hands of the medicine man, the taste of the ceremo-
nial musk and herbal medicines, and the smell of the incense “all combine
to convey the power of the chant to the patient” (p. 215). A hataałii usu-
ally displays a highly developed dramatic sense in carrying out the chant
but generally avoids the clever sleight of hand effects used by many other
cultural healing practitioners to demonstrate their abilities to the commu-
nity (p. 241). The following four sections describe the multidimensionality
of hypnotic-like procedures in the Coyote Way.
Unraveling Ceremony
This involves a number of bundles (made of feathers and plants), a
watery mixture to be consumed (made from corn and other plants), and a
rub-on medicine (made from herbs). At the beginning of the ceremony,
cornmeal is sprinkled to represent the world inside the hogan. The patient
circles the fire and sits in this microcosm of the world made present
through the cornmeal design. Songs evoke the origins of the Coyote Way,
“They were given, they were given . . . He brought it back, he brought it
back” (Luckert, 1979, p. 37). The bundle gets pressed against the body of
the patient in important places and the bundles are loosened to loosen the
knots in the patient’s body. Then the patient drinks the watery mixture
and the rub-on medicine is applied to the body while songs commemorate
the shamanic initiation of the original practitioner into the Coyote Way.
This ceremony concludes, as do all ceremonies that are part of the Coyote
Way, with a feather burning rite.
Fire Ceremony
The fire is made with fire sticks while chanting is going on. Reed-prayer
stick bundles are prepared (which include various bird feathers, pollen,
and tobacco); through this smoke the Holy People are tricked and they
burn the arrow, which is smuggled into the bundle—an arrow that has
affected the patient negatively; the patient carries these items about half a
mile in each of the cardinal directions and deposits them. The chanting
recounts the exploits of the first shaman as he walks in the four directions.
In addition, plant bundles are also used on the body of the patient. A
sweating rite follows and an emetic drink (made from juniper, pine, spruce,
algae, berry, and other plant ingredients) is prepared and consumed
and rubbed on the body after the sweat. Songs guide in the identification
with the Great Coyote, and the ceremony literally proceeds inside this
cosmic being.
Basket Drum Ceremony

Two large yucca leaves are knitted together into a drumstick for use on
an upside-down wedding basket. The healing progresses, as indicated by
chants like “I am reviving my mind in the presence of the Sun. . . . The
blessing is given, the blessing is given.” Each basket-drum session ends
with a feather burning rite.
Sand Painting Ceremony

During these ceremonies, the ye’ii or gods or holy people appear. The
sand paintings represent the cosmos in a controllable form. The image
recounts the emergence of humans as well as the origin of the Coyote
Way. The sand painting, depicting Holy People and corn, is an image of
balance, and the patient is placed on it while the ye’ii work on him or her
by administering medicines. In this way, the patient is literally, physically
moved from a place of imbalance and ill health onto a place of balance
and healing (by sitting in the balanced cosmos of the sand painting).
Hypnotic-like procedures affect the mentation of both the hataałii and
the patient during the chant. Sandner (1979) pointed out that the hataałii’s
performance empowers the client by creating a “mythic reality,” an invoca-
tion of cosmic balance, through the use of chants, dances, and songs (often
accompanied by drums and rattles), masked dancers, purifications (e.g.,
sweats, purgings, herbal infusions, ritual bathings, sexual abstinence), and
sand paintings. Joseph Campbell (1990) described the colors of the typical
sand painting as those “associated with each of the four directions” and a
dark center—“the abysmal dark out of which all things come and back to
which they go.” When appearances emerge in the painting “they break
into pairs of opposites” (p. 30).
The Navajo chants were considered by Sandner (1979) to facilitate sug-
gestibility and shifts in attention through repetitive singing and the use of
culture-specific mythic themes (p. 245). These activities prepare partici-
pants and their community for healing sessions. As we have seen in the
previous example, these healing sessions may involve symbols and meta-
phors acted out by performers, enacted in purification rites, or executed in
dry paintings (a more accurate term, since other substances are also used)
composed of sand, corn meal, charcoal, and flowers—but destroyed once
the healing session is over. Some paintings, such as those used in the
Blessing Way chant, are crafted from ingredients that have not touched
the ground (e.g., corn meal, flower petals, or charcoal).
Topper’s (1987) study of Navajo hataałii indicated that they raise their
clients’ expectations through the example they set of stability and compe-
tence. Politically, they are authoritative and powerful; this embellishes
their symbolic value as “transference figures” in the psychoanalytic sense,
representing “a nearly omniscient and omnipotent nutritive grandparental
object” (p. 221). Frank and Frank (1991) have stated it more directly:
“The personal qualities that predispose patients to a favorable therapeutic
response are similar to those that heighten susceptibility to methods of
healing in non-industrialized societies, religious revivals, experimental
manipulations of attitudes, and administration of a placebo” (p. 184).
The hypnotic-like procedures strengthen the support by family and
community members as well as the client’s identification with figures and
activities in Navajo cultural myths, both of which are powerful elements
in the attempted healing. But do these procedures deserve a description
that indicates a major shift in conscious functioning? Sandner (1979)
found that his informants were insulted when it was suggested that Navajo
hataałii change their state of consciousness to such an extent that their
sense of identity is lost; such a shift would distract the practitioners from
the attention to detail and the precise memory needed for a successful per-
formance. (This comment supports the utility of such less-loaded phrases
as “attentional shifts” and “changed patterns of phenomenological proper-
ties.”) Arguably, the self-concept of indigenous people and modern observ-
ers are different (Cushman, 1995; Kremer, 2004); the apparent greater
inclusiveness and fluidity (as far as boundaries to everyday consensual real-
ity are concerned) may make shifts in attention on certain occasions less
dramatic or less apparent, with the experient judging them to be quite nor-
mal (rather than dramatically different). Both of us observed the intertri-
bal Cherokee/Shoshone medicine man Rolling Thunder by all indications
fluidly moving in and out of profoundly different states of consciousness
while answering questions in conversation.
At best, the hataałii appear to modify their attentional states and their
patterns of phenomenological properties rather than to “alter” all of their
subsystems of consciousness, or their consciousness as a totality. Attention
determines what enters someone’s awareness. When attention is selective,
there is an aroused internal state that makes some stimuli more relevant
than others and thus more likely to attract one’s attention. A trait that is
more characteristic of shamans than a “shamanic state of consciousness”
might be the unique attention that shamans give to the relations among
human beings, their own bodies, and the natural world—and their willing-
ness to share the resulting knowledge with others (Krippner, 2002, p. 967).
HYPNOTIC-LIKE PROCEDURES IN BALI

Belo (1960) claimed to have observed similarities between the behavior
of Balinese shamans and mediums and those of hypnotized subjects.
Although there was no trained observer of hypnosis on Belo’s field trips, a
hypnotic practitioner observed several of her films and claimed to notice sim-
ilarities between “hypnotic trance” and “mediumistic trance.” In these other-
wise useful descriptions, we can observe the proclivity of Western observers
to use such terms as “hypnosis” and “trance” in describing shamanic proce-
dures rather than simply making direct behavioral comparisons or utilizing
the social group’s own explanations and phenomenological descriptions.
In traditional Balinese practice, the name of the main temple ceremony
is nyimpen, and the dance of Calon Arang often is performed during
nyimpen. There are several variations of the story of Calon Arang, but all
center on her revenge against the people of the ancient Hindu Javanese
kingdom of Daha after its ruler (or Raja) insults her by retracting an offer
to marry her daughter. Calling up her demon legions, she transforms her-
self into a frightening figure with ponderous hanging breasts, bulging eyes,
a long flaming tongue, and a mass of unruly flowing hair. Waving her
magic cloth, she has become Rangda, the queen of the witches, and wreaks
havoc with her powers. Understandably, this is one of the most powerful
plays in sacred Balinese drama, and its performance is typically charged
with energy and emotion.
Thong (1994), a psychiatrist who organized the first mental hospital on
Bali, noted that at the end of a performance of this dance it often takes
the efforts of a pemangku (village priest) to gently bring the dancers as well
as the spectators back to their ordinary mode of functioning. With the
help of his assistants, and armed only with holy water, the pemangku wan-
ders through the crowd sprinkling the entranced revelers; the sacred water
quickly revives them. Could this phenomenon be categorized as “mass hyp-
nosis”? Such a label would be less than accurate because, from Krippner’s
perspective following his witnessing of several performances, there was no
direct, overt goal-orientation of the affected individuals. Nor was there
anyone who “guided” participants to respond to suggestions. Therefore, the
APA Division 30 definition of hypnosis does not seem to apply to this
phenomenon, even if stretched to its limits.
In Thong’s (1994) opinion, the Balinese people’s repressed emotions find
an outlet in dance and drama—an outlet the culture has provided for them
to abreact, either vicariously or directly. Classical dance and drama in Bali,
based on legends and myths, are well attended and the more contemporary
dramatic presentations are even more widely attended. In both the classical
and contemporary performing arts, one can encounter every possible
Balinese emotion—love, joy, anger, reverence, and others. One can observe
intrigue, sexual passion, jealousy, and the violation of all the cultural
taboos. Not only do the players benefit from expressing these emotions and
breaking the taboos, but the audience attains catharsis as well. From
Thong’s perspective, the other Balinese arts—painting, sculpture, the crea-
tion of festival offerings—also help the Balinese to maintain a healthy
frame of mind. These art forms have retained their vitality; without them,
and their related cultural manifestations, the uniqueness of Bali would have
crumbled long ago.
Thong concluded that in the “altruistic trance states,” a dancer responds
to the needs of another person or a group of people. This state is usually
reached during or after the performance of a ritual and, in Bali, would
encompass all hypnotic-like phenomena during religious or healing cere-
monies as practiced by the balian, or shamanic practitioner. The practi-
tioners in this group rarely show signs of psychopathology. “Egoistic trance
states,” on the other hand, are entered in response to an individual’s per-
sonal needs. They are not preceded by a ritual and tend to occur spontane-
ously. In Bali, this state is believed to be brought about by the possession
of an individual by a bebai or evil spirit.
Thong concluded that in Balinese ritualistic dancing, the “I” gives way
to a loss of ego boundaries and a change in the body image. The Barong
dance ends with the dancers pressing kris knives against their chests as
the malevolent Rangda attempts to influence the dancers to harm them-
selves. The Barong, a benevolent “animal helper,” however, offers them
protection.
Thong determined that these hypnotic-like experiences could be divided
into three stages. During the first stage, dancers are consciously or uncon-
sciously preparing themselves; they have not yet lost reflective conscious-
ness and still retain voluntary control and decision-making capabilities.
The second stage brings intensification, at which time sense is lost and con-
sciousness is altered. During the third stage, the dancer falls into a condi-
tion of deep exhaustion but may be capable of returning to the second stage
if sufficiently aroused. The change from one stage to another can usually be
recognized by distinct somatic clues such as sighs, sobs, hisses, shouts, or
body movements.
According to Thong, the most important factor in moving from one
stage to another is the charged and expectant atmosphere that surrounds
shifting one’s attention. In other words, the social setting and expectancy
seem to be more critical than any physiological maneuver. The leaders of
the community play an important role because it is often the head of the
village, the sadeg, or some other important personage who first goes into a
“trance state,” serving as a role model for the others.
Perhaps the occurrence of hypnotic-like procedures cross-culturally is so

frequent because it plays an important cultural role. In Bali, so-called
“trance dancing” serves as a useful emotional outlet both for the dancer and
the observer. What Thong termed “altruistic trance states” are preceded by
a ceremony in which an attentional shift is expected and accepted as an in-
tegral element. The “trancers” in these dances are usually ordinary members
of the community with no more than the average number of psychological
or physical problems. These ceremonies facilitate social cohesion because
they are performed on behalf of the entire community.
What Thong called “egoistic trance states” occur outside of the ordinary
cultural context. They may involve malicious magical practices, in which
attempts are made (or are perceived to have been made) to influence,
coerce, or harm community members. These “trancers” show a tendency
for attacks of hysteria, even acute psychotic reactions and schizoid epi-
sodes. The Balinese themselves recognize these two types of “trancers” and
react differently toward each of them.

CONTEMPORARY SHAMANIC PRACTICES IN S APMI
The Sami traditions are probably best known for their use of elaborately
designed shamanic drums. The Sami people, who speak several distinct
languages, live in Sapmi, located in the Scandinavian Fennoscandia region
and on the Kola Peninsula. Rydving (1993) published a book entitled The
End of the Drum-Time that discusses the religious change at the end of the
seventeenth century with the intensification of Christianization; at that
time, the drums had to be hidden and numerous drums were destroyed or
were taken and ended up in museum collections. In recent decades, the
use of the drum has resumed, and some artisans (such as Lars Pirak) make
drums and sell them only with the promise of use (but not for show or as
mere museum pieces).
The shaman is called noaidi (the one who sees, from oaidnit, to see), and
he or she works with the drum, govadas, meaning “an instrument to de-
velop pictures with” (govva means picture) (Kallio, 1997). The drums
are instrumental in facilitating attentional shifts and modifications of the
noaidi’s pattern of phenomenological properties.
Valkeap€a€a (1991) has probably provided the most detailed evocation of
a contemporary traditional Sami worldview, which poetically celebrates the
power of the sun, beaivi; the title of the book is The Sun, My Father. It is a
work of healing that is effected by bringing old pictures taken by anthropol-
ogists from museum archives back to the land of the Sami people, Sapmi. It
is a shamanic work of art that utilizes traditional chanting (yoiking), sounds
of nature, poetry, and imagery to immerse the reader in the Sami world.
Nils-Aslak Valkeap€a€a is usually just known by the honorific Ailu or

Ailoha s, and his shamanic gifts are apparent in his numerous publications
and compact discs (CDs).
Places of offering, sieddit, play an important part in Sami traditional
practices; they can be found all over Sapmi. Frequently these are cracks in
rocks, and coins and other objects can usually be found in them. A rock
carving in Jiepmaluokta (Bay of Seal Cubs, near Alta, Norway) depicts the
offering of a reindeer eye to the earth (it dates to approximately 4200–
3600 BCE). One of the most interesting offering stones can be found at the
center of a spiral. Its name, Ceavccagead-gi (Fish Oil Stone), identifies a
place where offerings of gratitude for a good catch were and are made (it
is located on the northernmost fjord, Varangerfjord, opposite the Kola
Peninsula). In the Sami worldview, every person has an immortal farrosas,
a journey companion. The shaman or noaidi has three “animal helpers”:
saivoloddi, a bird that shows where to go; saivoguolli, a fish that helps enter
the underworld; and saivosarva, a reindeer, which could fight on behalf of
the noaidi (Kallio, 1997; Siri, 1998). Pirak (1996, personal communication)
related a dramatic tale of a shamanic fight that involves several instances
of shape shifting, including the transformation of one noaidi into a power-
ful loon. Ultimately, one of the shamans who were standing trial for
shamanizing or noaidivuohta is absolved of wrongdoing because the judge
acknowledges how beneficial his actions were.
For the Sami, shamanic traditions are returning in various ways, includ-
ing dreams that contain shamanic elements such as eagles, sunbeams, and
humans “with wings spread” (Siri, 1998, p. 34). Rock carvings showing
people with wings have been found in Scandinavia. The Sami traditions
see the sun as the giver of light, warmth, and fertility; sunbeams create
soul and spirit that travels to First Father who sends it on to First Mother
who creates a body for the soul. Kallio comments: “The first shaman was a
woman, the daughter of Sun and Eagle. Today this woman lives in a tree,
and that is where the shamans get their education” (in Siri, 1998, p. 34).
The design of old drums frequently has the sun at its center; it is under-
stood as the gateway or portal into the spirit world (Kallio, 1996, personal
communication); reindeer commonly stand right next to it. White rein-
deer carry particular shamanic significance.
The drum is used in two distinct ways: (1) to prophesize—with the help
of a ring, reindeer bone, or frog skin that moves across the drumhead dur-
ing drumming and lands on particular images that then get interpreted
(this use of the drum is illustrated in the movie Pathfinder, where it is used
to determine who is to kill a bear); and, (2) as an instrument for shamanic
journeying, where it is often used together with chanting.
Kremer experienced noaidivuohta (shamanic activity) on numerous occa-
sions in Sapmi along the river Deatnu. For one such ceremony, the setting
was a lavvu, the traditional Sami tipi out on the tundra by a lake. The cer-
emony commenced late in the evening when the midnight sun was low,
above the horizon. The drum used by Biret Maret Kallio was contemporary
in design and had been given to her by another noaidi; the images
reflected, as in older designs, the Sami worldview and “animal helpers”
with whom she has a particular relationship. The initial conversation cov-
ered a variety of shamanic topics, including how many white reindeer
Kremer had encountered during this trip. The birch wood fire with its par-
ticular smell, together with the smoke of the local juniper (reatka), were at
the center. Coffee was offered to Sarahkka, arguably the most important
female spirit in daily life; she lives in the fire and is one of three daughters
of Mattarahkku (the Tribal Mother or Mother Earth).
Old drums frequently depict the three sister spirits in the center. The
offering to the hearth (arran) was mandatory before beginning the shamanic
journeying work. The drumming was accompanied by chanting, at times
overtone chanting, and repeated loud invocations of the bear, guovza. The
combination of the setting, timing, smells of the fire, drumming, and chant-
ing facilitated a profound alteration of consciousness and intense experiences
of visual imagery. At the end, the three participants shared their experiences.
Kremer noticed profound attentional shifts; some of them hypnotic-like in
nature.
By contrast to Dine chantways or other Native American ceremonies,
such as those held by the Native American Church, the observations of
Sami noaidivuohta were characterized by informality and a spontaneous or
inspirational approach. Other settings included work with groups in the
lavvu and shamanizing using the drum in order to protect threatened pre-
historic sites. These procedures are complex performances that are not
covered by Division 30’s definition of hypnosis, but call for appreciation in
their own right.
AFRICAN-BRAZILIAN MEDIUMSHIP PROCEDURES

Unusual experiences were common in early West African cultures
where individuals were considered to be closely connected with nature,
the community, and their communal group. Each person was expected to
play his or her part in a web of kinship relations and community networks.
Strained or broken social ties were held to be the major cause of sickness.
A harmonious relationship with one’s community, as well as with one’s
ancestors, was important for health. At the same time, an ordered relation-
ship with the forces of nature, as personified by the orixas or deities, was
essential for maintaining the well-being of the individual, the family, and
the community. West Africans knew that disease often had natural causes,
but believed that these factors were exacerbated by discordant relation-
ships between people and their social and natural milieu. Long before
Western medicine recognized the fact, Africa’s traditional healers took the
position that ecology and interpersonal relations affected people’s health

(Raboteau, 1986).
West African healing practitioners felt that they gained access to un-
usual powers in three ways: by making offerings to the orixas, by foretelling
the future with the help of an orixa, and by incorporating an orixa (or even
an ancestor) who then diagnosed illnesses, prescribed cures, and provided
the community with warnings or blessings. The person through whom the
spirits spoke and moved performed this task voluntarily, claiming that such
procedures as dancing, singing, or drumming were needed to surrender
their minds and bodies to the discarnate entities. The slaves brought these
practices to Brazil with them; despite colonial and ecclesiastical repression,
the customs survived over the centuries and eventually formed the basis
for a number of robust Afro-Brazilian spiritual movements. Books about
spiritualism by a French educator, Alan Kardec, were brought to Brazil,
translated into Portuguese, and became the basis for a related spiritistic
movement (Spiritism or Espiritismo). There were followers of Mesmer in
this group, but Kardec proposed that spirits, rather than Mesmer’s invisible
fluids, were the active agent in altering consciousness, removing symptoms,
and restoring equilibrium (Richeport, 1992, p. 170).
Contemporary iyalorixas or m~aes dos santos (“mothers of the spirits”) and
babalawos or p~aes dos santos (“fathers of the spirits”) still teach apprentices
how to sing, drum, and dance in order to incorporate the various deities,
ancestors, and spirit guides. They also teach the iaôs (“children of the orixas”)
about the special herbs, teas, and lotions needed to restore health, and about
the charms and rituals needed to prevent illness. The ceremonies of the vari-
ous African-Brazilian spiritistic groups (e.g., Candomble, Umbanda, Batuque,
Quimbanda, and Xango) differ, but all share three beliefs: humans have a
spiritual body (that generally reincarnates after physical death); discarnate
spirits are in constant contact with the physical world; humans can learn
how to incorporate spirits for the purpose of healing (Krippner, 2000).
Shamans predated mediums in prehistory; Winkelman (2000) has provided a
useful delineation and description of these two groups of practitioners and
how their functions both differ and overlap.
Once the apprentices begin to receive instruction in mediumship, such
experiences as spirit incorporation, automatic writing, “out-of-body” travel,
and recall of “past lives” lose their bizarre quality and seem to occur quite
naturally. Socialization processes provide role models and the support of
peers. A number of cues (songs, chants, music, etc.) facilitate “spirit incor-
poration,” and a process of social construction teaches control, appropriate
role taking, and communal support. Richeport (1992) observed several
similarities between these mediumistic behaviors and those of hypnotized
subjects, for example, high motivation, the positive use of imagination,
and frequent amnesia for the experience. However, the guidance given
apprentices by their mentors only shows a superficial resemblance to
Division 30’s definition; for example, there is no formal induction, yet

the ceremony is more directive and structured than what one finds in
Ericksonian hypnosis and related procedures.
It should be noted that mediums resemble shamans in many ways but
lack the control of their attention that characterizes shamans. For exam-
ple, shamans are usually aware of everything that occurs while they con-
verse with the spirits, even when a spirit “speaks through” them. Many
mediums claim to lose awareness once they incorporate a spirit, and pur-
port to remember little about the experience once the spirit departs.
The traits most admired by fellow mediums and the larger community
resemble those traits that facilitate ordinary social interactions. Leacock
and Leacock (1972) observed that the Brazilian mediums in their study
usually behaved in ways that were “basically rational,” communicated
effectively with other people, and demonstrated few symptoms of hysteria
or psychosis. They engaged in intensive training and, as mediums, pursued
hard work that often put them at risk with seriously ill individuals
(p. 212). Such training and discipline are not likely to be the favorite pas-
times of fragile personalities or malingerers.
In dozens of African-Brazilian ceremonies and rituals that Krippner has
witnessed, a “trance” was induced by the rhythmic drumming and move-
ment as well as by the assault on the senses produced by the music,
incense, flickering candles, and—in some temples—pungent cigar smoke.
But it was apparent to him that powerful demand characteristics were also
at work. The very reason for the mediums’ presence was the incorporation
of spirits; as Kleinman (1980) argued, “providing effective treatment for
disease is not the chief reason why indigenous practitioners heal. To the
extent that they provide culturally legitimated treatment of illness, they
must heal” (p. 362).
In addition, the community of believers depended on the mothers,
fathers, and children of the orixas to provide a connection to the spirit
world that would ensure the well-being of the temple, prevent illness
among those who were well, and bestow healing upon those who were
indisposed. Krippner observed that when one medium incorporated an orixa
or spirit, an entire series of incorporations soon followed, domino like. Just
as many participants in hypnotic sessions seem eager to present themselves
as “good subjects” (Spanos, 1989), the mediums in Afro-Brazilian healing
sessions may be eager to present themselves as “good mediums,” and to
enact behaviors consistent with this interpretation. Krippner also noticed
that the presence of visitors appeared to increase both the speed and the
dramatic qualities of spirit incorporation.
A fairly consistent similarity among mediums is their supposed inability
to recall the events of the incorporation after the spirits have departed.
However, Spanos (1989) has pointed out that this amnesic quality could
just as easily be explained as an “achievement”; each failure to remember
“adds legitimacy to a subject’s self-presentation as ‘truly unable to remem-

ber,’ ” hence as deeply in “trance” (p. 101). In other words, the interpreta-
tion of hypnotic phenomena as goal-directed action is helpful in
understanding mediumship as an activity that meets role demands, as
mediums guide and report their behavior and experience in conformance
with these demands. It may not be that they lose control over the behavior
as they incorporate a spirit, but rather that they engage in an efficacious
enactment of a role that they are eager to maintain.
An alternative point of view would hold that the mediums actually do
lose control over their behavior, entering a “trance” state that allows
“hidden parts” of themselves to manifest as secondary personalities or, in
the case of the Brazilian mediums, as spirits. But some Brazilian practi-
tioners with whom Krippner discussed these issues made comments that
indicated that both the “role-playing” and “dissociative” paradigms merely
describe the mechanisms by which a medium actually incorporates the
orixa, discarnate entity, or spirit. It is the incorporation itself, and the sub-
sequent behavior of the spirit, that represent the crux of mediumship.
African-Brazilian spiritistic ceremonies enable clients and mediums to
arrive at a shared worldview in which an ailment can be discussed and
treated (Torrey, 1986). In some spiritistic traditions, there are mediums
who specialize in diagnosis, mediums who specialize in healing through a
laying-on of hands, mediums who specialize in purported distant, nonlocal
healing, and mediums who specialize in intercessory prayer. Treatment may
also consist of removing a “low spirit” from a client’s “energy field,” inte-
grating one’s “past lives” with the present “incarnation,” the assignment of
prayers or service-oriented projects, or referral to a homeopathic physician.
All of these procedures contain the possibility of enhancing clients’ sense
of mastery, increasing their self-healing capacities, and replacing their
demoralization with empowerment (Frank & Frank, 1991; Torrey, 1986).
The mediums are not the only ones who appear to manifest hypnotic-
like effects. Their clients also demonstrate apparent attentional shifts,
especially while undergoing crude surgeries without the benefit of anes-
thetics; however, Greenfield (1992) has observed that the Brazilian
mediums make no direct effort to alter their clients’ awareness during these
interventions. Greenfield has observed that “no one is consciously aware of
hypnotizing . . . patients . . . , and unlike the mediums, patients participate
in no ritual during which they may be seen to enter a trance state”
(p. 23). However, there are a number of cultural procedures that Green-
field found to be hypnotic-like in nature. One of them was the relationship
of client and healer, characterized by trust, and resembling “that between
hypnotist and client” (p. 23) in that these clients act positively in response
to what the medium tells them. Another procedure is the provision of a
context that allows the client to become totally absorbed in the interven-
tion, a healing ritual that galvanizes the client’s attention, and distracts
him or her from feeling pain. Greenfield added that the spiritistic aspects
of Brazilian culture foster “fantasy proneness” because large numbers of
people believe that preternatural entities are helping (or hindering) them
in their daily lives (p. 24).
Rogers (1982) has divided native healing procedures into several catego-
ries (p. 112): nullification of sorcery (e.g., charms, dances, songs); removal
of objects (e.g., sucking, brushing, shamanic “surgery”); “expulsion” of
harmful entities (e.g., fighting the entity, sending a spirit to fight the entity,
making the entity uncomfortable); retrieval of “lost souls” (e.g., by “soul
catchers,” by shamanic journeying); eliciting confession and penance (e.g.,
to the shaman, to the community); transfer of illness (e.g., to an object, to
a “scapegoat”); suggestion and persuasion (e.g., reasoning, use of ritual, use
of herbs); and shock (e.g., sudden change of temperature, precipitous physi-
cal assault). There are hypnotic-like segments of these procedures that
utilize symbols, metaphors, stories, and rituals—especially those involving
group participation.
CONCLUSION
Hypnosis is a noun while hypnotic-like is an adjective, hence the use of the
former term lends itself to abuse more easily than utilization of the latter. This
distinction is important when one reads such accounts as that by Torrey
(1986) who surveyed indigenous practitioners, concluding—on the basis of an-
ecdotal reports—that “many of them are effective psychotherapists and pro-
duce therapeutic change in their clients” (p. 205). Torrey observed that when
the effectiveness of therapeutic paraprofessionals has been compared, professio-
nals have not always been found to demonstrate superior therapeutic skills.
The sources of the effectiveness of professional psychotherapists, paraprofes-
sional therapists, and native healing practitioners are four basic components of
psychotherapy—a shared worldview, impressive personal qualities of the healer,
positive client expectations, and a process that enhances the client’s learning
and mastery (p. 207). We would suggest that an adjective such as psychothera-
pist-like would be a more accurate term than Torrey’s use of the noun psycho-
therapist in describing native practitioners; however, we are quite comfortable
with Strupp’s (1972) description: “The modern psychotherapist . . . relies to a
large extent on the same psychological mechanisms used by the faith healer,
shaman, physician, priest, and others, and the results, as reflected by the evi-
dence of therapeutic outcomes, appear to be substantially similar” (p. 277).
Especially valuable are qualitative analyses of the experiences of both
practitioners and their clients. Krippner (1990) has used questionnaires
to study perceived long-term effects following overseas visitors’ trips to
Filipino and Brazilian folk healers, finding such variables as “willingness to
change one’s behavior” to significantly correlate with reported beneficial
modifications in health. Cooperstein (1992) interviewed ten prominent
alternative healers in the United States, finding that their procedures

involved the self-regulation of their “attention, physiology, and cognition,
thus inducing altered awareness and reorganizing the healer’s construction
of cultural and personal realities” (p. 99). Cooperstein concluded that the
concept that most closely represented his data was “the shamanic capacity
to transcend the personal self, to enter into multiform identifications, to
access and synthesize alternative perspectives and realities, and to find sol-
utions and acquire extraordinary abilities used to aid the community”
(p. 121). Indeed, the shaman’s role and that of the alternative healer are
both socially constructed, as are their operating procedures and their
patients’ predispositions to respond to the treatment. It is not only impor-
tant to study the effects of the hypnotic-like procedures found in native
healing, but to accurately describe them, and understand them within their
own framework. Kremer and Krippner (1994) have used questionnaires
and self-reports to assess alterations and shamanic journeying content of
inexperienced subjects assuming purported trance postures and were only
able to partially support Goodman’s (1990) claims as to the specificity
of the experience induced by different postures (which were based on
shamanic sculptures and rock carvings).
The professionalization of shamanic and other traditional healers dem-
onstrates their similarity to practitioners of Western medicine (Feinstein &
Krippner, 1997). Nevertheless, the differences cannot be ignored. Rogers
(1982) has contrasted the Western and native models of healing, noting
that in Western medicine, “Healing procedures are usually private, often
secretive. Social reinforcement is rare. . . . The cause and treatment of
illness are usually regarded as secular. . . . Treatment may extend over a pe-
riod of months or years.” In native healing, however, “Healing procedures
are often public: many relatives and friends may attend the rite. Social rein-
forcement is normally an important element. The shaman speaks for the
spirits or the spirits speak through him [or her]. Symbolism and symbolic
manipulation are vital elements. Healing is of limited duration, often last-
ing but a few hours, rarely more than a few days” (p. 169).
Rogers (1982) has also presented three basic principles that underlie the
indigenous approach to healing: The essence of power is such that it can be
controlled through incantations, formulas, and rituals; the universe is con-
trolled by a mysterious power that can be directed through the meticulous
avoidance of certain acts and through the zealous observance of strict obli-
gations toward persons, places, and objects; the affairs of humankind are
influenced by spirits, ghosts, and other entities whose actions, nonetheless,
can be influenced to some degree by human effort (p. 43). This world-
view—one that fosters the efficacy of hypnotic-like procedures—varies
from locale to locale but is remarkably consistent across indigenous cul-
tures. The ceremonial activities produce shifts of attention for both the
healer and the client. The culture’s rules and regulations produce a
structure in which the clients’ motivation can operate to empower them

and stimulate their self-healing aptitudes.
Western practitioners of hypnosis utilize the same human capacities
that have been used by native practitioners in their hypnotic-like proce-
dures. These include the capacity for imaginative suggestibility, the ability
to shift attentional style, the potential for intention and motivation, and
the capability for self-healing made possible by neurotransmitters, internal
repair systems, and other components of mind/body interaction. These
capacities often are evoked in ways that resemble Ericksonian hypnosis
(Erickson, Rossi, & Rossi, 1976) because of their emphasis on narrative
accounts. Hypnosis and hypnotic-like activities are complex and interac-
tive, and hence take different forms in different cultures. Yet, as with any
form of intervention, “the mask . . . crafted by the group’s culture will also
fit a majority of its members” (Kakar, 1982, p. 278). The multidimension-
ality of indigenous hypnotic-like approaches can be seen as an important
characteristic that appear to apply cross-culturally.
It has become increasingly apparent to cross-cultural psychologists that
the human psyche cannot be extricated from the historically variable and
diverse “intentional worlds” in which it plays a co-constituting part. Suppos-
edly, writing makes reality accessible by representing consensual reality, but
far too often it becomes a substitute for the reality it purports to represent
(Krippner, 1994). Therefore, we are dismayed when we see Western terms
haphazardly applied to frenetic actions; for example, amok in Indonesia
has been called “a trance-like state” and latah “a condition akin to hysteria”
(Suryani & Jensen, 1993). The cross-cultural exploration and knowledge
exchange about hypnotic-like procedures poses significant paradigmatic and
epistemological challenges that both authors have explored in other places
(Kremer, 1994, 1996, 2000, 2002b, 2004; Krippner, 2000, 2004; Krippner &
Winkler, 1995). By investigating ways in which different societies have
constructed diagnostic categories and remedial procedures, therapists and
physicians can explore novel and vital changes in their own procedures—
hypnotic and otherwise—that have become obdurate and rigid.
Western medicine and psychotherapy have their roots in traditional
practices and need to explore avenues of potential cooperation with native
practitioners of those healing methods that may still contain wise insights
and practical applications. Using APA Division 30’s useful definition as a
guide, we hope that Western terms will not be superimposed on indigenous
shamanic and mediumistic practices that deserve to be studied and appre-
ciated in their own context.
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Chapter 7
Lay Hypnotherapy and the Credentialing

of Zoe the Cat
Steve K. D. Eichel
Just a ball of confusion, oh yeah, that’s what credentialing is today.

(Apologies to The Temptations)
The issue of credentialing in hypnosis has always been a confusing one. It

reflects the intermittent battle between “lay” hypnotists and health profes-
sionals who utilize hypnosis (“clinical hypnotists”).1 Recent attempts to
establish a solid credentialing process, such as the certification programs
established by the American Society of Clinical Hypnosis (ASCH), may
have inadvertently made the situation even worse.
I don’t know if I helped matters. I spent nearly a decade serving on the
board of governors of the Greater Philadelphia Society of Clinical Hypnosis.
During those years, I grew increasingly uneasy with the growing acceptance
lay hypnosis seemed to be enjoying in the media, despite some of its spokes-
persons’ clearly dubious claims and equally questionable backgrounds. Publi-
cations in the alternative health field were especially welcoming to lay
hypnotists, and often lauded and promoted lay hypnosis associations (and
their unsupported claims) in their reference and referral sections, typically
without mentioning the groups most often associated with clinical hypnosis.
I started paying closer to the questionable credentials many lay hypnotists
seemed to claim. I grew tired of sounding defensive to therapist-shopping
clients who challenged me with something on the order of: “I found some-
body with all these certifications and diplomas who charges a fraction of
what you psychologists charge, and promises to cure me in one or two
sessions.” In 2002, in a somewhat rash attempt to deal with my growing frus-
trations, I decided to prove a point. I got my cat certified.
There is a back story to my actions. I had become involved in a lay hyp-
nosis association, the Association to Advance Ethical Hypnosis (AAEH),
back in the early 1980s. I did not qualify for membership in ASCH because,
at the time, they did not accept masters-level practitioners (even though I
was a licensed psychologist). My experience with AAEH brought me in
touch with several other lay associations (there seem to be significant cross-
memberships). I found much to like, and sometimes more to dislike, in these
associations. For one, most of them supported and even encouraged stage
hypnosis (AAEH did not, which is one of the reasons I gravitated toward
it). I did receive some good training. However, some of the training was du-
bious. For example, I was instructed in highly simplistic methods for dealing
with some fairly serious psychological issues, including chronic depression,
trauma, and addiction. “Research” in support of many of these methods con-
sisted of anecdotal reports from practitioners. Other methods had empirical
support but were taught out of context. The majority of the people I met at
various meetings and workshops sponsored by lay associations had no train-
ing whatsoever in a healing art, yet were being taught intensive therapeutic
techniques, like hypnotic regression to treat trauma. As I became more fa-
miliar with people considered to be “master hypnotists” and leaders within
the lay associations, I discovered that a significant number of them claimed
degrees and credentials that were suspect and, in some cases, unearned.2 I
became even more disturbed. After two years, I severed my relationship with
these associations.
The independent practice of psychology is a competitive activity, albeit
(compared with other endeavors and even professions) a relatively genteel
one with fairly strict rules. I was used to answering questions from poten-
tial clients about my practice, experience, and qualifications without say-
ing anything about my competitors. However, I was unprepared to deal
with inquiries about “certified hypnotherapists” who appeared to have im-
pressive credentials that I believed were bogus. “Believed” is the operative
term here; I had no real proof. So in late 2001, I decided to get some.
Getting Zoe certified as a hypnotherapist was easier than I imagined.
All it took was some creativity and a credit card. First, I needed a full
name. I decided on a tongue-in-cheek name, “Zoe D. Katze.” In German,
die katze literally translates into “the cat,” so my pet’s name literally meant
“Zoe the cat.” I had no problem authorizing “Zoe D. Katze” to use my
credit card. The rest was fairly easy. I went to the Web sites of what
seemed to be the three largest lay hypnosis associations: the National
Guild of Hypnotists (NGH), the American Board of Hypnotherapists
(ABH), and the International Medical & Dental Hypnosis Association
(IMDHA). I answered their questions, which included making up training
and workshop experiences, falsifying dates, and so forth. I (or Zoe) was
never asked for proof of the training experiences, a professional license of
any sort, or for that matter any kind of proof of anything. All that seemed
to really matter was having a valid credit card number.
Lay Hypnotherapy and the Credentialing of Zoe the Cat 127
Within a few weeks, Zoe’s certificates arrived. One attested to her hav-
ing “completed the required studies” in order to be “found by the Board of
Directors to possess the qualifications” to be a certified hypnotherapist.
Two certificates alluded to an actual examination process by stating she
had “been found by the Board of Examiners to possess the education and
training qualifications . . .” or that she “demonstrated knowledge and profi-
ciency satisfactory to the Examining Committee.” One of the certificates
proclaimed her as “authorized to the lawful professional title of Certified
Hypnotherapist.” Needless to say, the only examination Zoe could have
passed would have been by a veterinarian.
Having obtained several hypnosis certifications, I then decided to extend
my experiment to an organization I resigned from after concluding that it
was nothing more than a credentials mill. This time, I was applying for
board certification in psychotherapy through the American Psychotherapy
Association (not to be confused with the American Psychological Associa-
tion). In medicine, board certification (also known as Diplomate status) is
understood to be the highest level of competency that can be formally
assessed. It is a postgraduate, post-licensure process that involves a review of
credentials, experience (in medicine, usually a postgraduate fellowship) and
then an intensive examination by a panel of one’s peers. The examination
is considered to be more rigorous than the profession’s licensing exam. It is
the equivalent of moving from journeyman to master craftsman.
After filling out another Internet application and authorizing payment

of the requisite fee, Zoe received a call a few days later (the fact that her
name was not on my answering machine did not seem to raise any suspi-
cions) advising her that she would need to submit a curriculum vitae (CV)
to complete her “examination” process. I decided to have some fun with
this. Of course, I first gave her an academic history, including a PhD from
a made-up university. Not content with the clue inherent in her name, I
peppered her CV with various other clues to Zoe’s real identity, including
such gems as an academic appointment at “Garfield School of Nursing”
and an employment history that included positions with “Lagata Commu-
nity Mental Health Center,” “St. Felix Home for Children,” and my per-
sonal favorite, “Tacayllaermi Friends School” (“Tacayllaermi” being “I’m
really a cat” spelled backwards). A few weeks later, Zoe received her
diploma. Her congratulatory letter proclaimed that achieving Diplomate
status “is limited to a select group of professionals who, by virtue of their
extensive training and expertise, have demonstrated their outstanding abil-
ities in regard to their specialty.”
Having contented myself that I now had proof of what I had long
suspected about the illegitimacy of some hypnosis and psychotherapy
credentialing services, I initially sat on this information, not knowing what

(if anything) to do next. However, my question was soon answered as the
referrals to “Dr. Zoe D. Katze” began to come in. Zoe was even approached
to do an interview for a major magazine about “hypnobirthing.” I eventu-
ally grew tired of explaining why “Dr. Katze” could not see clients or grant
interviews, and in 2002 decided to post an article (Eichel, 2002) on my per-
sonal Web site so I could refer people to it rather than be engaged in
lengthy discussion.
I am unsure how Mark Hansen, a legal affairs writer for the American
Bar Association, found my article. Two years previous to my article, Hansen
had published “Expertise to Go,” an article highly critical of the American
College of Forensic Examiners (ACFE). The organization that board certi-
fied Zoe was the American Psychotherapy Association, an offshoot of
the ACFE. Mark called me after he read my article and interviewed me
extensively. In October 2002, Hansen published “See the Cat? See the
Credentials? Psychologist’s Scam Gets His Pet ‘Board-Certified.’” Hansen
concentrated primarily on Zoe’s board certification as a psychotherapist; to
me, her certification as a hypnotherapist seemed equally problematic.
The Bar Association’s electronic journal is far more conspicuous than
my personal Web site. Since her debut in Hansen’s article, Zoe’s story has
appeared in hundreds of Web articles, a variety of university psychology
courses, several licensing board citations, numerous articles, and at least
one book. Sources as diverse as the James Randi Foundation and Skeptical
Inquirer, John Bear (a former FBI expert on diploma mill scams), and the
False Memory Syndrome Foundation have picked up this story. At least
two editorials have been written about me in a major lay hypnosis journal,
and on one occasion I had to threaten legal action against a lay hypnotist
who referred to me as an immoral “liar and cheat” in an online publica-
tion. In 2005, I wrote a follow-up article for an online hypnosis informa-
tion clearinghouse (Eichel, 2005) in which I further detailed some of the
aftermath of Zoe’s fame. In July 2009, Zoe’s story and pictures (including
her certificates) appeared on a news program in San Diego, California, in
connection with a civil suit filed against a custody evaluator who is alleged
to have bogus certifications. In August 2009, I was interviewed by BBC
reporter Andy Smythe, who conducted a similar experiment in Great
Britain and successfully got his own cat (George) certified by various
United Kingdom lay hypnosis associations.
A BRIEF HISTORY OF HYPNOSIS CREDENTIALING

Credentialing in hypnosis has a complicated history. Following the
debunking of Mesmer and his assertion that “animal magnetism” was the
basis of mesmerism, the medical use of hypnosis was treated with benign
neglect (when not actively discouraged) despite some fairly significant
claims attesting to its usefulness, especially in surgery (as an anesthesia).
In European psychiatry and neurology, hypnosis continued to be taught
and pioneered by Jean-Martin Charcot, Hippolyte Bernheim, and Pierre
Janet. Joseph Breuer and his colleague Sigmund Freud pioneered hypno-
analysis. However, Freud later disavowed hypnosis and claimed it was
vastly inferior to his new analytic technique, free association. Generations
of psychiatrists trained in the Freudian tradition followed suit. In surgery,
advances in chemical anesthesia rendered the labor-intensive and less reli-
able induction of hypnosis all but moot. Hypnosis enjoyed a resurgence fol-
lowing World War II when it was used by some psychiatrists to facilitate
abreaction in cases of “war neurosis” or “battle fatigue” (later recognized as
post-traumatic stress disorder). However, for most Americans hypnosis was
primarily associated with stage entertainers, charlatans, and horror/science
fiction movies.
As medicine disavowed or merely ignored hypnosis, and with the nascent
field of clinical psychology still firmly under the boot of psychiatry, others
outside the medical field quickly filled the void. First to arrive on the scene
were the stage hypnotists. Their goal was to entertain, not to heal; they had
little or no dedication to the professionalization or scientific exploration of
hypnosis. In fact, just the opposite was true. Many stage hypnotists, includ-
ing prominent lay hypnotist Ormond McGill, encouraged the association of
hypnosis with supernatural powers as a way of increasing its mystique and
stage appeal (McGill, 1996). Further sullying the reputation of hypnosis,
many stage entertainers began utilizing the title “Doctor” to promote their
art; Ormond McGill, for example, used the stage name “Dr. Zomb.” (To this
date, there are many lay hypnotists who claim doctorates, often from
diploma mills or schools that are not accredited by an agency recognized by
the U.S. Department of Education or foreign equivalents.3)
LAY HYPNOSIS CREDENTIALING

The first lay hypnosis certification in the United States was probably
the National Guild of Hypnotists (NGH), founded in 1951 by Rexford
North. The Association to Advance Ethical Hypnosis (AAEH), founded
in 1956 by Harry Arons, also began certifying lay hypnotists (called
“Hypnosis Consultants”) in the late 1950s. Part of Arons’s motivation was
his belief that lay hypnotists need an ethics code, one that explicitly for-
bids its Hypnosis Consultants from practicing outside their area of exper-
tise or from claiming degrees from unaccredited universities.4 It also
discouraged members from engaging in stage hypnosis for entertainment
purposes (AAEH, 2009). To date, the NGH claims to be the single largest
hypnosis association that has credentialed the largest number of “certified
hypnotherapists” in the United States.
For many years, the second largest lay hypnosis credentialing organiza-
tion was the American Council of Hypnotist Examiners (ACHE). The
ACHE grew out of the California-based Hypnotist Examining Council,
founded in 1973. With Gil Boyne as its first president, the ACHE went
national in 1980. Boyne claims a PhD in transpersonal psychology from
Westbrook University in New Mexico, an unaccredited institution that
has been called a diploma mill by FBI “DipScam” consultant Dr. John Bear
(2003). He also lists honorary degrees from Newport University and the
University of Humanistic Studies in California5; the former has been
accused of committing academic fraud.6
Another California-based organization, the American Board of Hypnother-
apy (ABH) began life in 1982 as the California Board of Hypnotherapy,
founded by A. M. Krasner. A year earlier, Krasner had founded the American
Institute of Hypnotherapy, which later morphed into American Pacific Univer-
sity, another unaccredited school/diploma mill according to Consumer Fraud
Reporting Organization (2009) and the Oregon Department of Education.
PROFESSIONAL HYPNOSIS CREDENTIALING

Although experimental psychologists, most notably Clark Hull (1933,
2002), studied hypnosis in the early half of the twentieth century, the
medical and allied clinical professions lagged behind. The first professional
hypnosis association, the Society for Clinical and Experimental Hypnosis
(SCEH), was founded in 1949. In 1955, the British Medical Association
was the first to recognize hypnosis as a scientifically legitimate therapeutic

technique. In 1957, the American Society of Clinical Hypnosis (ASCH)
was founded by Milton Erickson, MD. Membership in either SCEH or
ASCH required a doctorate in medicine, dentistry, or psychology.7
For many years, the only formal credential for health professionals was the
diploma (board certification) in hypnosis issued by one of the constituent
boards of the American Boards of Hypnosis (now called the American Boards
of Clinical Hypnosis), which formed in the late 1950s. The ABCH consists
of four constituent boards, the American Board of Medical Hypnosis, the
American Board of Psychological Hypnosis, the American Board of Hypnosis
in Dentistry, and the American Hypnosis Board for Clinical Social Work.
Each board conducted both written and oral examinations; successful comple-
tion of these examinations led to board certification in hypnosis and Diplo-
mate status. The diploma from the ABCH has been formally recognized by
the International Society of Hypnosis (ISH), ASCH, SCEH, and the Ameri-
can Psychological Association. Prior to 1972, psychologists applying for board
certification also had to be diplomates of the American Board of Professional
Psychology (ABPP), perhaps because some states still did not have psychol-
ogy licensing laws on their books. Most health professionals did not feel the
need for board certification in hypnosis, but instead seemed satisfied that their
licenses and memberships in ASCH and/or SCEH were sufficient to commu-
nicate their training and competence in hypnosis.
In order to qualify for membership in either ASCH or SCEH, professionals
were required to obtain appropriate training as clinicians and/or researchers.
They had to show proof of licensure (when applicable) and/or full member-
ship in their professional association. However, lay hypnotists, perhaps realiz-
ing that medicine and psychology were not going to include them, were eager
to claim hypnosis as a separate and independent profession. The largest lay
hypnosis association, the National Guild of Hypnotists (NGH), was founded
in 1951, two years after SCEH and six years before ASCH.
Several factors combined to lead ASCH to institute its own certifica-
tion program. First, there was a growing awareness of a need for a “middle
path” between ASCH/SCEH membership and ABCH board certification,
one that would be meaningful but attainable without the obstacle of a
cumbersome board certification exam. According to some ASCH officers
with whom I have spoken, there was also a realization that many health
professionals were seeking and obtaining hypnosis certification and that
ASCH had essentially ceded this market to the lay associations. ASCH
was also losing membership and revenue, and there were some who
believed a certification program might be one way of reinvigorating the
association by drawing in both new members and a new revenue source.
ASCH developed a unique certification plan, with two levels.8 Both certif-
ications require a minimum of a master’s degree from a regionally accred-
ited institution, licensure or certification as a health professional, and
membership in one’s professional association. The entry level certification

(“Certification in Clinical Hypnosis”) requires a minimum of 40 hours of
ASCH-approved workshop training, a minimum of 20 hours of individual-
ized training/consultation with an ASCH-approved consultant, and a min-
imum of two years of independent practice utilizing clinical hypnosis. The
second and more advanced level of certification, called “Approved Consul-
tant in Clinical Hypnosis,” is for those professionals who want to train and
supervise9 professionals seeking the entry level certification. It requires a
minimum of 60 additional hours of ASCH-approved workshop training, a
minimum of five years of independent practice utilizing clinical hypnosis,
and a minimum of five years of membership in ASCH, SCEH, or equiva-
lent (ASCH, 2009).
Two other associations, the National Board for Certified Clinical Hyp-
notherapists and the American Psychotherapy and Medical Hypnosis
Association, state their certification programs are limited to graduate-level
and/or state-licensed health practitioners. Both are relatively small pro-
grams and/or do not seem to impact the field of clinical hypnosis in an
identifiable, organized fashion.
At present, lay “certified hypnotherapists” far outnumber those certified by
ASCH or ABCH. I counted over 40 lay hypnosis associations in the United
State10 that together claim to have certified over 40,000 people, including
apparently an unknown number of teenagers.11—and at least one cat.
WHAT’S THE BIG DEAL?

Furthermore, America suffers not only from a lack of standards, but also
not infrequently from a confusion or an inversion of standards.
—Irving Babbit
In an editorial I published in the 1997 newsletter of the Greater Philadel-

phia Society of Clinical Hypnosis, I strongly questioned the “war” between
professional hypnosis and lay hypnosis societies (Eichel, 1997, 2009).
Twelve years later, my arguments still seem relevant.
The official position held by ASCH, SCEH, ISH, and APA Division 30
is that lay hypnosis and the training of lay hypnotists constitutes unethical
practice. The ASCH by-laws and ethics code are clear and specific: hypnosis
is a treatment modality—not a treatment in and of itself—that should be
strictly limited to qualified practitioners of the healing arts. Of course,
ASCH has over the years modified its view of who is “qualified.” Master’s-
level licensed psychologists and professional counselors were not considered
qualified for ASCH membership until fairly recently. To qualify for certifica-
tion as a lay hypnotist, no education or training are required other than a
specified number of hours of hypnosis training. Apparently, even this
requirement can be waived (or ignored), as my cat experiment proved.
Given the lax procedures followed by the lay associations, it seems that their
certified members need not be literate (or, based on the results of my experi-
ment, human). I could not find any reliable estimate as to how many lay
people have been trained in hypnosis, and how many of those are practicing
lay hypnotists. The claims made by some of the better-known trainers
(which reach into the millions) seem exaggerated. NGH claims thousands
of certified members. It is safe to assume that there are several thousand
more that have been trained and certified by other lay hypnotist organiza-
tions. I do not know how many people have paid for the services of lay hyp-
notists over the past two decades or so, but it is probably safe to assume they
number well into the tens of thousands. At worst, this means thousands
have received incompetent and possible harmful treatment. Certainly, lay
hypnotists have (inappropriately, according to clinical hypnotists) cut into
the practices (and incomes) of health professionals.
CONFLICTING PARADIGMS
There are two fundamental—and defining—differences that distinguish
the paradigms of hypnosis espoused by lay versus clinical hypnotists.
Commitment to Science
Clinical hypnosis is predicated on rigorous scientific investigation.
SCEH and ASCH distinguish between “soft science” (e.g., case studies,
nonexperimental research) and “hard science” (e.g., quasi- and “true” ex-
perimental research), and share the belief of all formal sciences that the
latter is ultimately more valid than the former. Lay hypnosis does not
appear to make this distinction. There is a very clear preponderance of
uncontrolled anecdotal studies in the lay hypnosis articles I have read. In
fact, “hard” research is almost entirely missing from this literature, and in
some cases is even denigrated. The exception (in my limited reading) has
been when hard research appears to support the aims and purposes of lay
hypnosis (e.g., I found several references to NIH’s recent positive review of
hypnosis as a valuable adjunct to traditional medical treatment of cancer
and pain).
Hypnosis as a Distinct Profession

The other difference between lay and clinical hypnotists is more politi-
cally volatile. ASCH and SCEH are quite adamant in their belief that
hypnosis is a valuable clinical activity but does not by itself constitute
treatment. Lay hypnotists vehemently disagree. They view hypnosis as
a treatment that can be used apart from other medical and/or psychologi-
cal treatments, thus hypnosis is viewed as a distinct profession. The ABH
informational brochure, for example, states that among its purposes are “to
promote the recognition of hypnosis as a viable therapeutic modality” and
“to promote the recognition of hypnotherapy as a separate and distinct
profession” (American Board of Hypnotherapy, 1994).
The political ramifications of this paradigm dispute are manifold. If one
accepts hypnosis as a distinct profession, then hypnotists can and should
be separately trained and credentialed, and perhaps even licensed. In a
sense, this question can be reframed as, “Who owns hypnosis?” There are
several precedents for this conflict. Organized medicine’s initial opposition
to the licensing of psychologists was based on a rejection of clinical psy-
chology as a distinct profession separate from the practice of medicine.
Physicians further objected to psychologists rendering diagnoses independ-
ent of psychiatric supervision. A similar battle has been waged by organ-
ized psychology against the licensing of counselors; several state
psychology associations argued that counselors and other master’s-level
therapists should not be licensed because “counseling” or “psychotherapy”
are activities performed by psychologists, and as such do not merit recogni-
tion as distinct professions. I imagine organized psychology might have
taken clinical social work to task on this point as well, had well-recognized
forms of social work credentialing (e.g., the ACSW) not preceded psychol-
ogy licensure in many states.12
During its early battles for licensure, organized psychology successfully
pointed to organized medicine’s inability to prove that patients were being
harmed by psychologists who in fact were already practicing independently
(or under very nominal medical supervision). Organized counseling made
the same argument when faced with the opposition of state psychology
associations to counselor licensure. The same arguments have been voiced
by organized clinical hypnosis against lay hypnotists. It is important to
note here that anecdotal evidence of harm has been found by most state
legislatures to be an inadequate argument against licensure of a new health
profession. For the same reason, state attorneys have been hesitant to pros-
ecute uncredentialed/unlicensed mental health practitioners on the sole
ground of practicing a healing art without a license. Clearly, one hears far
more anecdotal complaints against physicians and psychologists than
against lay hypnotists. Lay hypnotists have noted the lack of hard evidence
that they are harming people. Some claim this battle is merely part of a
larger turf war waged to protect practitioners (as opposed to consumers) in
an era of shrinking health care dollars.
PROBLEMS GALORE
The lay hypnosis organizations I have studied profess to define, support,
and adhere to a limited scope of practice. An article about the Council of
Professional Hypnosis Organizations (COPHO), a lay hypnosis umbrella
organization that until recently included the National Guild of Hypnotists,

states that:
The member organizations in COPHO [the Council of Professional

Hypnosis Organizations] teach hypnotherapy as a vocational practice.
That is, hypnosis is understood as a helping tool to assist persons
with non-clinical or non-medical issues such as routine smoking ces-
sation, minor weight management, the finding of lost objects, general
relaxation, time management and performance enhancement at
work. The member organizations of COPHO do not teach or allow
members (unless qualified to do so by another credential) to use hyp-
nosis as a tool for the diagnosis or treatment of mental or medical
conditions. (Giles, 1995, p. 10)
However, after studying lay hypnosis literature, I find that lay hypnotists
consistently violate their purported limited scope of practice and training
with what appears to be the approval of their lay hypnosis organizations. In
1995, I analyzed the content of the “NGH Annual Convention and Educa-
tional Conference and Summer Institute” published in the June 1995 issue
of the Journal of Hypnotism. The Summer Institute listed 30 courses, 12 of
which were concerned with material I would consider appropriate only for
graduate-level counselors or therapists (e.g., “The Application of Hypno-
analytic Technique in the Practice of Clinical Hypnosis,” “Addictions
Hypnotherapy,” “Parts Therapy as Practiced by Charles Tebbets”). The
conference itself listed well over 100 seminars and workshops. Some (with
titles like “Hypnosis for Drug Addiction,” “Rational [-Emotive] Hyp-
notherapy,” and “Dealing with Traumatic Memories in Hypnotherapy
Practice”) sounded completely inappropriate for lay hypnotists. Other semi-
nars and workshops appeared to involve attempts to teach medical practice.
The 2007 NGH Annual Convention brochure listed topics like
“Borderlines among Us,” “Improve Your Success with Alcohol & Drug
Issues,” “Waking Hypnosis for Panic and Anxiety Disorders,” none of which
were taught by individuals with a graduate degree. In 2009, the NGH an-
nual convention listed “What to Do When the Alcoholic Calls You,”
“Double Binds,” “Real Medical Hypnosis Made Simple,” “Returning Vets –
Dealing with PTSD,” “The Affect Bridge Technique,” “Applications of
Clinical Medical Hypnosis,” and “Pediatric Hypnotism—Using Hypnosis to
Help Transform Children’s Lives.”
WHAT DO CREDENTIALS MEAN, REALLY?

In most health professions, the basic credential is a license. Psychother-
apy and hypnotherapy are activities that appear to be very difficult to regu-
late. With the possible exception of psychological testing, they do not
require an ability to utilize a clearly defined or unique technology (like sur-

gery) or a tangible asset (like pharmaceuticals). Instead, they rely primarily
or exclusively on communication and human interaction. Ultimately,
then, we are up against an extremely challenging proposition: How does
one “license” a form of human interaction?13 Mental health licensing
boards have taken on this improbable task with varying degrees of effec-
tiveness, and they typically do not attempt to define or enforce any set of
behaviors except upon those who submit to licensing. Of course, there are
strong incentives to becoming licensed, like the ability to qualify for insur-
ance reimbursement or for certain agency, health care service, or govern-
ment positions. But by and large one can get by without a license to
practice, especially if one has other sources of income. Some unlicensed
practitioners have succeeded quite handsomely, thank you; unlicensed
therapist-cum-author John Gray is one of the prime examples, and neuro-
linguistic programmer and motivational speaker Anthony Robbins is
another.
For the thousands of private practice “hypnotherapists” who are
engaged in what is essentially a small part-time business or even a hobby,
licensing is largely superfluous and—with its rigid experience require-
ments, laborious application and examination procedures, and continuing
education requirements—perhaps even an irritant. In fact, for some who
wish to call themselves “doctor,” even traditional graduate schools seem
to be a waste of time. State licensure requires an accredited graduate
degree in a clearly professional health field. Accredited graduate degrees
take time, money, and significant effort. But if one never expects to get
licensed, why bother? A “quickie” degree from an unaccredited school or
even a mail-order diploma will suffice, especially if one feels “entitled” to
it because of age, experience, or the belief that one is uniquely talented
or gifted.
In psychology and mental health, research on whether licensing actually
assures competence has yielded inconclusive results. Nevertheless, licens-
ing and certification are minimally capable of doing two things: (1) guar-
anteeing that an individual has mastered a journeyman’s level of
knowledge about the field (at least at the time of the examination) and
shares a somewhat common educational/training experience; and (2) pro-
viding a system of accountability to the public.
Lay hypnotists and, sadly, many mental health professionals as well, can
take advantage of a veritable smorgasbord of credentials. Compared with
the conservative, rigidly regulated and highly structured world of medi-
cine, counseling and psychotherapy are the Wild West of credentialing.
When a physician claims board certification, her patients can be reason-
ably assured that their doctor has completed a fairly uniform course of
training and has passed a tough examination. In mental health, credential-
ing is a far more varied and amorphous affair. Until relatively recently,
“board certification” meant one was either a Diplomate of the American

Board of Professional Psychology (ABPP) or, if a social worker, of the
American Board of Examiners in Clinical Social Work. There were also a
small number of proficiency certifications available (e.g., rehabilitation
counseling, career counseling) to those who completed substantial training
requirements (and usually an examination) in that area. However, some-
thing happened in the 1980s and 1990s that led directly to the prolifera-
tion of credentialing (and pseudo-credentialing) in mental health. First,
the advent of managed care, coinciding with the proliferation of graduate
school programs in mental health (especially at the master’s degree level),
led to uncontrolled growth in the supply of practitioners while demand
became increasingly restricted. As a result, many mental health practi-
tioners began to scramble for a means (any means) to distinguish them-
selves and be perceived as above the common horde.
Second, the last 20 years have seen a proliferation of specialties and
“techniques,” some valid, others more questionable. Some appear to be the
peculiar invention of their creators. New specialties such as trauma treat-
ment, neuropsychology, and forensic psychology, developed as a result of
advances in the science as well as the practice of psychology. However,
the 1980s and 1990s also saw the advent of “specialties” that seemed to be
responses to popular trends and even superstitions rather than advances in
science. The health fields experienced an explosion of “certified specialists”
that included “energy therapists,” “alien abduction therapists,” and “past
life regression therapists.”
How confusing this must be to clients and consumers of our services.
And how frustrating this is to the legitimate clinician who might be left
feeling “credential challenged” or even intimidated by the hypnotherapist
who advertises himself or herself with multiple impressive-sounding
credentials.
CONCLUSIONS
If we are to have such a discipline we must have standards, and to get
our standards under existing conditions we must have criticism.
—Irving Babbit
Hypnosis as Technology
Although many questions about the nature of hypnosis remain, the one
characteristic all experts seem able to agree on is that hypnosis involves a
specialized form of rapport. Rapport is the core ingredient of all therapeu-
tic conversations. Therefore, hypnosis can be described as a specialized
form of therapeutic conversation. In other words, clinical hypnosis
involves the purposeful combination of rapport with a systematic mode of

communicating in order to guide clients’ internal experience to achieve
therapeutic goals.
The organized clinical hypnosis community has occasionally engaged in
some double-talk about the potential dangers of hypnosis. For example,
many false memory syndrome proponents contend that clinical hypnosis is
a dangerous therapeutic modality because it produces false memories. Clin-
ical hypnotists have countered that there is a growing body of research
indicating that hypnosis is no more likely to produce memory distortions
than other forms of therapeutic conversations. So while most of us con-
tend that clinical hypnosis is no more dangerous than any other form of
therapeutic conversation, we also say it is too dangerous to allow individu-
als without graduate-level training to learn and utilize it. If hypnosis is no
more dangerous than other forms of therapeutic conversation, we should
be able and willing to teach it to the same populations we teach counsel-
ing to—including, for example, addictions counselors, BA-level mental
health workers, and peer counselors—in other words, “lay” people.
There was a time when the “technology” of psychotherapy (e.g., techni-
ques for establishing and maintaining empathy and rapport) was considered
too complex and nuanced to learn outside formal graduate-level training
programs. Many psychologists were suspicious of programs that involved
training peer or “lay” counselors. As peer counseling programs like Women
in Transition and Women Organized against Rape proliferated in the 1960s
and 1970s, however, a growing body of research began to allay our fears.
With supervision, and when generally limited to problem-focused and/or
time-limited approaches (e.g., short-term support groups), well-trained lay
counselors were found to be at least as effective as professionals with a broad
range of problems, including some serious psychological disturbances
(D’Andrea & Salovey, 1983; Covert & Wangberg, 1992; Everly, 2002;
Moore, 2005). I am unaware of any research indicating that lay counselors
pose a greater threat to client well-being than professional therapists. There-
fore, I wonder what would be the harm in teaching the “technology” of hyp-
nosis to lay people, especially if the content of their education were
regulated, and the practice of “hypnotechnology” were supervised, by profes-
sionals? At present, however, there seems to be little or no motivation on
the part of either lay or clinical hypnotists to advocate for this practice
model.
Still, there is the matter of Zoe D. Katze. When the news of Zoe’s certif-
ications became public, the responses from the “burned” hypnosis associa-
tions were understandably angry. However, all of their anger has been
directed at me. An officer of the IMDHA actually contacted my credit
card company and told them I was using my own credit card fraudulently.
My credit card company sent me his letter with a note stating they were
confused and did not see how they could take action, since the payee and
not the payer made the complaint. (And, by the way, all the organizations
kept my money.) The NGH published two highly critical editorials
about me, and one member referred to me as “the dishonest, misrepresent-
ing, liar named Steve K. D. Eichel” on an NGH-sponsored listserv. As far
as I can tell, in the seven years since Hansen’s article in the ABA eJour-
nal, not one of these associations has initiated a substantive and critical
examination of their certification process. Some superficial changes have
been made.
In my opinion, additional laws are unlikely to help. In fact, I cannot
think of a legal or legislative solution that would positively affect credential-
ing without creating even worse problems. Unlike physicians, who often
deal with immediate life and death issues, mental health clinicians typically
treat more subtle and (with the exception of a relatively small percentage of
critical emergencies) less immediately dangerous situations. As a result, the
public and our lawmakers are less likely to worry about the inflated or even
implausible claims made by some hypnotherapists. In addition, even tradi-
tional and licensed psychotherapists tend to loathe guidelines, treatment
manuals, or any external agent claiming to be able to judge or measure our
competence. We do not want anything beyond broad-and-inclusive sugges-
tions when it comes to external agents telling us what constitutes “good”
versus “bad” therapy. We have good reasons. Human behavior and the
“mind” are more complicated than the liver or a broken bone. What is
“good” and “bad” for the psyche is often less easily defined than what is good
for the liver or bad for the fibula. Psychotherapists continue to argue and
debate treatment issues, and many value this marketplace of ideas. Those
who claim to know the absolute truth about the human psyche are more
likely to be psycho-demagogues and therapy cult leaders than benevolent
role models.
With the possible exception of the most outrageous forms of “certified
therapies,” we may be forced to tolerate an extremely broad array of cre-
dentialing bodies, from the legitimate to the questionable to those that are
outright shams. It is up to each of us to examine our own motivations for
obtaining credentials, to police ourselves and our own professions, and to
do our best to educate the public.
Still, one has to ask: What value can a credential hold when it can be
obtained for a common household pet? The unmasking of Dr. Zoe D.
Katze, Certified Hypnotherapist, has made some people very angry.
Unfortunately, to my knowledge, their anger has not yet resulted in serious
changes to the credentialing processes they employed. Following the pub-
licity surrounding Zoe’s certification, the NGH began to require applicants
for membership to include a photocopy of their driver’s license (or some
other official identification), presumably to screen out nonhumans and
people below the age of 16. There is no evidence that they attempt to
confirm the validity of these documents any more than they confirmed the
(non)existence of the Tacayllaermi Friends School or the Garfield School

of Nursing. I have been told that NGH also withdrew from COPHO, so
they will no longer certify by reciprocity (the recognition of another asso-
ciation’s certification as sufficient for one’s own certification). Otherwise,
I could not find a substantive change in their Internet membership and
certification process. The other associations do not appear to have made
any changes whatsoever.
Reform in the near future appears unlikely. Professional hypnosis associ-
ations will need to continue to educate the public on the issue of how lay
hypnotists differ from clinical hypnotists. Zoe’s story certainly had an effect
on the public and other professionals. Similar research might keep the heat
on lay hypnosis associations and eventually lead to some real change.
Finally, professional hypnosis associations should strongly consider support-
ing research that will (hopefully) provide evidence that their credentialing
processes (e.g., ASCH certification, ABCH board certification) actually
assess competence and protect the public.
NOTES
1. “Clinical hypnotists” are individuals who possess at least a master’s
degree from a regionally accredited program in the healing arts, and whose
training (if not received directly from an ASCH-approved organization or
individual) matches the guidelines set forth in Standards of Training in Clini-
cal Hypnosis (Hammond and Elkins, 1994). A “lay hypnotist” is anyone who
is not trained and credentialed as an advanced-degree health professional,
and practices hypnosis or “hypnotherapy.” Since ASCH will not train any-
one who is not at least in formal training toward an advanced degree in the
health sciences, it is safe to assume that lay hypnotists are generally trained
by one of the myriad of lay hypnosis training institutes and/or organizations,
many of which also offer some form of credentialing in hypnosis and/or
hypnotherapy.
2. In my various interactions with lay hypnosis associations, I once met a
lay hypnotist who had obtained a doctor of naturopathy degree from a mail-
order college in England. He referred to himself as “doctor” and on several
occasions was actually granted temporary hospital privileges in order to visit
ill “patients.” His hypnotherapy and naturopathy practices were very small; his
primary occupation was selling bull semen.
3. For example, when most people see St. John’s University, they think of
the well-known, accredited university in New York. However, there is another
St. John’s University. It exists in an office in Springfield, Louisiana, and is,
according to Florida’s St. Petersburg Times (Bousquet & Matus, 2007), an unac-
credited diploma mill. A number of lay hypnosis leaders claim degrees from
St. John’s, however I could not find them listed in any public document as
alumni of St. John’s in New York.
4. The AAEH Code of Ethics states, in part, that, “The Association per-
mits the practice of hypnosis for medical or diagnosable mental ailments only
by those members who are qualified to do so by virtue of their education and
training and/or state licensure. Use or granting of nonacademic titles and
degrees is unethical and shall be considered cause for expulsion. A member
may not use any letter designation after his/her name which implies a degree
or license, unless the member has such an academic degree or official license.
Recognized degrees are those awarded by accredited academic institutions of
higher learning. Demonstrations shall be conducted in a dignified and profes-
sional manner and shall not include bizarre or humiliating or hazardous
effects.”
5. According to Gil Boyne’s biography, retrieved on September 6, 2009,
from http://www.hypnotistexaminers.org/about_gb.html.
6. In July 2007, the Secretariat of Public Education of Mexico issued an
alert accusing eleven schools of being diploma mills that commit academic
fraud; Newport University was among them.
7. ASCH has since changed its membership requirements to include non-
doctoral level, licensed/certified health professionals with at least a master’s
degree (e.g., social workers, professional counselors, and nurse practitioners).
8. Other professional associations have apparently approved of and copied
this bi-level certification program, most notably the EMDR International
Association, which now certifies professionals as “EMDRIA Certified
Therapist” and “Approved Consultants in EMDR.” The American Association
of Marriage and Family Therapists was the first to adopt this certification
model.
9. Since all applicants for ASCH certification are licensed at the inde-
pendent practice level, legally their training in hypnosis cannot be called
“supervision.” ASCH therefore adopted the term “consultation” to refer to the
required twenty hours of individualized, face-to-face training. The professio-
nals providing the training are therefore called “consultants” rather than
supervisors.
10. By my count, there are over forty certifying hypnosis associations in the
United States. The associations offering certification include: 5-PATH1 Hyp-
notherapists Association, 5-PATH1 International Association of Hypnosis
Professionals, Alchemical Hypnotherapy Association, American Association
of Professional Hypnotherapists, American Board of Clinical Hypnotherapy,
American Board of Hypnotherapy, American Council of Hypnotist Examiners,
American Hypnosis Association, American International Association, American
International Association of Hypnosis, Association for Integrative Psychology,
Association for Past Life Research and Therapies, Association for Transperso-
nal Psychology & Hypnotherapy, Association of Professional Hypnosis and
Psychotherapy, Association of Registered Clinical Hypnotherapists, Associa-
tion to Advance Ethical Hypnosis, Atlantic Board of Hypnosis, Clinical and
Therapeutic Hypnosis Association, International Association for Regression
Research & Therapies, International Association for Teenage Hypnotists
(!!), International Association of Counseling Hypnotherapists, International
Association of Counselors and Therapists, International Association of Heal-

ing Professionals, International Association of Medical and Therapeutic Spe-
cialists, International Certification Board of Clinical Hypnotherapy,
International Hypnological Association, International Hypnosis Association,
International Hypnosis Federation, International Hypnosis Hall of Fame
Guild, Inc., International Medical and Dental Hypnotherapy Association,
National Association of Certified Hypnosis Counselors, National Association
of Clergy Hypnotherapists, National Association of Transpersonal Hypno-
therapists, National Board of Hypnosis Education and Certification, National
Board of Professional and Ethical Standards, National Council of Hypnother-
apy, National Federation of NeuroLinguistic Psychology, National Guild of
Hypnotists, Professional Board of Hypnotherapy, Texas Association for Inves-
tigative Hypnosis, Time Line Therapy Association (NLP).
11. The most bizarre (in my opinion) lay hypnosis association is the Interna-
tional Association for Teenage Hypnotists, which states on its Web site that it
is “an international association strictly for teenagers who want to learn hyp-
nosis” that has created a “teenage hypnotist certification program” that “allows
the more ambitious and talented members of the IATH to attain formal and
official recognition for their achievements in the study of hypnosis” (IATH,
2009). This statement leads me to wonder if the IATH would make an excep-
tion for precocious 11- and 12-year-olds who are not technically teenagers?
12. A primary issue here involves two terms whose presence in a licensing
law are central to the health professional’s right to independent (i.e., medi-
cally unsupervised) practice: diagnosis and treatment. Since treatment ensues
from diagnosis, to be truly independent a health professional must be legally
authorized to perform both. Just as physicians once argued that, without formal
medical training, psychologists are not competent to diagnose and then treat
mental disorders, psychologists have argued that “counselors” are inadequately
trained to diagnose and treat individuals with psychological problems.
13. It can be argued that the professions of education and law also rely
almost entirely on interaction and communication, and indeed until the twen-
tieth century, teachers were not licensed, and people who “read law” or
clerked and then passed the examination could be admitted to the bar without
any formal legal education. However technologies specific to teaching devel-
oped and public education became fairly standardized. It is not necessary to be
certified as a teacher to work as one in private schools. Law became increas-
ingly complex, and began to require skills and knowledge that necessitated
formal legal education.
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Eichel, S. (2005). This cat is not a hypnotist, or How to find a qualified hypno-
therapist. http://www.hypnosisnetwork.com/library/cat_hypnosis.php
Everly, G. S. (2002, Spring). Thoughts on peer (paraprofessional) support in the
provision of mental health services. International Journal of Emergency Mental
Health, 4(2), 89–92.
Eye Movement Desensitization & Reprocessing International Association
(EMDRIA). (2009). Training and certification in EMDR. Retrieved 9/6/09
from http://www.emdria.org/.
Giles, C. S. (1995). Legislative and governmental concerns. Journal of Hypnotism,
10(2), 10–11.
Hammond, D. C., & Elkins, G. R. (1994). Standards of training in clinical hypnosis.
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Chapter 8
Pedagogical Perspectives on Teaching

Hypnosis
Ian E. Wickramasekera II
The tradition of hypnosis has reached a critical point in its history where
educational and training efforts are now of extraordinary importance to its
future. This chapter contains an historical review of a number of pedagogi-
cal perspectives on teaching mental health professionals, medical person-
nel, scientists, and others about how to utilize hypnosis. Many different
traditions of hypnosis and hypnotic-like practices have emerged over the
past centuries of human history. Many of these traditions have often
employed some strikingly different pedagogical methods of instruction and
espoused radically different viewpoints on the nature of hypnotic phenom-
ena. This chapter reviews them, starting with the hypnotic-like practices of
various mystical traditions and ending with the modern training guidelines
established by members of the American Society of Clinical Hypnosis. The
chapter concludes with a discussion of how it is possible to draw together
some of the best elements of each of these different pedagogical traditions
into one training program for teaching hypnosis within a graduate school
setting.
TEACHING HYPNOSIS IS THE CHALLENGE OF OUR TIMES

We live within an extraordinary and exciting period of time within the
overall history of hypnotism. Many of our forebears in the tradition of hypno-
sis dedicated their lives to establish the scientific legitimacy of hypnosis in
basic research, medical practice, and psychotherapy (Barabasz & Watkins,
2005; Forrest, 2001). We stand upon a mountain of evidence today about
the value of hypnosis in basic science (as discussed in Chapters 1–6 of this
volume and by Posner & Rothbart, 2010) and in clinical work (reviewed in
Volume 2 of this book and in Barabasz & Watkins, 2005, and Rainville &
Price, 2003). We know that hypnosis is a very useful treatment for patients
with pain (see Vol. 2, Ch. 5; Montgomery et al., 2002; Patterson & Jensen,
2003), and we even have a good initial understanding of the neurophysiology
underlying hypnotic analgesia (Rainville et al., 1997). Hypnosis has also
been shown to be useful in alleviating some of the most common psychologi-
cal complaints such as depression (Vol. 2, Ch. 4; Kirsch, Montgomery, &
Sapirstein, 1995). In short, hypnosis has been shown to be helpful to many
patients with the most common medical and psychologically oriented prob-
lems seen by clinicians today. The scientific tradition of hypnosis has clearly
succeeded in producing large amounts of the kinds of scientific data on the
nature and utility of hypnosis that would surely have pleased our forbears
such as Clark Hull (1933).
However, it has become painfully obvious that somehow the hypnosis
community has not been growing much in recent years despite the great
amount of progress that has been made in establishing the clinical and sci-
entific legitimacy of hypnosis. In fact, recent membership trends in hypno-
sis organizations such as the Society of Psychological Hypnosis (Division 30
of the American Psychological Association) suggest that the numbers of
people seriously interested in using hypnosis is declining (Wickramasekera,
2008). Many of the most respected professional and scientific organizations
that are dedicated to hypnosis have lower levels of membership than they
did in the past. There also seems to be a significant “graying” of the field of
hypnosis given that these organizations have far fewer students and
younger-aged members than they did in the past. Ironically, there is a real
danger that the community of hypnosis may continue to decline further
even at a time when the scientific underpinnings of clinical hypnosis are
stronger than ever.
Teaching hypnosis has become one of the real challenges of our times.
Educational and training efforts are now as important to our future as are
the continuing efforts to establish the scientific and clinical legitimacy of
hypnosis. This chapter is meant to help serve as an aid to those who would
answer the call to help bring about growth in the hypnosis community
through teaching hypnosis to others. We will first begin with an historical
examination of the various pedagogical perspectives that have been
employed to teach others about how to use hypnosis and hypnotic-like
practices (Krippner, 2005) in the remote and recent past. A number of dif-
ferent approaches have been advanced over the years to teaching about
hypnotic phenomena, and we shall try to draw out some of the best ele-
ments of each pedagogical perspective. Finally, we shall conclude with a
brief look at how we can synthesize the best elements of the previous tradi-
tions into one training program for use within a graduate school setting. I
will endeavor to create an outline of a training model that I created for
use in establishing a certificate program for teaching hypnosis within a
graduate school of clinical psychology setting. It is my belief that we can
Pedagogical Perspectives on Teaching Hypnosis 147
learn about how to teach hypnosis from following the methods of our for-
bears. My model is meant to be a synthesis of both ancient and relatively
recent pedagogical perspectives on teaching hypnotic phenomena. So let
us now begin with an examination of the historical perspectives on teach-
ing hypnosis to begin building the foundations of my approach to teaching
hypnosis.
HISTORICAL PERSPECTIVES
The Western tradition of hypnosis may rightly be said to have started from
the efforts of pioneering individuals like Franz Anton Mesmer, Jose Custodio
de Faria (Abbe Faria), and James Braid over 200 years ago (Forrest, 2001).
The pedagogical methods of these early pioneers were quite different than
those of our current modern training organizations such as the American
Society of Clinical Hypnosis (ASCH) and the Society of Clinical and Experi-
mental Hypnosis (SCEH). However, hypnotic-like practices, such as mindful-
ness meditation, had been taught for thousands of years long before any of
these individuals had established their doctrines and methods of pedagogy
with hypnosis (Kvaerne, 1995; Rahula, 1974; Ray, 2002). In this section, we
will examine some of the critical and unique pedagogical perspectives that
teachers of hypnosis and hypnotic-like practices have employed from ancient
to recent times.
Ancient Pedagogical Perspectives on Teaching

Hypnotic-Like Practices
Human beings have been practicing and teaching others how to use
hypnotic-like practices, such as mindfulness meditation, for thousands of
years. Literally millions of people have been taught how to practice and
teach others about meditation since the time of the early sages, such as
Shakyamuni Buddha (Rahula, 1974) and Tonpa Shenrab (Kvaerne, 1995).
However, I do not wish in any way to equate hypnotic-like practices, such
as mindfulness meditation, with actually being forms of hypnotism. Clearly
there are very meaningful cultural, phenomenological, psychophysiologi-
cal, and spiritual differences between hypnotic-like practices and hypnosis
(Krippner, 2005). However, there is enough evidence to suggest that prac-
tices like mindfulness meditation are very similar to hypnosis (see Chapter
2 of this volume and Holroyd, 2003) in their overall nature. I therefore
assert that there is something that the tradition of hypnosis can learn from
the ancient pedagogical perspectives on teaching meditation to others that
we may use in reviving the tradition and community of hypnosis.
In this section, I will focus on the critical pedagogical perspectives of
the meditative traditions of Tibetan Buddhism and B€on-Buddhism. I have
selected Buddhism and B€on-Buddhism since I am personally familiar with
them and I understand them far better than any of the other ancient tradi-
tions of hypnotic-like meditative practices. The traditions of Buddhism and
B€on-Buddhism are also comparatively well preserved today amongst the an-
cient traditions. The reader will therefore be free and able to explore any-
thing that they see reflected in these words if they wish to. I will leave it to
others to write down their own observations of the similarly unique peda-
gogical perspectives that come from appreciating the value of other ancient
mystical traditions such as Gnosticism, Quaballah, Sufism, or Tantra.
The ancient Buddhist and B€on-Buddhist methods of pedagogy for teach-
ing meditation are often quite different from the methods that we employ
in hypnosis today. Meditation teachers in these schools employ a radically
different epistemology in talking about how we can learn the truth about
our mind’s potential and our personal psychology. Meditation teachers in
Buddhist and B€on-Buddhist schools also typically employ a much closer
relationship with their students. This relationship style could best be com-
pared with the relationship between a therapist and their client in West-
ern clinical psychotherapy (Wickramasekera, 2004). Let us now examine
these two key areas of Buddhist and B€on-Buddhist pedagogy more closely
regarding epistemology and the teacher-student relationship.
Curiously, Buddhist and B€on-Buddhist teachers have traditionally
eschewed adopting a materialistic outlook on determining the nature of
truth regarding our mind and our own unique psychology. Instead, an indi-
vidual is supposed to seek out the nature of one’s own mind through a
course of disciplined introspection within one’s practice of meditation. This
is not to say that one is taught to trust one’s own psychological experience
entirely at face value. In fact, a good deal of instruction is given to students
regarding the nature of self-deception (Trungpa Rinpoche, 1973). One is
supposed to work through one’s tendencies toward self-deception through
encountering it directly in one’s meditation practice and in post-meditation
experiences in everyday life. Consider the following quotes from the
modern-day B€on-Buddhist teacher Tenzin Wangyal Rinpoche (1998):
All of our experience, including dream, arises from ignorance. It is igno-

rance of our true nature and the true nature of the world, and it results
in entanglement with the delusions of the dualistic mind. (p. 24)
If we are not careful, the teachings can be used to support our

ignorance. That is why practice is necessary, in order to have direct
experience rather than just developing another conceptual system to
elaborate and defend. (p. 26)
The ancient traditions tell us that practicing meditation is really the

only way to learn about its nature or to learn about how to teach it
to others. The most revered teachers of meditation in Buddhism and
B€on-Buddhism are usually people who have devoted many years to their
meditation practice. These teachers have also commonly undertaken long,
continuous retreats that may last as long as three years or more. A medita-
tor who develops a good conceptual understanding of the meditation liter-
ature, but who has not experienced these concepts directly in their
own practice, would generally be considered a fraud in the Buddhist and
B€on-Buddhist communities. We can see that an injunction to engage in
personal practice is a clear-cut pedagogical method of the ancient tradi-
tions of hypnotic-like practices. These teachers tend to be very skeptical of
people who let either their conceptual understanding or their experiential
understanding dominate their perception of phenomena.
All of this of course is the exact inverse of our Western tradition of
experimental psychology. Western psychology has thrived on using material-
istic and empirical methods of investigating the mind. Modern experimental
psychologists traditionally have tended to characterize methods of introspec-
tion and phenomenology as being inherently unscientific and unreliable. So
perhaps it is not too surprising that the Western tradition of hypnosis has not
usually employed personal practice as a pedagogical method that commonly.
The emphasis in most hypnosis training programs actually seems to be
on learning about hypnosis through learning to hypnotize others rather
than learning through cultivating a practice of self-hypnosis. The original
critique of introspection in Western psychology came from the early Behav-
iorists’ rejection of the experimental tradition of Gestalt psychology
(Skinner, 1987). However, over time, modern researchers in psychology and
clinical neuroscience have returned to being interested in using introspective
and phenomenological data (Pekala, 1991; Rainville & Price, 2003).
“Mentalistic” terms like trance and consciousness that we use commonly in
hypnosis are not nearly as criticized as they once were in science (Skinner,
1987). Our modern-day tradition of hypnosis may (twice in this sentence)
benefit from following some of the ancient perspectives of Buddhism and
B€on-Buddhism now that a respect for introspection and phenomenology
are once again returning to psychology and science. We can therefore place
more value on teaching our students about hypnosis through encouraging
their practice of self-hypnosis. In this way, we can follow the pedagogical
methods that the ancient meditative traditions have endorsed for thousands
of years while also inviting our students to engage in a lifetime practice that
will help them deal with the stresses of their own life.
The pedagogical methods of the ancient Buddhist and B€on-Buddhists can
also be distinguished from the contemporary pedagogical methods of hypno-
sis regarding how they develop a teacher-student relationship. Buddhist and
B€on-Buddhist teachers of meditation are taught to establish a very close rela-
tionship with their students. A great teacher is said to be a very special per-
son who possesses at least three essential qualities, such as unlimited
friendliness (maitri), empathy, and being completely authentic in their
interactions with students and in their realization (Wickramskerea, 2004).

Chogyam Trungpa Rinpoche (1974) once wrote that a good teacher is:
Anyone who can reflect you as a mirror does, and with whom, at the
same time, you have a relationship as a personal friend. (p. 171)
Supposedly this person is such a spokesman (for the enlightened state

of mind), soaked in the awake state of being himself. (p. 23)
These three qualities of maitri, empathy, and authenticity are of course

quite similar to the three core conditions that Carl Rogers (1957) named as
positive regard, empathy, and congruence when establishing his ideas about
the core elements of client-centered psychotherapy (Wickramasekera, 2004).
Furthermore, Rogers’s work on these three elements of the therapeutic rela-
tionship have been almost universally adapted into all other forms of psycho-
therapy (Horvath & Luborsky, 1993; Keijsers, Schaap, & Hoogduin, 2000). I
refer the reader to my earlier article on this subject (Wickramasekera, 2004)
where I discuss these striking similarities in more depth. However, suffice it
to say that being with one’s meditation teacher should ideally be an experi-
ence where one feels very comfortable and intimate.
I have no doubt that most people who are now practicing and using hypno-
sis have at one time or another had a special relationship like this with a hyp-
nosis instructor. This may commonly be a clinical supervisor or dissertation
adviser who has been charged to provide them with supervision after they
have received some initial training in hypnosis. The American Society of
Clinical Hypnosis has wisely created an approved consultant program to en-
courage this kind of close mentorship between students and their teachers.
SCEH and the Society of Psychological Hypnosis have also attempted in the
past to match mentors with mentees through various programs. A panel led by
Dr. Michael Nash at the 2008 annual meeting of SCEH in Philadelphia,
Pennsylvania, elicited many spontaneous personal recollections from the audi-
ence members about their treasured relationships with mentors. Many of the
spontaneous recollections discussed the primary importance that such close
personal relationships had played in introducing and sustaining their involve-
ment with the hypnosis community. Sadly, there is a limited number of teach-
ers who are actually capable of serving as mentors. The need for such teachers
appears to exceed the current resources that we now have in the hypnosis
community. Therefore, we should all look for ways in which we can personally
serve as mentors to the new people coming into the community of hypnosis.
The Public Demonstration of Hypnosis:

An Early Pedagogical Method
Many of these early pioneers of hypnosis, such as Mesmer, Abbe Faria,
and James Braid, utilized public demonstrations of hypnotic phenomena
extensively as a critical element of their pedagogical methods. A close

reading of many of these early hypnotists’ methods suggests that they did
this for a variety of reasons involving the mass appeal of the phenomena
to the public. One reason that the early hypnotists seemed to enjoy using
public demonstrations was to reach as many people as possible to inform
them about their views of hypnosis. Hypnosis and hypnotic phenomena
became one of the top areas of fascination during the period of the early
hypnotists (Forrest, 2001), and their demonstrations drew very large public
audiences and inspired many dramatic works and newspaper articles. It
may be said that some of these early pioneers may have held more prurient
reasons for trying to reach as many people as possible (Forrest, 2001), how-
ever, I will leave these ethical considerations to the side for now. Abbe
Faria is a good example of one such early hypnotist who seems to have
had a very genuine desire to use his public demonstrations to inform the
public about the nature of hypnotic phenomena. It is said that Abbe Faria
began all his public demonstrations of hypnosis with a half-hour lecture
about the nature of the phenomena. His lecture was supposed to have
emphasized a message that the real power of hypnosis lies within the abil-
ities of the hypnotic subject rather than in himself as the hypnotizer (Car-
rer, 2004). Abbe Faria was thus one of the first of the early hypnotists to
try and use public demonstrations to counteract people’s misconceptions
about the nature of hypnotic phenomena.
Unfortunately, most of the people putting on public demonstrations of
hypnosis today seem to have no other purpose than entertainment in mind
(Barber, 1986). However, there is still an undeniable appeal for public
demonstrations of hypnosis, and that appeal can be used to reach new peo-
ple in an ethical fashion. For example, a recent public demonstration of
hypnosis put on by Dr. Guy Montgomery at the 2009 annual meeting of
the APA in Toronto drew a very large audience that was much larger than
that seen at any other session related to hypnosis that year (Wilmarth,
2009). A quick show of hands from the audience that day revealed that
most of the participants had never received any prior formal introduction
to hypnosis despite being psychologists or graduate students of psychology.
Many of the audience members reported afterwards that they came to the
demonstration out of a simple desire to see a demonstration of hypnotic
phenomena and to learn something about it from a reputable source.
Standards of Training for Hypnosis and the

Spiral Curricula Method
The establishment of professional organizations devoted to hypnosis and
hypnotic-like practices in the West began at the same time that the early
hypnotists were giving their demonstrations. Mesmer formed a group that
came to be known as the Society of Harmony (Forrest, 2001). The Society
of Harmony employed a kind of graded series of initiations into Mesmer’s

ideas about animal magnetism. The structure and content of these initia-
tions were held in some secrecy so that overall the Society of Harmony
somewhat resembled similar organizations of Freemasonry that were popu-
lar at the time (Forrest, 2001). Many other organizations have continued
to spring up in the 200 years since Mesmer’s Society of Harmony. These
organizations have varied wildly in their commitment to science on one
end of the spectrum and in their encouragement of mysticism on the other
end. Many of these organizations did organize classes on how to use hyp-
notic and hypnotic-like practices although curiously none of them appears
to have crafted a rigorous and detailed set of training standards (Wark &
Kohen, 2002) for use in perpetuating their methods.
In 1992, Gary Elkins, PhD, and Corydon Hammond, PhD, began a new
project within the American Society of Clinical Hypnosis that has become
one of the most important contributions to the teaching of hypnosis
(Elkins & Hammond, 1994; Wark & Kohen, 2002). Their aim was to cre-
ate a highly rigorous and detailed set of academic standards for teaching
others about hypnosis. They began their project by contacting 242 interna-
tionally distinguished scholars of clinical and experimental hypnosis. They
surveyed these experts for their opinions on topics such as how course con-
tent should be prioritized, how much time should be allotted for each
topic, and many other similar issues. Elkins and Hammond (1994) put
together all this information and created the first real standards for teach-
ing hypnosis. Their standards employed a format using two intensive
20-hour classes with introductory and intermediate levels. These standards
are now known as the Standards of Training in Clinical Hypnosis
(SOTCH), and they have been adopted and endorsed by both ASCH and
SCEH. The introductory level version of the SOTCH contains 15 content
areas such as theory, induction methods, and ethics (Hammond & Elkins,
1998). The intermediate-level version of the SOTCH contains more
advanced-level content from the first class, as well as more emphasis on
clinical applications with psychological and medical disorders.
One of the best qualities of the SOTCH standards is that they teach
about hypnosis from within all the major traditions of hypnosis. No one
approach or theory of hypnosis predominates in the curriculum since the
authors took great pains to include balanced information about all the
clinical and theoretical traditions of hypnosis. However, both versions of
the SOTCH do leave out some information and training experiences
that some experts might consider highly essential elements of a basic or
intermediate-level class in hypnosis. For instance, participants are not
given instruction in how to administer, score, and interpret a variety of
hypnotic assessment instruments in either class. This is an unfortunate
state of affairs as it seems to contribute to the relative neglect of the use of
standardized hypnotic testing instruments in research and clinical practice.
Many people never appear to take the additional classes that would be
necessary to learn about hypnotic assessment (Pekala & Wickramasekera,
2007), even though the material is quite simple to learn.
A number of individuals have attempted to refine the SOTCH stand-
ards into even more useful formats. Wark and Kohen (2002) developed a
pedagogical method of employing the SOTCH standards within a frame-
work that they describe as “the spiral curriculum.” The authors adapted
some of the pedagogical perspectives of David Kolb (1984) into a flexible
approach that was designed to accommodate a variety of learning styles.
The hallmark of their approach is of course how they employ the “spiral,”
which is the idea of teaching about hypnosis in a series of graduated steps.
The authors describe the “spiraling” element of their pedagogical method
in stating: “The actual teaching is presented in a way that accommodates
many learning styles. After the entry level concepts are presented, instruc-
tion is ‘spiraled’ up to the next level with appropriate review, adding more
complexity and detail, again in a way designed to reach participants
regardless of learning style. This process then continues, reviewing and
adding levels and details to related concepts” (p. 124).
The authors applied the spiral methods to the SOTCH standards and
have created a flexible version of the SOTCH. This way of teaching the
SOTCH seems very well suited for adaptation at weekend sessions; this
approach to teaching hypnosis is very popular.
A TRAINING PROGRAM FOR TEACHING HYPNOSIS

WITHIN GRADUATE SCHOOLS
We are now in a good position to put together a synthesis of some of
the best pedagogical methods for teaching hypnosis. In this section, I will
provide the reader with a brief outline of my development of a certificate
program for teaching hypnosis within a graduate school setting. This certif-
icate program was designed to be a relatively flexible adaptation of the
SOTCH standards while using the spiral curriculum approach to add addi-
tional and more advanced material.
A Three-Class Model
The hypnosis training program that I am presenting here was initially
developed at the Adler School of Professional Psychology in Chicago, Illi-
nois, and was approved by both ASCH and SCEH. The training program is
a synthesis of many materials that I had been fortunate enough to receive
in my own training such as the SOTCH standards (Elkins & Hammond,
1998) and the spiral curriculum methods of Wark & Kohen (2002). The
SOTCH standards call for an individual to complete two 20-hour training
classes (introductory and intermediate levels) in order to receive a basic
level of education in hypnosis that would allow one to apply for a basic
level of proficiency in hypnosis. However, the model being presented here
is of a three-course model with each course providing 36 hours of instruc-
tion on using hypnosis at the basic, intermediate, and advanced levels. My
desire was to create a program that would exceed the SOTCH standards in
its depth of instruction while also providing the students with many addi-
tional hours of practice time within a safe and comfortable environment.
The first two courses utilized the SOTCH standards completely for their
framework. I was able to use the additional time (16 hours) that I had in
this format to modify each class to the unique interests of each group of
students that were coming through the program. For example, in some
classes the students reported being very interested in applied psychophysi-
ology and biofeedback. I was able to use some of the extra time in these
classes to give lectures and demonstrations on the psychophysiology of
hypnosis. This lecture naturally led to a discussion of the relative merits of
integrating the methods of biofeedback with hypnosis for patients with
challenging symptom presentations. However, I reserved the majority of
the additional time in the basic and intermediate courses for additional
practice sessions and experiential exercises. In this way the students were
able to devote a much greater amount of time to developing a conceptual
and experiential understanding of what hypnosis is. The third class was
designed to present more advanced material than is usually taught in
the SOTCH standards, such ego state therapy, age regression, assessment
of psychophysiological disorders, methods of hypnoanalysis, and the
Stanford Hypnotic Susceptibility Scale: Form C (SHSS:C; Weitzenhoffer
& Hilgard, 1962).
Emphasis on Personal Practice and Enriching the

Mentorship Opportunities
It is primarily within the context of the additional practice time that
I attempted to actualize two of the critical pedagogical perspectives that
we encountered when reviewing how Buddhists and B€on-Buddhists teach
hypnotic-like practices. It was easy to implement these traditions’ emphasis
on personal practice just by increasing the amount and frequency of the
in-class practice time. I also asked the students to practice self-hypnosis
and to keep a daily record of their practice. The students were required to
write down their spontaneous phenomenological observations of how each
session went. The final assignment of each of these three classes called for
the students to describe how various theories of hypnosis might conceptu-
alize what they were reporting in their personal journals. In this way the
pedagogical methods that I employed all placed an increased value on
deepening the students’ personal practice of hypnosis just as the Buddhist
and B€on-Buddhist teachers recommend.
I try to spend as much time as possible being with each student in their
practice sessions and getting to know their style as a hypnotist as well as
their personal experiences of hypnosis. I do attempt to utilize a person-
centered approach to teaching when conducting these sessions. I’ve found
that this seems to reduce many of my students’ apprehensions about giving
a live demonstration of their skill as a hypnotist and also to allow them to
have a genuine experience of hypnosis. Initially, the students often worry
about so many extraneous things such as whether or not they have found a
good “hypnotic voice.” I have often found that establishing a friendly, em-
pathic, and congruent relationship with my students does seem to help
them get past the initial awkwardness that many students experience upon
first learning about and experiencing hypnosis. I have also attempted to
augment the mentorship opportunities that are available to my students in
other ways. For instance, I encouraged all the students to seek out other
mentors besides myself in the Chicago hypnosis community. I handed out
membership applications to ASCH, SCEH, and personally paid for their
first year of membership in the Society of Psychological Hypnosis upon
their completion of the three-course sequence.
Providing Demonstrations of Hypnosis and Other

Hypnotic-Like Practices
It never ceases to amaze me how easy it is to gather a large group of peo-
ple if you simply mention beforehand that there will be a live demonstra-
tion of hypnosis. I scheduled a free lecture and demonstration of hypnosis
for all members of the Adler community at the start of each academic year.
The title of this lecture was “What is hypnosis?” and its intent was to pair a
brief lecture on the true nature of hypnotic phenomena with a brief and
unobtrusive group administration of hypnosis. I timed the lecture to occur
in the first week of the trimester so the students would have a few weeks to
decide if they might want to take my basic level class. This class usually
was taught over the course of two weekends that were scheduled in such a
way as to not conflict with any other popular weekend-format courses.
I also provided demonstrations of hypnotic-like practices such as mind-
fulness meditation on a regular basis at Adler. For instance, I initiated a
weekly mindfulness meditation group that was open to all members of the
Adler community. People who are interested in meditation are also fre-
quently interested in hypnosis. The mindfulness group also became another
avenue for me to engage in mentorship with the hypnosis students, in
which I was also able to encourage their personal practice. Both of these
types of demonstrations were well attended, and I tend to think that they
were very helpful in encouraging the popularity of the hypnosis training
program at Adler.
Use of the Spiral Curriculum Method to Deepen the

SOTCH Material
I drew upon Wark and Kohen’s (2002) spiral curriculum model quite
extensively when designing the three-course sequence of topics. In each
class I attempted to enrich the students’ previous understanding of hypno-
sis by introducing them to new course content and experiential practice
exercises that matched their current level of understanding and expertise
with hypnosis. I often devoted some of the additional time that I had in
these classes to cover topics in more depth that a given group of students
might find interesting or have might have trouble understanding. I often
simply changed the learning format from didactic to experiential or from
experiential to didactic when I noticed that a class had become stuck on
understanding a given topic. For example, I often role-played some of the
original experiments that led Ernest Hilgard (1977/1986) to develop his
neo-dissociation theory of hypnosis. This allowed the students to see a live
demonstration of the phenomena that Hilgard actually had in mind when
crafting his theory.
I also extensively used the spiral curriculum method when I added a
module on hypnotic assessment into all three classes. I believe strongly in
the value of hypnotic assessment (Pekala & Kumar, 2000) and I wished to
devote some of the additional time that I had available to teach the stu-
dents about how to employ hypnotic assessment in their clinical work and
research. All of the students were taught to administer, score, and interpret
the Phenomenology of Consciousness Inventory-Hypnotic Assessment Pro-
cedure (PCI-HAP; Pekala, 1995), the Harvard Group Scale of Hypnotic
Susceptibility (HGSHS; Shor & Orne, 1962), and the Stanford Hypnotic
Susceptibility Scale: Form C (SHSS:C; Weitzenhoffer & Hilgard, 1962)
throughout the three-course sequence. The instruments were taught in
order of the relative difficulty of the skill required to administer them as
well as the knowledge required to fully appreciate the hypnotic phenom-
ena being elicited by the testing procedures. The students first learned
about hypnotic assessment through mastering the administration and inter-
pretation of the PCI-HAP in the first class. The PCI-HAP appears to be
the best instrument to teach introductory students about hypnotic assess-
ment due to the ease of administration and its inherent pedagogical
value in teaching methods of hypnotism (Pekala & Wickramasekera, 2007).
I then followed up with teaching the Harvard and Stanford instruments in
the second and third classes, respectively. Starting with the PCI-HAP in
the introductory class and then building to the Stanford Form C in the
advanced class appeared to help the students build a foundation of skill and
understanding about hypnotic phenomena. Using the spiral approach
seemed to help the students not only to master using the instruments but
also to understand its relevance in clinical practice and research.
CONCLUSION
Hypnosis and hypnotic-like practices have been practiced and taught to
others for many thousands of years. In this chapter we have reviewed some of
the critical pedagogical perspectives and methods of many different tradi-
tions. Teachers of hypnotic-like practices such as mindfulness meditation
have often placed a value on developing a personal practice in order to prop-
erly understand the true nature of the phenomena. These teachers have also
strived to develop a special relationship with their students that is very simi-
lar to the person-centered approach of Carl Rogers (Wickramasekera, 2004).
Early teachers of hypnosis such as Abbe Faria (Carrer, 2004), often profited
from using public demonstrations of hypnosis as a way of drawing atten-
tion to their ideas about the true nature of hypnotic phenomena while
addressing the public’s misconceptions of what is happening in the hyp-
notic relationship. More recently there has been great progress on estab-
lishing standards of training for hypnosis (Elkins & Hammond, 1998 that
have even been merged with excellent pedagogical perspectives such as
the spiral curriculum model (Wark & Kohen, 2002). This chapter has
concluded with a brief look at how we can utilize and integrate all these
pedagogical methods and insights to create hypnosis training programs
within graduate school settings.
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About the Editor and Contributors
THE EDITOR
Deirdre Barrett, PhD, is a psychologist on the faculty of Harvard Medical
School’s Behavioral Medicine Program. She is the past president of both the
International Association for the Study of Dreams and the American Psycho-
logical Association’s Division 30: Society of Psychological Hypnosis. Dr. Bar-
rett has written four books: The Committee of Sleep (Random House, 2001);
The Pregnant Man and Other Cases from a Hypnotherapist’s Couch (Random
House, 1998); Waistland (Norton, 2007); and Supernormal Stimuli (Norton,
2010). She is an editor of two additional books, The New Science of Dreaming
(Praeger/Greenwood, 2007) and Trauma and Dreams (Harvard University
Press, 1996), and has published dozens of academic articles and chapters on
health, hypnosis, and dreams. She is editor-in-chief of DREAMING: The Jour-
nal of the Association for the Study of Dreams.
Dr. Barrett’s commentary on psychological issues has been featured on Good
Morning America, The Today Show, CNN, Fox, and the Discovery Channel.
She has been interviewed for dream articles in the Washington Post, the New
York Times, Life, Time, and Newsweek. Her own articles have appeared in Psy-
chology Today and Invention and Technology. Dr. Barrett has lectured at Esalen,
the Smithsonian, and universities around the world.
THE CONTRIBUTORS
Steve K. D. Eichel, PhD, ABPP, is a licensed and board-certified psychologist
in Newark, Delaware, with training in clinical counseling and forensic psy-
chology. He became interested in hypnosis while still in college and began his
formal training in clinical hypnosis in 1982. Dr. Eichel is an ASCH-approved
consultant in clinical hypnosis; he is also a former president of the Greater
Philadelphia Society of Clinical Hypnosis and served on its board of governors
for ten years. Most of his hypnosis-related research and writing has focused on
deceptive, unethical, and coercive persuasion and the manipulation of states
162 About the Editor and Contributors
of consciousness, especially by destructive religious, political, and therapy

cults. He has also presented national and regional workshops on integrating
hypnosis and hypnotic techniques in the treatment of trauma and addictions.
Dr. Eichel currently divides his time between a broad clinical practice, serving
on the Delaware State Board of Examiners of Psychologists, the Board of
Trustees of the American Board of Professional Psychology, the Professional
Advisory Board of the International Cultic Studies Association, and the exec-
utive committees of several other professional associations.
Melvin A. Gravitz, PhD, is Clinical Professor of Psychiatry and Behavioral

Sciences at George Washington University School of Medicine and Behav-
ioral Sciences in Washington, DC. He is certified in clinical and in forensic
psychology by the American Board of Professional Psychology and in clinical
and in experimental hypnosis by the American Board of Psychological Hypno-
sis. He is past president of the American Society of Clinical Hypnosis and
APA Division 30: Society of Psychological Hypnosis. With a special interest
in the history of hypnosis and its forensic applications, he has a personal
library of some 2,500 volumes in that field and is a frequent contributor to
hypnosis literature.
J€urgen W. Kremer, PhD, Dipl.-Psych., received his education at the University

of Hamburg in Germany and is the editor of ReVision – A Journal of Conscious-
ness and Transformation. His past positions include: dean of faculty and vice
president of academic affairs at Saybrook University in San Francisco; aca-
demic dean and program director of the Integral Studies Program and the
East-West Psychology Program, as well as codirector of the PhD program for
traditional knowledge at the California Institute of Integral Studies. He con-
tinues to teach at Saybrook University, CIIS, and Sonoma State University
and holds a full-time position at Santa Rosa Junior College. He has cowritten
several books, including Towards a Person-Centered Resolution of Intercultural
Conflicts” (1980), and contributed extensively to journals, handbooks, readers,
and more popular venues. After receiving his doctorate in clinical psychol-
ogy at the University of Hamburg, Germany, and working for some years in
private practice, Dr. Kremer relocated to San Francisco to teach at Saybrook.
He has edited special ReVision issues on Peace and Identity; Paradigmatic
Challenges; Culture and Ways of Knowing; Indigenous Science; and Trans-
formative Learning. He has done extensive fieldwork on the use of indige-
nous hypnotic-like procedures, especially in Sapmi (arctic Europe) and the
Southwestern United States; he has applied his findings in clinical and non-
clinical settings.
Stanley Krippner, PhD, is professor of psychology at Saybrook University, San

Francisco, California. In 2002, he received the Division 30 Award for Distin-
guished Contributions to Professional Hypnosis from the Society of Psycholog-
ical Hypnosis of the American Psychological Association. During the same
year, he received the American Psychological Association Award for Distin-

guished Contributions to the International Advancement of Psychology. He is
a Fellow of APA Division 30, of the Society for Clinical and Experimental
Hypnosis, and the American Society of Clinical Hypnosis. He has lectured
and conducted workshops in psychological hypnosis in Brazil, Cuba, India,
Italy, Mexico, Russia, Sweden, and the United States, and is a member of the
Swedish Society of Clinical Hypnosis. He is a fellow of the Association for
Psychological Sciences, the Society for the Scientific Study of Religion, and
the Society for the Scientific Study of Sexuality. He is the coeditor of Varieties
of Anomalous Experience: Examining the Scientific Evidence; Broken Images, Bro-
ken Selves: Dissociative Narratives in Clinical Practice; and The Psychological
Impact of War Trauma on Civilians: An International Perspective. He has coau-
thored Personal Mythology, Extraordinary Dreams, and Haunted by Combat:
Understanding PTSD in Combat Veterans.
Robert G. Kunzendorf, PhD, is professor of psychology at the University of

Massachusetts, Lowell, and is coeditor of the journal Imagination, Cognition,
and Personality: Consciousness in Theory, Research, Clinical Practice. He has pub-
lished over 100 articles concerned primarily with visual imagination, con-
sciousness (including hypnotic phenomena that are conscious, but not self-
conscious), and existential issues. In addition, he has coedited four books: The
Psychophysiology of Mental Imagery, Mental Imagery, Hypnosis and Imagination,
and Individual Differences in Conscious Experience. He is currently working on
two more books: a monograph on The Evolution of Consciousness and Self-
Consciousness and a coauthored work on Envisioning the Dream through Art
and Science.
David Spiegel, MD, is the Jack, Lulu, & Sam Willson professor in the School
of Medicine, associate chair of Psychiatry & Behavioral Sciences, director of
the Center on Stress and Health, and medical director of the Center for Inte-
grative Medicine at Stanford University School of Medicine, where he has
been a member of the academic faculty since 1975. He is past president of the
American College of Psychiatrists and is past president of the Society for Clin-
ical and Experimental Hypnosis. He has published 10 books, 349 scientific
journal articles, and 148 chapters on hypnosis, psychosocial oncology, stress
physiology, trauma, and psychotherapy. His research has been supported by
the National Institute of Mental Health, the National Cancer Institute, the
National Institute on Aging, the John D. and Catherine T. MacArthur Foun-
dation, the Fetzer Institute, the Dana Foundation for Brain Sciences, and the
Nathan S. Cummings Foundation, among others. He is winner of 22 awards,
including the 2004 Judd Marmor Award from the American Psychiatric Asso-
ciation for biopsychosocial research and the Hilgard Award from the Interna-
tional Society of Hypnosis. His research on cancer patients was featured in
Bill Moyers’s Emmy award-winning PBS series, Healing and the Mind, and
recently on the Jane Pauley Show and Good Morning America.
Lynn C. Waelde, PhD, is a professor at the Pacific Graduate School of Psy-

chology, Palo Alto University, California, and a consulting associate professor
at Stanford University School of Medicine. Her clinical and research interests
focus on stress disorders and therapeutic applications of meditation and mind-
fulness. Her trauma research has addressed diversity issues such as race-related
stress and ethnic identity, dissociation, and responses to natural disasters. She
has also investigated applications of meditation and mindfulness to diverse
health and mental health issues. She is founder and director of the Inner
Resources Center of the Kurt and Barbara Gronowski Psychology Clinic. The
center conducts psychoeducational programs, clinical interventions, professio-
nal training, and research concerning the applications of mind-body therapies,
especially meditation, for mental, emotional, physical, and spiritual well-being.
Waelde has a bachelor’s degree in psychology and a master’s degree in anthro-
pology from Louisiana State University. She received her master’s and doctoral
degrees in developmental child clinical psychology from the University of Col-
orado at Boulder. She completed her predoctoral internship at the VA Medi-
cal Center in New Orleans, where she completed training as a PTSD
specialist.
Matthew White, MD, MS, did his undergraduate work at Stanford University
and earned his MD and MS from the UC Berkeley / UC San Francisco Joint
Medical Program. After residencies in Internal Medicine at UC San Francisco
and in Psychiatry at Stanford University he is currently completing an NIMH-
sponsored post-doctoral fellowship. His research focuses on using functional
MRI to study hypnosis as well as various psychiatric disorders, including
depression, obsessive-compulsive disorder, and trichotillomania.
Ian E. Wickramasekera II, PsyD, is on the faculty of the University of Illinois

Medical School, Chicago. He previously directed the hypnosis training pro-
gram at the Adler School of Professional Psychology from 2004 to 2008. In his
research and clinical work, he draws upon his background in B€on-Buddhism,
humanistic/transpersonal psychology, hypnosis, and mind/body medicine. His
major research interests in hypnosis revolve around the topic of empathy in its
relationship to hypnotic phenomena. He is also fascinated with the transfor-
mation of suffering into happiness that occurs within therapeutic relationships
and through developing the inner disciplines of mind/body medicine such as
hypnosis, meditation, and relaxation. He is a past president of APA Division
30: Society of Psychological Hypnosis. His research and writings have
appeared in journals such as American Journal of Clinical Hypnosis, Dissociation,
International Journal of Clinical and Experimental Hypnosis, and the Journal of
Humanistic Psychology. He received the award for early career contributions
from the American Society of Clinical Hypnosis in January 2007. In August
2007 he also was honored with the award for early career contributions from
the Society of Psychological Hypnosis.
Index
absorption in imaginative activity, 16 American Hypnosis Board for Clinical

Adler School of Professional Social Work, 132
Psychology in Chicago, 153 American Medical Association, 56
African-Brazilian mediumship, 100, American Psychological Association,
115–119 132
agency, hypnotic inversion of, 45–47 American Psychotherapy Association,
age regression, 65 127, 133
alerting, 41 American Society of Clinical Hypnosis
alterations in consciousness, 99, 100 (ASCH), 125, 132, 133, 142, 147,
altruistic trance states, 112, 113 150, 152
Alzheimer’s disease, 43 amnesia, 28; hypnotic deactivation of
American Association of Marriage and self-conscious source monitoring
Family Therapists, 142 associated with, 7–9
American Board of Examiners in amygdala, 46
Clinical Social Work, 138 anterior cingulate gyrus, 41
American Board of Hypnosis in Approved Consultant in Clinical
Dentistry, 132 Hypnosis, 133
American Board of Hypnotherapists/ Arons, Harry, 131
Hypnotherapy (ABH), 126, 131 Association to Advance Ethical
American Board of Medical Hypnosis, Hypnosis (AAEH), 125, 131;
63, 132 AAEH Code of Ethics, 142
American Board of Professional attention systems, hypnotic changes
Psychology (ABPP), 132, 138 in, 41–42
American Board of Psychological autobiographical memory, 46
Hypnosis, 63, 132 automaticity, hypnotic effects on,
American Boards of Hypnosis (now 44–45
American Boards of Clinical automatic writing, 65
Hypnosis), 132 awareness, 99
American College of Forensic
Examiners (ACFE), 129 Bali, hypnotic-like procedures in,
American Council of Hypnotist 111–113
Examiners (ACHE), 131 Balinese folk customs, 100
166 Index
basket drum ceremony, 109 dissociated memories, hypnotic

Bernheim, Hippolyte, 130 recovery of, 10–11
blood oxygen level-dependent (BOLD) dissociated perceiving with or without
signal fluctuations, 41 a hidden observer: hypnotic
body painting, hypnotic-like deactivation of self-conscious source
procedures, 104 monitoring during, 5–6
B€on-Buddhism, 147, 148, 149, 154 dissociaters: comparison with
Braid, James, 97, 147, 150 dissociaters, 28–32, Dissociative
Braidism, 97 Disorder, 31–32, hidden observers,
Breuer, Joseph, 130 29, nightmares, 29, 30–31, Post-
British Medical Association, 131 Traumatic Stress Disorder, 31–32,
Buddhists, 147, 148, 149, 154 trauma histories, 29, 31, waking
imagery hypnotic characteristics
California Board of Hypnotherapy, 131 of, 18
canonical brain networks, connectivity dissociation group, 25–28; early
analysis during mindful mediation, memories of fantasies and parental
43–44 discipline, 25–27; experience of
chanting, hypnotic-like procedures, 98, hypnosis, 27–28
103 Dissociative Disorder, 31–32
Charcot, Jean-Martin, 130 Dissociative Experiences Scale, 11
cleansing, hypnotic-like procedures, DLPFC, 39, 41, 44
103 DPPFC, 39
clinical hypnotists, 141n1; hypnosis as drama, hypnotic-like procedures, 104
distinct profession, 134–135, versus dreams, 17; fantasizers versus
lay hypnotists, conflicting dissociaters, 29, 30–31
paradigms, commitment to science,
134 early memories of fantasizers: in
consciousness, 99 dissociation group, 25–27 parental
Consumer Fraud Reporting discipline and, 21–23,
Organization, 131 egoistic trance states, 113
contextual positioning, 64 Elkins, Gary, 152
control instruction, 5 EMDR International Association, 142
Council of Professional Hypnosis environment, distraction in, 68
Organizations (COPHO), 135–136 Erickson, Milton, 132
Coyote Way, 106–107 ethical considerations, for forensic
credentialing, meaning of, 136–138. hypnosis, 72–73
See also hypnosis credentialing executive attention, 41
culpability, 69
cultural context, hypnotic-like false memories, hypnotic creation of,
procedures, 102 10–11
fantasizers, 17, 18–25; comparison with
dACC, 39, 41, 43, 44 dissociaters, 28–32, Dissociative
dancing, 112 Disorder, 31–32, hidden observers,
daydreams, 17 29, nightmares, 29, 30–31, Post-
default-mode network (DMN), 41, 44 Traumatic Stress Disorder, 31–32,
dietary practices, hypnotic-like trauma histories, 29, 31, waking
procedures, 103 imagery hypnotic characteristics of,
Index 167
18; earliest memories of, and health benefits, of mindfulness

parental discipline, 21–23; meditation, 39–40
experience of hypnosis, 23–25; HGSHS-A, 24
vividness of imagery, 19–21 hidden observer, 5
fantasy-proneness scale, 16 Hilgard, Ernest, 156
Faria, Abbe, 147, 151 hippocampus, 43, 44
fear, 68 homovanillic acid (HVA), 41
Federal Model, 62 Hurd Rules, 62
film: featuring hypnosis, 85–91; hypnosis: dissociaters’ experience of,
inductions of hypnosis in, 79–80 27–28; as distinct profession,
fire ceremony, 108–109. See also realis- 134–135; effects on automaticity,
tic cinema hypnosis 44–45; fantasizers’ experience of,
fMRI, connectivity analysis during 23–25; forensic (see forensic
mindful mediation, 42–43 hypnosis); inductions in film,
forensic hypnosis, 53–74; ethical 79–80; lay versus professional,
considerations, 72–73; illustrative 133–134; in media, 77–92; in
cases, 69–72; interview for, 62–64; musical theater, 82–83;
laboratory experiments, 57; legal neuroimaging of, 38–39; public
issues, 58–62; mechanisms of demonstration of, 150–151; realistic
memory and, 55–57; real-life studies, cinema, 83–91, 85–91; in song,
57–58; resistance, 67–69; techniques, 82–83; stereotypes of, 80; teaching
64–66; therapeutic serendipity, (see teaching hypnosis); as
66–67; varieties of, 54–55 technology, 138–141; in television,
Freud, Sigmund, 130 81–82. See also individual entries
frontoinsular cortex, 39, 40, 42, Hypnosis Consultants, 131
43, 44 hypnosis credentialing, 125–143; brief
history of, 130–131; lay, 131;
Gnosticism, 148 problems of, 135–136; professional,
graduate schools: training program for 131–133
teaching hypnosis within, hypnotic analgesia, 5
demonstrations, providing, 155, hypnotic blindness, 5
personal practice and mentorship hypnotic creation, of false memories,
opportunities, 154–155, spiral 10–11
curriculum method, 156, three-class hypnotic deactivation, of self-
model, 153–154 conscious source monitoring, 1–11;
Greater Philadelphia Society of associated with posthypnotic
Clinical Hypnosis, 125, 133 amnesia, 7–9; dissociated memories,
gustatory stimulation, hypnotic-like recovery of, 10–11; dissociation with
procedures, 103 or without a hidden observer, 5–6;
false memories, hypnotic creation
hallucination: during hypnotic of, 10–11; hallucination during, 3–5,
deactivation of self-conscious source 4; hypermnesia for, 9–10
monitoring, 3–5 hypnotic deafness, 5
Hammond, Corydon, 152 hypnotic hypermnesia: for self-
Harvard Group Scale of Hypnotic conscious source monitoring, 9–10
Susceptibility (HGSHS), 17, 156 hypnotic-like practices, 100; ancient
healing ceremonies, 38 pedagogical perspectives on
168 Index
teaching, 147–150; in graduate long-term memory (LTM), 55–56. See

schools, teaching, 155 also memory
hypnotic-like procedures, 97–121; Los Angeles Police Department, 57
African-Brazilian mediumship
procedures, 115–119; in Bali, McGill, Ormond, 130
111–113; historical and cross- media, hypnosis in, 77–92, 85–91;
cultural issues, 100–102; implications, 91–92; inductions in
multidimensionality, in Dine film, 79–80; musical theater, 82–83;
(Navajo) chantways, 106–111; realistic cinema, 83–91, 85–91;
multi-sensual perspectives on, song, 82–83; television, 81–82
102–104; in Sapmi, 113–115; medial prefrontal cortex, 41
shamanic consciousness during, Medical Hypnosis Association, 133
104–106 memories, 66; long-term, 55–56; short-
hypnotisme, 97 term, 55–56; static phenomenon, 66
hypothalamus, 44 Mesmer, Franz, 97, 147
mesmerism, 97
ideomotor signals, 65 metaphors, 66
image-vividness, 4–5 mind/body techniques, 38
imaginative suggestibility, 125 mindfulness-based stress reduction
inappropriate methods of induction, 68 (MBSR), 39–40
indigenous, 100 mindfulness meditation: canonical
integrative theory, 1 brain networks, functional
intentionality, 45 connectivity analysis of– 43–44;
International Medical & Dental fMRI, functional connectivity
Hypnosis Association (IMDHA), analysis of, 42–43; health benefits
126, 139 of, 39–40; hypnotic changes in
International Society of Hypnosis attention systems, 41–42; hypnotic
(ISH), 132 trance and, resting state networks
interstimulus interval (ISI), 44 connectivity analysis during, 42;
interview: for forensic hypnosis, 62–64 neuroimaging and, 40–41
misconceptions about hypnosis, 68
Janet, Pierre, 130 monoeidism, 97
motor activity, 46
kami, 101 motor cortex, 45
Krasner, A. M., 131 movement, hypnotic-like procedures,
104
languages, 99 musical theater: hypnosis in, 82–83
lay hypnosis credentialing, 131. See
also hypnosis credentialing National Board for Certified Clinical
lay hypnosis versus professional Hypnotherapists, 133
hypnosis, 133–134 National Guild of Hypnotists (NGH),
lay hypnotists versus clinical 126, 131, 132, 133, 138, 140
hypnotists, conflicting paradigms: negative transference, 68
commitment to science, 134; neo-dissociation theory, 25, 156
hypnosis as distinct profession, neuroimaging: of hypnosis, 38–39; and
134–135 mindfulness meditation, 40–41
legal issues, forensic hypnosis, 58–62 nightmare, 17, 30
Index 169
North, Rexford, 131 Sami traditions, 100

North American shamanism, 100 sand painting ceremony, 109–111
Sapmi: contemporary shamanic
Obsessive personality traits, 68 practices in, 113–115
occipital cortex, 46 self-consciousness, 3, 9
olfaction, hypnotic-like procedures, 103 self-conscious source monitoring:
Oregon Department of Education, 131 associated with posthypnotic
orienting, 41 amnesia, 7–9, dissociated memories,
recovery of, 10–11, dissociation with
parental discipline: and early memories or without a hidden observer, 5–6,
of fantasizers, 21–23, in dissociation false memories, hallucination
group, 25–27 during, 3–5, hypnotic creation of,
percussion, hypnotic-like procedures, 10–11, hypnotic deactivation of, 1–
103 11; during sleep, 2, hypermnesia for,
Phenomenology of Consciousness 9–10
Inventory-Hypnotic Assessment sexual fantasies, 27
Procedure (PCI-HAP), 156 shamanic consciousness, during
possibly imagined, 11 hypnotic-like procedures,
posterior cingulate cortex (PCC), 44 104–106, 105; Dina (Navajo)
post-traumatic source amnesia, 11 chantways, hypnotic-like
Post-Traumatic Stress Disorder, 31–32 procedures in, 106–111, basket drum
professional hypnosis credentialing, ceremony, 109, fire ceremony,
131–133. See also hypnosis 108–109, sand painting ceremony,
credentialing 109–111, unraveling ceremony,
pseudo-hallucinations, 3 108
psychogenic amnesia, 10 shamanism, 100
public demonstration, of hypnosis, shame and embarrassment, 68
150–151 short-term memory (STM), 55–56. See
also memory
Quaballah, 148 singing, hypnotic-like procedures, 103
sleep; somnambulistic phenomena
rapport, 138 during, 2
realistic cinema hypnosis, 83–91. See Society for Clinical and Experimental
also film Hypnosis (SCEH), 131, 132, 147,
region-of-interest (ROI) analysis, 41 150; Frye Rule, 58
religious belief, 68–69 Society of Harmony, 151–152
resistance, forensic hypnosis, 67–69 Society of Psychological Hypnosis,
resting-state connectivity, 43 146, 150, 97
resting-state networks (RSNs), 43; somnambulistic phenomena, 2
connectivity analysis during mindful song; hypnosis in, 82–83
mediation, 42 source-monitoring theory, 10
revivification, 65 spiral curricula method, 153,
ritual implements, hypnotic-like 156
procedures, 103 standards of training, teaching
hypnosis, 151–153
sacred geography, hypnotic-like Standards of Training in Clinical
procedures, 102 Hypnosis (SOTCH), 152–154
170 Index
Stanford Hypnotic Clinical Scale, 5 opportunities, 154–155, spiral

Stanford Hypnotic Susceptibility curriculum method, 156, three-class
Scale: Form C (SHSS: C), 154, 156 model, 153–154;
Stanford Scale of Hypnotic television; hypnosis in, 81–82
Susceptibility, 17 Tellegan’s Absorption Scale, 17
static concept of memory, 66 Tellegen and Atkinson’s Absorption
stereotypes, of hypnosis, 80 Scale, 16, 19
storytelling, hypnotic-like procedures, therapeutic serendipity, 66–67
102 three class model, 153–154
striatum, 41 Tibetan Buddhism, 147, 148, 149
Stroop interference paradigm, 44–45, 47 Time regression, 65
subliminal stimuli, 9–10 trance, 45
Sufism, 148 trauma histories; fantasizers versus
suggestibility, 37 dissociaters, 29, 31
Susto, 100 Trust Imagination instruction, 5
Try Hard instruction, 5
tactile stimulation, hypnotic-like
procedures, 104 unraveling ceremony, 108
Tantra, 148
tape recorder model, 66 verbal instructions, hypnotic-like
teaching hypnosis, 145–147; historical procedures, 103
perspectives, 147–153, public vivid imagery and fantasies, 19–21
demonstration, 150–151, spiral voxel-based morphometry (VBM), 40
curricula method, 153, standards of
training, 151–153, teaching wagamama, 100
hypnotic-like practices, ancient waking-sleeping cycles, hypnotic-like
pedagogical perspectives on, procedures, 104
147–150; within graduate schools, within-subject correlation, 4
training program for, Women in Transition, 139
demonstrations, providing, 155, Women Organized against Rape,
personal practice and mentorship 139
Volume 2: Applications in Psychotherapy
and Medicine
Deirdre Barrett, Editor

Copyright 2010 by Deirdre Barrett
All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted, in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise,
except for the inclusion of brief quotations in a review, without prior
permission in writing from the publisher.
Library of Congress Cataloging-in-Publication Data

Hypnosis and hypnotherapy / Deirdre Barrett, editor.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-313-35632-2 (hard copy : alk. paper) — ISBN 978-0-313-
35633-9 (ebook) — ISBN 978-0-313-35634-6 (vol. 1 hard copy : alk.
paper) — ISBN 978-0-313-35635-3 (vol. 1 ebook) — ISBN 978-0-313-
35636-0 (vol. 2 hard copy : alk. paper) — ISBN 978-0-313-35637-7 (vol.
2 ebook)
1. Hypnotism. 2. Hypnotism—Therapeutic use. I. Barrett,
Deirdre.
[DNLM: 1. Hypnosis—methods. 2. Mental Disorders—therapy. WM 415
H9961 2010]
RC495.H963 2010
615.80 512—dc22 2010015824
ISBN: 978-0-313-35632-2
EISBN: 978-0-313-35633-9
14 13 12 11 10 1 2 3 4 5
This book is also available on the World Wide Web as an eBook.
Visit www.abc-clio.com for details.
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This book is printed on acid-free paper
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Contents
Acknowledgments vii
Introduction
Deirdre Barrett ix
Chapter 1 Ericksonian Approaches to Hypnosis and Therapy

Stephen R. Lankton 1
Chapter 2 Ego Psychology Techniques in Hypnotherapy

Arreed Franz Barabasz 49
Chapter 3 Hypnotic Dreams

Deirdre Barrett 97
Chapter 4 The Merits of Applying Hypnosis in the Treatment of

Depression
Michael D. Yapko 123
Chapter 5 Hypnosis in Interventional Radiology and Outpatient

Procedure Settings
Nicole Flory and Elvira Lang 145
Chapter 6 Hypnosis in the Treatment of Smoking, Alcohol, and

Substance Abuse: The Nature of Scientific Evidence
Kent Cadegan and V. Krishna Kumar 165
vi Contents
Chapter 7 Hypnosis and Medicine: In from the Margins

Nicholas A. Covino, Jessica Wexler, and Kevin Miller 177
Index 203
Acknowledgments
I would like to thank Debbie Carvalko from Praeger Publishers for her
advocacy of this project, and for her advice, organization, and review of
these volumes. I would also like to thank the book’s advisory board:
Arreed Barabasz, PhD, EdD; Elvira Lang, MD; Steve Lynn, PhD; and
David Spiegel, MD, for their help in identifying topics to be covered and
advice on the best authors to cover them.
Finally, I want to acknowledge the professional hypnosis societies that
introduced me to the members of the advisory board and to most of the
chapter authors. These organizations taught me much of the hypnosis I’ve
learned since my basic graduate school training, as they have for many of the
chapter authors. They provide forums in which advances in hypnosis are
shared in a timely manner among practitioners. The first two societies listed
here publish academic journals in which much of the research and clinical
techniques summarized in these volumes has appeared. All five conduct stim-
ulating conferences with research presentations and workshops—for students
as well as practicing professionals. All maintain referral lists from which
potential clients can locate skilled hypnotherapists in their geographic area.
They constitute a rich resource for readers wishing to pursue more learning
about hypnosis.
The Society for Clinical and Experimental Hypnosis

SCEH Executive Office
P.O. Box 252
Southborough, MA 01772
Tel: 508-598-5553
Fax: 866-397-1839
Email: info@sceh.us
Publishes International Journal of Clinical and Experimental Hypnosis
viii Acknowledgments
American Society of Clinical Hypnosis

140 N. Bloomingdale Rd.
Bloomingdale, IL 60108
Telephone: 630-980-4740
Fax: 630-351-8490
Email: info@asch.net
Publishes American Journal of Clinical Hypnosis
Society of Psychological Hypnosis

Division 30–American Psychological Association
APA Division 30 Membership
1400 N. La Salle, Unit 3-S
Chicago, IL 60610
http://www.apa.org/divisions/div30/homepage.html
European Society for Hypnosis

ESH Central Office
Inspiration House
Redbrook Grove
Sheffield, S20 6RR
United Kingdom
Telephone : þ44 11 4248 8917
Fax : þ44 11 4247 4627
E-mail : mail@esh-hypnosis.eu
http://www.esh-hypnosis.eu/index.php?folder_id¼14&file_id¼0
International Society for Hypnosis

http://www.ish-web.org/page.php
Introduction
Deirdre Barrett
Hypnosis is named for the Greek god of sleep though, even in ancient
times, few thought of it as literal sleep—this was simply the best analogy
for an altered state so far from waking cognition and behavior. Western
medicine first called the phenomena “mesmerism” after Franz Mesmer,
who conducted group trance inductions in eighteenth-century Europe.
Mesmer attracted attention for his flamboyant style and his cures of hyste-
ria that eluded other physicians of the time. Of course, Mesmer did not
invent hypnosis, he merely rediscovered techniques that had been prac-
ticed around the world since the dawn of history. A fourth-century BCE
Egyptian demotic papyrus from Thebes describes a boy being induced into
a healing trance by eye fixation on a lighted lamp.1 Third-century BCE
Greek temples in Epidaurus and Kos, dedicated to the god Asclepius—
whose snake-entwined staff is now our modern medical symbol, the
caduceus—used hypnotic-like incubation rituals to produce their dramatic
cures.2 Mesmer’s contribution was that he reminded the Western world of
this marvelous therapy. Young doctors flocked to him to study, but the
medical establishment was no friendlier to alternative medicine then than
now. Mesmer was exiled from medical practice, but therapists and the gen-
eral public have remained fascinated with hypnosis ever since.
In recent years, we have been able to understand hypnosis much better
than Mesmer did with his eighteenth-century versions of magnetic and
electrical fields of the body. Indeed we are able to see what real changes in
brain activity occur during the process, but also a wealth of modern cogni-
tive, linguistic, and personality research help explain it. Hypnosis and
Hypnotherapy brings together the latest research on the nature of hypnosis
and studies of what it can accomplish in treatment. Volume 1 addresses
the question of what hypnosis is: the cognitions, brain activity, and per-
sonality traits that characterize it, as well as cultural beliefs about hypnosis.
In Chapter 1, Robert Kunzendorf describes how cognitive processing differs
x Introduction
during hypnosis from usual waking modes. He characterizes the core

change as “the deactivation of self-conscious source monitoring.” This lack
of awareness of the self as the origin of many perceptions during hypnosis
leads to experiencing imagery as hallucinations and to alterations of memory
processing including dissociation, amnesia, and hypermnesia. Kunzendorf
explains how these changes can sometimes enable hypnosis to recover
repressed memories but also increase the possibility of creating false ones.
The most common misconception in hypnosis lore is the notion that
trance, hallucinatory imagery, the will to carry out suggestions—indeed all
the phenomena of hypnosis—emanate from the hypnotist. In fact, it is the
subject who produces these. In Chapter 2, I examine personality traits
associated with the ability to enter hypnotic trance. Very few people are
totally unhypnotizable, but the number able to experience the deepest
hypnotic phenomena—eyes open hallucinations, negative hallucinations
(failing to perceive something that is right in front of one), suggested
amnesia and analgesia sufficient for surgery—is similarly small. Hypnotiz-
ability is not a present/absent dichotomy but a continuum. Many traits
were historically hypothesized to determine hypnotizability such as hysteric
personality, passivity, “weak will,” and “need to please,” but these actually
bear little or no correlation when subjected to modern research analyses.
This chapter summarizes the cluster of traits that do predict response to
hypnotic induction. All of the interview and test questions that correlate
highly concern hypnotic-like experiences of everyday life vividness of
imagery, propensity to daydream, and the ability to block out real
sensory stimuli. I also present a distinction between two types of high
hypnotizables—one of whom has more of a propensity toward vivid, hallu-
cinatory imagery, and the other toward dissociative, amnestic separation of
memory. The first group “fantasizers” tend to have a history of parents who
read them much fiction and encouraged fantasy play, while the second
group “dissociaters” have a history of trauma or isolation during which they
learned amnestic defenses.
In Chapter 3, David Spiegel, Matthew White, and Lynn Waelde review
the effects of hypnosis on physiologic functions. Past studies have found
that induction of the hypnotic state reduces sympathetic nervous system
activity and increases parasympathetic activity, as measured by the low fre-
quency/high frequency ratio in spectral analysis of heart rate, and by
increases in vagal tone. Both of these changes are associated with the abil-
ity to self-soothe. Hypnosis has also been found to affect the secretion of
cortisol and prolactin and to modulate other neural and endocrine compo-
nents of the stress response. The authors then describe recent brain imag-
ing of hypnosis at their lab and other research facilities. The most
consistent changes are found in the frontal attentional systems. Spiegel,
White, and Waelde explain why these often track with the alterations of
autonomic tone noted in the peripheral studies of hypnosis. They describe
Introduction xi
how hypnosis is associated with changes in the executive attention func-

tion of the anterior cingulate gyrus and involves “activation” rather than
“arousal” in neurological terms—and dopaminergic rather than noradren-
ergic in biochemical ones. This type of activation promotes “chunking,” or
reducing the number of parallel systems, and indicates an inner rather than
outer focus. Spiegel, White, and Waelde compare brain imaging findings
in hypnosis with those associated with mindfulness meditation and discuss
the physiological similarity of states produced by the two techniques.
Finally, they discuss shifts in brain activity associated with particular hyp-
notic phenomena such as alterations of pain perception and with the
lessened sense of self-agency during hypnosis that was characterized as
essential in Chapter 1.
In Chapter 4, Melvin Gravitz describes forensic hypnosis—the role it
has played in police investigation and the court system. Views of hypnosis
have swung from touting hypnosis as a truth serum to seeing it as inherently
invalidating witness testimony. Gravitz reviews the precedents and opinions
at all levels, up to and including the U.S. Supreme Court, and offers his
own balanced view of appropriate uses and safeguards. He discusses how
the hypnotic alterations of memory discussed in Chapters 1 and 3, and the
hypnotic-associated personality traits dealt with in Chapter 2, manifest
specifically during criminal witness proceedings. Next, in Chapter 5, I dis-
cuss the depiction of hypnosis in art and media—film, television, theater,
music, and cartoons. These depictions emphasize behavioral control rather
than rich alterations of subjective experience. Most films cast hypnosis in a
dark light—as a tool for seduction or murder. When hypnosis is portrayed
positively, it is often either as a truth serum—similar to the overly optimis-
tic court opinions discussed in Chapter 4 (in fact, these often appear in
courtroom dramas) or as endowing subjects with impossible psychological,
mental, or athletic abilities. The chapter concludes with a discussion of how
more realistic depictions of hypnosis in media might be encouraged.
In Chapter 6, Stanley Krippner and J€urgen Kremer discuss hypnotic-
like practices in shamanism and folk medium traditions with illustrative
examples from various North American tribes, Balinese folk customs,
contemporary Sami (indigenous Scandinavian) practices and African-
Brazilian mediumship. They describe the many similarities in these soci-
eties’ inductions and Western hypnosis, including verbal inductions and
suggestion, sleep analogies, and heavy reliance on imagery and storytelling
(the latter being characteristic mostly of Ericksonian hypnosis to be
described in Volume 2, Chapter 1, rather than of all Western hypnosis).
Krippner and Kremer also contrast trance-induction practices that are
common in the indigenous cultures but not in Western hypnosis including
chanting, percussion, dance or other ritualistic movement, and the burning
of incense. They note a fundamental difference in the two types of indige-
nous practices of shamanism versus mediumship. Shamans are usually
xii Introduction
aware of everything that occurs while they converse with spirits, even
when a spirit “speaks through” them, whereas mediums claim to lose
awareness once they incorporate a spirit, and purport to remember little
about the experience once the spirit departs. This distinction is similar
to the two types of high hypnotizables—fantasizers and dissociaters—
described in Chapter 2. Krippner and Kremer describe how these cultures
foster fantasy proneness and train dissociation to some degree, but that
there also seem to be significant “demand characteristics” to produce the
culturally sanctioned behavior. Krippner has also researched individual
variables of subjects within these cultures, finding some of the same char-
acteristics associated with improvement by Western psychotherapy such as
“willingness to change one’s behavior” predict beneficial outcome to treat-
ment with shaman or medium.
In Chapter 7, Steve Eichel describes the responses of the main lay hyp-
nosis credentialing groups (those not associated with the mental health
professionals, dentistry or medicine, but purporting to represent the
“profession” of hypnosis) to applications for credentialing from a distinctly
unqualified practitioner . . . his pet cat Zoe. Eichel uses the humorous ploy
of getting Zoe certified with applications listing study at ImaCat U and
hefty licensing fees to point out what’s wrong with the concept of com-
mercial “credentialing” groups unaffiliated with state licensing or university
certification. Eichel goes on to describe why it is important to have clini-
cians trained in the underlying disorders that they are treating before
applying hypnosis to them.
Finally, in Chapter 8, Ian Wickramasekera describes in more detail how
this training should be conducted. He reviews the history of how hypnosis
has been taught—in Western psychotherapy and medicine, but also in the
indigenous cultures covered in Chapter 6, ending with a description of the
modern training guidelines established by the American Society of Clini-
cal Hypnosis. Wickramasekera discusses how it is possible to draw together
the best elements of each of these different pedagogical traditions into a
training program for teaching hypnosis either within a university setting or
a postgraduate certificate program.
Volume 2 addresses the clinical applications of hypnosis in psychotherapy
and medicine. In the term hypnotherapy, the second half of the term is as im-
portant as the first. Except for some generalized effects on relaxation and
stress reduction, it is not the state of hypnosis itself that affects change, but
rather the images and suggestions that are utilized while in the hypnotic
state. Because hypnosis bypasses the conscious mind’s habits and resistances,
it is often quicker than other forms of therapy, and its benefits may appear
more dramatically. However, the reputed dangers of hypnotherapy are really
those of all therapy: first, that an overzealous therapist may push the patient
to face what has been walled off for good reason before new strengths are
in place; and second, that the therapist will abuse his or her position of
Introduction xiii
persuasion. People come to hypnotherapy with similar complaints and hopes

to those they bring to any treatment for physical or psychological problems.
Despite the added role of hypnotizability, most of the same factors deter-
mine the outcome: the skill of the therapist, the patient’s motivation to
drop old patterns, the rapport between patient and therapist, and how sup-
portive family and friends are of change.
Volume 2 begins by introducing the different branches of hypnotic psycho-
therapy. In Chapter 1, Stephen Lankton describes Ericksonian hypnotherapy—
the approach derived from the body of writing, training, and lectures of the
late Milton Erickson. Ericksonian techniques include designing individual-
ized inductions in the client’s distinctive language, incorporating the
client’s metaphors for their disorders into the suggestions for change and
using indirect suggestion—which is ambiguous, vague, and more permissive—
to avoid provoking resistance. In Chapter 2, Arreed Barabasz traces the his-
tory of psychodynamic and ego psychology applications to hypnosis
and then describes in more detail modern ego state hypnotherapy. Ego
state theory posits that people’s personalities are separated into various
segments. Unique entities serve different purposes. Ego states often start as
defensive coping mechanisms and develop into compartmentalized sections
of the personality, but they may also be created by a single incident of
trauma. Ego states maintain their own memories and communicate with
other ego states to a greater or lesser degree. Unlike alters in multiple person-
alities, ego states are a part of normal personalities. Conflicts among states
take up considerable energy, often forcing the individual into withdrawn, de-
fensive postures. Hypnosis can facilitate communication between ego states,
allow memories associated with one to become available to the whole person,
and teach people to shift states more consciously and adaptively.
Chapter 3 continues the discussion of psychodynamic uses of hypnosis,
with my summary of the research and clinical work on hypnotic dreams
and the variety of ways of combining hypnosis and dreamwork for the mu-
tual enhancement of each. One can use hypnotic suggestions that a person
will experience a dream in the trance state—either as an open-ended sug-
gestion or with the suggestion that they dream about a certain topic—and
these “hypnotic dreams” have been found to be similar enough to noctur-
nal dreams to be worked with using many of the same techniques usually
applied to nocturnal dreams. One can also work with previous nocturnal
dreams during a hypnotic trance in ways parallel to Jung’s “active imagi-
nation” techniques to continue, elaborate on, or explore the meaning of
the dream. Research has also found that hypnotic suggestions can be used
to influence future nocturnal dream content, and that hypnotic suggestions
can increase the frequency of laboratory-verified lucid dreams. Hypnotic
suggestion can also be used simply to increase nocturnal dream recall.
In Chapter 4, Michael Yapko discusses the newest branch of hypnotherapy—
cognitive behavioral—and especially its use in treating depression. He describes
xiv Introduction
how the classic conceptualization of hypnosis as “believed-in imagination” is

consistent with modern cognitive behavioral theory. Hypnosis can serve as a
means of absorbing people in new ways of thinking about their subjective
experience and as a method of replacing automatic negative thoughts with
positive beliefs and expectancies. It can foster skill acquisition, breaking old
associations and instilling new ones. Yapko reviews the growing body of
research on the effectiveness of such techniques. Finally, because insomnia is
such a common symptom of depression, he describes in detail how hypnosis
can resolve insomnia by inducing relaxation and interrupting the ruminations
that interfere with sleep.
The remainder of the volume addresses applications of hypnosis to med-
ical problems. In Chapter 5, Nicole Flory and Elvira Lang review the use
of hypnosis for analgesia from nineteenth-century surgery prior to the dis-
covery of ether up to modern times. The authors describe how surgery has
evolved from more traditional large-incision techniques toward the inser-
tion of surgical instruments through tiny skin openings under the guidance
of X-rays, ultrasound, magnet resonance imaging (MRI), and endoscopes.
They then review in detail their own carefully controlled research on uti-
lizing hypnosis to alleviate pain, anxiety, and other distress associated with
surgery in the new interventional radiological settings. Despite previous
speculation by others that it would add excessive costs or time to the pro-
cedures, the authors found that teaching hypnosis-naive patients techni-
ques on the operating table shortened procedures by decreasing patient
interference and decreased costs by lowering subsequent complication
rates. In addition to reducing the main target symptoms of pain and anxi-
ety, hypnotic interventions kept patients’ blood pressure and heart rate
more stable. Flory and Lang conclude that hypnotic techniques can be
safely and effectively integrated into high-tech medical environments.
In Chapter 6, Kent Cadegan and Krishna Kumar review studies on using
hypnosis to treat smoking, alcoholism, and drug abuse. There is much more
research on its use for smoking cessation than for any other addictive disor-
der. They report that results are encouraging even for two-session hypnotic
smoking cessation treatment, but that there is no evidence for the efficacy
of the one-session approach, though clinically, this is frequently practiced.
Efficacy of hypnotherapy is less rigorously documented for other addictions,
though there is growing interest in its use. Research on hypnosis to aid so-
briety in alcoholics has found positive effects, but with small sample sizes
and only short-term follow-up. There is less data yet on hypnotic interven-
tions in drug addiction. In one recent study, veterans at an outpatient sub-
stance abuse treatment center benefitted from training in self-hypnosis, with
a very strong main effect for practice—the more regularly they practiced
their self-hypnotic suggestions, the likelier they were to remain abstinent.
Cadegan and Kumar predict that, with more research like this, it will even-
tually become possible to say to a potential client that hypnosis can help
Introduction xv
them control their addiction if they have certain characteristics (e.g., hyp-
notizability, motivation to quit, and availability of social support), and if
they are willing to practice (with specification about the nature and amount
of practice).
Finally, in Chapter 7, Nicholas A. Covino, Jessica Wexler, and Kevin
Miller briefly review the research on hypnotic pain control, already
described in Chapter 6 as establishing a clear efficacy for hypnosis in that
area. They then review the research on hypnosis in other health related
areas, such as insomnia, asthma, bulimia, and a number of more function
gastrointestinal disorders such as hypermotility (leading to cramps and
chronic diarrhea) and hyperemesis (uncontrolled vomiting, usually due ei-
ther to cancer chemotherapy or as a complication of pregnancy). They
conclude that results on all these disorders are clearly positive but need
more research. They emphasize the point—which is true of both applica-
tion of hypnosis to psychotherapy discussed earlier in this volume and to
its role in medicine—that there is great promise for its use with many ill-
nesses and conditions. However, for hypnosis to be better accepted, it is
imperative that researchers in the field update older studies with ones that
pay more attention to current norms of “empirically validated treatments”
and integrate promising strategies from related research such as the mind-
fulness meditation discussed in Volume 1, Chapter 3. Then this powerful
technique will begin to be applied to many disorders in a way that it is
currently only utilized routinely for pain control, anxiety, and smoking
cessation.
NOTES
1. Griffith, F. I. & Herbert Thompson (Eds.) (1974) The Leyden Papyrus:
An Egyptian Magical Book. New York: Dover Publications.
2. Hart, Gerald (2000) Asclepius: The God of Medicine. London: Royal Soci-
ety of Medicine Press.
Chapter 1
Ericksonian Approaches to
Hypnosis and Therapy
Stephen R. Lankton
INTRODUCTION
The focus for this chapter is an approach to change based upon the life
work of Milton Erickson, MD. This is often referred to as the Ericksonian
Approach to hypnosis and therapy. It represents a distinctive and effective
approach to psychotherapy and the use of hypnosis as an adjunct to psy-
chotherapy (Zeig, 1982). Dr. Erickson’s approach can be distinguished by
differences between his selection and use of therapeutic content and in
handling of the process of change in psychotherapy. Ironically, process
and content distinctions are themselves sometimes blurred in Ericksonian
approaches, and these points will be discussed.
HISTORY AND BACKGROUND

The Ericksonian Approach has been derived from the body of work, train-
ing, and lectures provided by Milton Erickson, MD (1901–1980). Erickson
was generally acknowledged to be the world’s leading practitioner of medical
or clinical hypnosis. His name and his ideas have been used by many profes-
sionals to denote some aspect of their work. However, it is often unclear what
specific aspect of their work merits that distinction. This presents a difficulty I
will address later. Similarly, with the rise of a rash of nonprofessionals who
refer to themselves as “certified hypnotherapists,” even greater reference is
made to their so-called “Ericksonian Hypnotherapy.” As with other
approaches to change, such as Gestalt therapy and cognitive behavior therapy,
there is no formal body of control over the use of Erickson’s name.
There is no universally accepted and established standard on how one
interprets Erickson’s practices or how one applies his approach in treatment.
While this situation may lead to much misinformation, there are several
scholarly works written by Erickson and about his work that preserve an
accurate record of his approach, concepts, techniques, and philosophy
(Erickson & Rossi 1979; Erickson, 1980g, h, i, & j; Fisch, 1990; Haley, 1973;
Lankton & Lankton, 2008/1983, 2007; Lankton, 2004; Rossi, Ryan, & Sharp,
1983; Zeig, 1980; Zeig & Lankton, 1988). I will return to the delineating fea-
tures of Erickson’s approach shortly. First, for the record, I will briefly discuss
Milton Erickson, the man.
At the time of his death on Tuesday, March 25, 1980, Erickson was
said to have written over 300 professional papers and hypnotized over
30,000 subjects. He was born in Aurum, Nevada, on December 5, 1901.
Many readers will probably be familiar with the major accomplishments
during his later life: his family of eight children; his many grandchildren;
and his worldwide professional impact. For those who are not familiar with
his early development and his early professional life, I will provide a brief
summary.
It was at age eight that Erickson decided to become a doctor when he
grew up, after a family doctor pulled his tooth and gave him a nickel.
Around the age of 12 he and some friends learned about hypnosis for the
first time from a cheap pamphlet that one of them purchased. Later, he
learned techniques of deep introspection that would come to serve him
well in his professional life.
He developed infantile paralysis of polio in August 1919, at age 17. He
recalled hearing the physicians explain to his mother that her son would
not live to see another sunset (personal communication, August, 1974).
He indicated that he felt great anger that a mother should be told such a
thing about her son. When his family members came into his room after
meeting with the doctors, he instructed them to arrange the furniture in a
particular way. The rearranged furniture allowed him to see out the west
window. Erickson said that he would be “damned if I would die without
seeing one more sunset” (personal communication, August, 1974; Rossi,
Ryan, & Sharp, 1983, p. 10). Of course, he lived. This experience was
powerful in forming Erickson’s worldview.
His pre-college years were filled with hours and days of concentration
and contemplation. Having survived the predicted death, Erickson was
told he would never walk again. He had no sensation or control below his
neck. Yet, not being of the mind to accept such speculation without chal-
lenge, he spent hours learning to discover feelings and sensations in those
muscles not completely destroyed by polio. Erickson learned to revivify
and retrieve experiential memories of shoveling, hoeing, and so on.
Within a year, he had regained the use of his upper torso and was up
on crutches. His later success resulted in having completely regained the
use of his legs and his ability to walk and pedal a bicycle around his under-
graduate campus. He explained all of these successes to the act of discover-
ing the experiential resources and doing so by appealing to simple,
Ericksonian Approaches to Hypnosis and Therapy 3
previously learned skills such as using a shovel or a hand hoe. Sufficiently

revivifying his use of such tools gradually gave him the access to his motor
skills. These episodes of willful intention and the lessons he took from
them shaped his professional approach in many ways. He crystallized for
himself a path of overcoming one’s real or perceived limitations no matter
how serious.
In time, Erickson began a premed curriculum at the University of
Wisconsin. He actually began officially practicing hypnosis as an undergradu-
ate and was considerably capable by the time he graduated in 1928 with his
medical degree. He met and studied hypnosis with Clark Hull who later
sponsored him in his internship. As he studied hypnosis in a class taught by
Hull, Erickson first began to recognize the difference in the existing view of
hypnosis and how it works and what he learned from his own life experience.
He did not think, as he was being taught, that the key to hypnosis was sug-
gestion (planted in the unconscious), but rather that the key was developing
the experiential resources needed in each particular context.
Erickson interned at Colorado Psychopathic Hospital in child psychia-
try and then began working as a senior psychiatrist at Rhode Island State
Hospital. In the spring of 1934, he began as the head of psychiatric
research at Wayne County General hospital in Eloise, Michigan. Eloise
was home to 40,000 psychiatric patients! At that time he began openly
practicing and writing about hypnosis. In 1939 he became an associate
professor at the Wayne University College of Medicine. He held the posi-
tion of full professor in Wayne University’s Social Service Department
and Michigan State College’s clinical psychology program.
Dr. Erickson moved to Phoenix in the summer of 1948 in order to find
a climate that would reduce his sensitivity to allergens. He worked in the
Arizona State Hospital for a period and then went into private practice.
Erickson contracted a second type of polio or post-polio syndrome, in
1953. At this time he lost the use of muscles in his back, diaphragm, abdo-
men, left leg, right arm, mouth, and tongue. In that state, however, he still
continued to work with patients and professionals from around the world.
Some were ongoing students and some only visited briefly. Among them
were such luminaries as Aldous Huxley, Margaret Mead, and Gregory
Bateson. Hundreds of well-known psychiatrists, psychologists, and thera-
pists worked with him or visited him including Herbert Speigel, Lawrence
Kubie, Seymour Hershman, Irving Secter, Lynn Cooper, Theodore Sarbin,
Theodore X. Barber, Andre Weitzenhoffer, Martin Orne, Ernest Hilgard,
Jay Haley, Daniel Goleman, Ernest Rossi, Robert Pearson, Sid Rosen,
Moshe Feldenkrais, Jeffrey Zeig, myself, and many others.
Erickson once remarked that these physical limitations had also made
him more observant. The skills he developed for his own survival he uti-
lized in his observation of others. He became vigilant of the minute muscle
movements people employ and found them to be revealing of information
that had bearing on clinical issues (Haley, 1967). Erickson said, “My tone
deafness has forced me to pay attention to inflections in the voice. This
means I’m less distracted by the content of what people say. Many patterns
of behavior are reflected in the way a person says something rather than
in what he says” (Haley, 1967, p. 2). This keen sense of observation of
meaningful patterns of behavior is yet another hallmark that distinguishes
Erickson’s approach to therapy and hypnosis from most other therapies.
There are several in-depth biographical works on Erickson; this discussion
is not intended to summarize or replace them (Haley, 1993; Erickson &
Keeney, 2006; Rossie & Ryan, 1985). To explain an Ericksonian approach
to therapy and the use of hypnosis and therapy, it is important to establish
the absolute necessity of retrieving experiential resources by means of the
hypnotic experience. His early recovery from polio, in retrospect, had
become the acid test of those concepts. While such a perspective may seem
reasonable to many therapists of today, this notion was at odds with tradi-
tional psychiatry during much of Erickson’s professional life. This approach
calls for an active, that is, strategic, and participatory therapist—a far cry
from an analyst who attempted to be invisible behind a couch.
RATIONALE AND PHILOSOPHY

Erickson’s work spanned 50 years and 30,000 clients (Lankton & Lankton,
2008/1983, p. xiii) who came from a broad background: rich, poor; single,
married; adults, children; “neurotic,” “psychotic”; inpatient, outpatient; urban,
rural; and educated, illiterate. Derived from and used with this rich diversity,
there are several tenets that affect the practice of therapy as well as the way in
which problems and people are viewed.
Assessment and Treatment Planning

“It is not surprising to find at the heart of Erickson’s work a diagnostic
framework that beats to the rhythm of today’s systems and communication
theories” (Lankton & Lankton, 2008/1983, p. 28). Erickson formulated
and used a relationship and family approach to treating individuals long
before it was fashionable. His approach is apparently rooted in the aware-
ness that people operate from internal maps of the world and that these
have been learned. These internal guidelines contain rules for interaction,
experience, and perception, and these constitute internal experiential
resources. In addition, our internal maps will contain learned limitations
regarding how we each interact, perceive, and experience the world.
It is perhaps only of minor significance that Dr. Erickson was a pioneer
in applying this sort of diagnostic framework. His early writings indicate
that he was also well versed in psychodynamic theory. It will be shown
later that he occasionally discussed matters such as defense mechanisms
and other analytic-dynamic concepts. However, he was reluctant to codify

his model of the human mind or human conduct. He would frequently tell
students that he made up a new approach for each client. To some degree,
this must certainly have been an exaggeration. However, he was sensitive
to the unique needs of each individual and did tailor his communication
and interventions to that person.
Nevertheless, we can see at a higher level of analysis repeated patterns
in his behavior. Before examining these, it is important to mention that
Dr. Erickson’s work must be considered more than a collection of techni-
ques and patterns. He was a very careful observer, diagnostician, and was a
consummate professional who kept careful notes. While it is somewhat easy
to understand the interventions that he used, it is more difficult to recog-
nize the diagnostic mindset that he held while using these interventions.
As any trained health care professional should do, Erickson kept detailed
case files that recorded his observations, assessments, diagnosis, interven-
tions, and the client’s responses to those interventions. He referred to his
case files before each session and entered progress notes as soon as possible
after each session. While his diagnostic histories were not obtained from a
chronology of psychosocial events, they were obtained by careful observa-
tion and a selective history of the client’s current life context and relation-
ships (personal communication, August, 1975).
Utilization of Client Behavior

Utilization was one of the hallmarks of Erickson’s work. Utilization is a
process of using the client’s energy, point of view, skills, and potentials.
“Whatever the patient presents to you in the office, you really ought to use”
(Erickson & Rossi, 1981, p. 16). Utilization is a term that Erickson used to
depict his approach in two important areas. One is the here-and-now use
of material presented from the client. If a client demonstrates relaxation,
tension, talkativeness, silence, questioning, passivity, movement, stillness,
fear, confidence, and so forth, it is to be accepted and used (that is, the
client would be directed to continue it) to further the therapeutic move-
ment in a natural way. Tension and “resistance” are not seen as or labeled
as such, but rather, are accepted and in some manner used to facilitate a
context for change. If a mother, father, and child cling closely to one
another, rather than attempting to spatially separate them and calling their
resultant hesitation or anxiety “resistance,” the therapist may ask them to
let the child hold them even closer together with each arm as the interview
takes place. This is using the here-and-now behavior to increase the join-
ing and the comfort of the client as well as to reduce the discomfort or
anxiety that any other intervention would create.
The second manner in which utilization is intended to be understood
applies to using the potential abilities each client brings to the session
(Erickson, 1981, p. 17). Using the latent resources each person brings to a
session will allow for a rich diversity in a “typical” therapy session. Each
person, for instance, can fantasize, recall, regress, anticipate, relax, forget,
imagine, alter consciousness, and so forth, and, using these natural abil-
ities, the client and therapist can cooperate in developing a wide range of
helpful contexts for change.
Speak the Client’s Own Experiential Language

It follows from the utilization approach that therapists must “speak the
client’s own experiential language” and “meet them at their model of the
world” (Lankton & Lankton, 2008/1983, p. 5). He states, “therefore, you
ought to start simply and let the patients elaborate in accord with their own
personality needs—not in accord with your concepts of what is useful to
them” (Erickson, 1981, p. 12). Communicating in this manner requires that
the therapist be flexible in his or her manner. This behavioral flexibility is to
be used in the service of matching the client’s type of language, conceptual
and family orientation, cultural background, and even the client’s speed of
speaking, bodily posture in movement, and breathing rate, when possible.
Dr. Erickson himself had difficulty in moving his limbs, however, first-hand
observation of his behavior revealed that he would change other nonverbal
behavior to be in rhythm with his clients (Lankton, 2003/1980).
Reduction of Resistance
Several aspects of Erickson’s approach can be viewed as components that
reduce resistance. These include his attempt to speak the client’s language,
utilization of the material given rather than confront or block the material
given, introduce ambiguity, allow the client’s personal interpretation of the
ambiguity to temporarily prevail, avoid labels, initially seek very small
changes in the therapeutic direction, interpret and reframe client behavior
in such a way as to make it appear positive, and so on. By blending therapeu-
tic intervention and guidance with the client’s own predisposition for move-
ment, emotion, and thought, Ericksonian therapy can provide very little for
clients to resist. A good analogy to help understand this type of interaction
with clients is to compare it to the martial arts. Some aspects of conven-
tional therapy might be compared to the confrontation in the martial art of
karate, while Ericksonian therapy could be compared to approaches such as
in tai chi or aikido (Ueshiba, 1991). In karate, the practitioner learns to
block and punch in order to defend against the aggression of the opponent.
In tai chi or aikido, the practitioner learns to use the forward movement and
energy of the opponent to reduce conflict without aggression. Compare
Erickson’s view to that of the founder of aikido: “Regarding technique, it is
necessary to develop a strategy that utilizes all the physical conditions and
elements that are directly at hand. . . . When your opponent wants to pull
you must learn to anticipate and direct such a pull” (Ueshiba, 1991, p. 35).
Flexibility and Direct Communication

It’s important to note that not all clients bring resistance to therapy.
Some clients are highly motivated and cooperative and simply seek the
tools they need for change. Other clients commonly seen present a great
deal of defensiveness and poor communication or cooperation skills. A
hallmark of doing therapy in a fashion that was representative of Erickson’s
work is the skill of being flexible—that is, the ability to effect change in
the most rapid manner despite adapting to the type of client who arrives
in the office. When a client arrives who is cooperative, communicates
well, and is motivated for change, it is most appropriate to use direct com-
munication, direct hypnotic suggestion, and decisive non-evasive behavior.
Dr. Erickson was an expert at this sort of communication. In fact, it can
be shown that he used that type of communication for the longest period
of his professional career.
The principle of utilization alone dictates that if a congruent client
comes requesting information and ideas, the therapist ought to take the
direct and non-evasive posture that will help fulfill the client’s learning
needs as soon as possible. For such a client, using indirect, ambiguous, or
metaphoric techniques for anything other than illustrating a point with
greater clarity would conceivably be an injustice. In this type of direct
communication, Erickson was well equipped.
In other words, when initially working with a client who arrives in the
office presenting a good deal of motivation, a history of rich personal and
interpersonal resources, and is a good communicator, the use of indirect
suggestion or metaphor would be less efficient than the use of direct sug-
gestion and non-ambiguous communication. Once again the Ericksonian
therapist should be flexible enough to respond by matching these commu-
nication signals with similar communication.
Similarly, referring to the principle of utilization, when a client comes
to the office who is argumentative, condescending, and competitive, the
model provided by Erickson prescribes that therapy should allow the client
to win the argument, be one up, and win the competition. An approach
of direct communication may provide the best target against which such
clients can argue, criticize, and compete. For these clients, the introduc-
tion of ambiguity and indirect suggestion could conceivably be inappropri-
ate because it would provide no solid content for the continuance of that
client’s skill set (regardless of how self-defeating it might be).
However, beyond the context of interview management and after such
a client was in trance, then the use of indirect techniques might be most
appropriate. This is in part due to the fact that such clients are often not
able to easily bring forth the necessary positive experiences to promote

change. In these circumstances, indirect techniques become valuable
because of the role they play in stimulating thought. To use a colorful
analogy, one might say that the mental search that is necessary to person-
alize and make sense of the ambiguity of indirect techniques is analogous
to the active stirring around inside a “junk drawer” to locate a lost object.
Rearranging the items of random “junk” often reveals treasures that have
been overlooked. In that same way, the listeners of indirect suggestion,
binds, anecdote, and metaphor turns over various ideas in their mind in
order to discover the best meaning to give the ambiguity. This act of
examining and re-examining ideas often yields ideas, methods, and ave-
nues for retrieving desired therapeutic experiences.
Finally, a fourth example would be the case of a client who enters therapy
with the customary ambivalence, relatively more impoverished background
of resource experiences, moderate communication skills, but encumbered by
various learned limitations. Such clients are not particularly compliant nor
do they fully understand how to locate and reassociate various experiential
resources. Such clients perhaps represent the majority of customary outpa-
tient mental health patients. With these clients a mixture of both direct and
indirect suggestion is the most logical way to proceed. Indirect suggestions,
anecdotes, binds, and metaphor help listeners create a conditional mental
search and tentative understanding. This creates expectancy in the mind of
the listener that helps them bring a solid understanding to any subsequent
direct communication that follows. This pattern of using indirection fol-
lowed by direct suggestion, for most clients, will usually prove to be the most
efficient both prior to and during trance experiences.
It has been three decades since the death of Dr. Erickson. Yet, some
individuals in the therapeutic community may be under the impression
that Erickson’s most distinctive feature was his use of indirect communica-
tion. This would be an incorrect assumption. The most distinctive feature
about Erickson’s work would likely be best stated in the terms flexibility
and utilization. While other features are also predominately important in
his work—such as taking a nonpathological approach, trying to get the cli-
ent moving as soon as possible, being active and strategic in the therapy,
and emphasizing the present and future development of the client rather
than the historical past—flexibility and utilization were the hallmarks of
Dr. Erickson’s work throughout the course of his career.
Indirection and Ambiguity

Indirection is an orientation to offering ideas that Erickson developed in
the last few decades of his career. It became a well-known principle of his
approach (Erickson & Rossi, 1980a; Haley, 1963, 1973, 1967; Watzlawick,
Weakland, & Fisch, 1974; Fisch, Weakland, & Segal, 1982; Lankton &
Lankton, 2008/1983) in the last half decade before his death. One aspect of
indirection is the latitude it provides for each client’s own experience and
thinking. The use of ambiguity can sometimes instill a certain curiosity that
can give rise to a degree of pleasant mental excitement toward change.
Rather than detracting from communication, ambiguity often enhances
it. This applies not only to hypnosis but also to normal communication con-
ducted with families in waking state conversation.
Perhaps the vast majority of clients that are seen in outpatient psycho-
therapy are neither highly motivated nor good communicators—nor are
they extremely rigid poor communicators. Instead, it might be fair to say
that the vast majority of clients for many therapists, especially those in
outpatient settings, are only moderately good communicators who are
ambivalent about changing and somewhat defensive about their lack of
experiential resources. For these individuals, therapy often results in defen-
siveness and an inability for them to identify and retrieve the needed
resources for change. In situations such as these, indirect techniques are
often most helpful. Their helpfulness lies in the manner in which they
engage the client. They facilitate a mental search process while reducing
defensiveness by disguising the desired goal. When clients identify a “fit”
between what the suggestion has hinted and their own personal history,
the experiential options are expanded. Since they have not had to comply
with the therapist’s directions, clients who respond to indirection have
developed their own answer or their own resource actions from, so to
speak, within themselves (Lankton & Lankton, 2008/1983).
It is important that the reader bear in mind that indirection does not
constitute a defining feature of Erickson’s approach. It constitutes one of
the pillars that he relied upon in his career, having perfected it in his later
years. However, there is a danger in promoting the use of indirect techni-
ques among inexperienced therapists or professionals using hypnosis. The
danger is found not in the technique itself, but rather in an attitude that
is occasionally inferred by would-be practitioners who have not thoroughly
learned the clinical logic behind indirect techniques. Using indirect tech-
niques correctly and effectively takes a great deal of work and study. It is
unfortunately too common that I hear students of an indirect approach
state that a therapist only needs to simply “trust their unconscious” and
tell clients content that is spontaneously delivered.
The model displayed by Erickson was anything but a “fly-by-the-seat-of-
your-pants” or spontaneous approach. Erickson worked out the wording of his
inductions and his early stories over a period of dozens of drafts. He would
write out, for example, a 20-page induction and edit it down to 12 pages.
Then he would edit his 12-page induction down to 7 pages. Eventually he
would continue the edit until what remained was a page and a half of a well-
crafted induction (Haley, 1967). While he was a keen observer, he did not
interpret meaning to his observations flippantly. He was a strong critic of
people who claim to be mind readers (personal communication, August,

1978). He developed his understanding and observational skills over the
period of many years and built those understandings on a foundation that
originated from a deeply personal insight into his own motor behavior. Thera-
pists who believe they can replicate that sort of observational talent are likely
to be grossly mistaken.
Being aware that one will not be as perceptive as Erickson means that
those professionals who wish to apply his work in their therapy will need
to augment their face-to-face communication with clients. There will be a
need for more verbal confirmation from clients. And too, there may be a
need for the use of other assessment tools. Even simple tools like the Inter-
personal Check List (Leary, 1957) can provide valuable insight about the
range of behavior a client is capable of producing for those of us who are
not as perceptive as Erickson.
The use of tools of indirection includes metaphor, indirect suggestion,
therapeutic binds, anecdote, and ambiguous function assignments (Lankton &
Lankton, 2008/1983, 1986). In contrast to direct techniques and direct
suggestion, indirect techniques are difficult to learn, understand, and use.
Therefore, I have often written about and taught these techniques in my
professional publications and workshops. It is my intention to provide a
sufficient articulation of these ambiguous techniques so as to make possible
to construct well-conceived empirical research studies about them and to
help therapists use them wisely. Lacking such careful articulation, these
techniques will simply be lost to history. Therefore, I will provide further
details and an illustration about these lesser understood and practiced tech-
niques of Erickson’s work.
Hypnotic Language
Hypnotic language refers to verbal and nonverbal communication that
elicits unconscious responses in a single listener or in multiple listeners.
Traditionally, when one speaks of hypnotic language, it means direct sug-
gestion, and means that the hypnotist makes a clear and direct request for
a certain response. For example, “Close your eyes. Listen to everything I
say. Follow my suggestions completely.” In addition, however, when one
speaks of hypnotic language, it may mean a form of indirect suggestion
where the relationship between the operator’s suggestion and the subject’s
response is less obvious. Indirect language can also include forms of confu-
sion, anecdote, and metaphor. For example, “Your conscious mind may
not immediately realize how much your unconscious mind will learn. You
might enjoy how much you learn sooner or later.”
Direct suggestion can be defined as the language that elicits an uncon-
scious response to a stated goal. Direct suggestion gets best results when the
operator’s prestige and authority is high and the principles of repetition,
along with the evocation of ideosensory and ideomotor processes are used
(Weitzenhoffer, 1957). Sometimes these are enhanced by goal-directed
fantasy that is often recognized as the basis of direct suggestion (Barber,
Spanos, & Chaves, 1974).
Erickson states that “much of hypnotic psychotherapy can be accom-
plished indirectly” (Erickson & Rossi, 1981, p. 13). Indirect suggestion is
hypnotic language that is recognized for being ambiguous, vague, and more
permissive in nature. Responses to indirect suggestion are recognized as
being a function of the subject’s personal need, and, perhaps because of
this, they may be more effective, or at least experienced as being more rel-
evant, than direct suggestion at an individual level. The rationale for
using indirect suggestion is also characterized by a number of basic features
that are of particular interest:
• Indirect suggestion permits the subject’s individuality, previous expe-

rience, and unique potentials to become manifest;
• The classical psychodynamics of learning with processes like associa-
tion, contiguity, similarity, contrast checking, and so forth, are all
involved on a unconscious level;
• Indirect suggestion tends to bypass conscious criticism and learned
limitations. Because of this it can be more effective and long lasting
than direct suggestion.
Indirect suggestion may be successfully used with subjects who are

awake; in waking state its suggestive influence is much greater than that of
a direct suggestion. It frequently exerts an effective influence on people
who do not yield to direct suggestion, as was pointed out by V. Bekhterev
and colleagues (Bekhterev, 1998). It could be said that the stronger sugges-
tion is the one that is more concealed.
Language can be direct, indirect, confusing, anecdotal, logical, rational,
poetic, and metaphoric. Let me say that again, all language is hypnotic lan-
guage and it varies by degree of effectiveness. If we classify communication
by degrees of effective hypnotic response that it produces, we would be able
to place all communication into a continuum of hypnotic language—from
minimally effective to powerfully effective. We can measure this effective-
ness in several ways by answering some simple questions of both low and
highly hypnotizable subjects: How soon does the person respond to the lan-
guage? How long does the effect last? How resistant to change is the
response? How much energy, effort, or repetition must be used to obtain
the response?
In any event, the goal in using hypnotic language is to elicit experience
in the listener. The goal is not, as some uninformed people might think, to
place an idea in the subconscious. Again, the goal of language is to elicit
experience: cognitive, perceptual, emotional, and behavioral experience.
Depathologizing
Since problems are not thought to be “inside” a person’s head, there is a
depathologizing of people (Fisch, 1990). Problems are thought to be the
result of trying to move toward a more normal state in an unfolding life
cycle (Haley, 1973, p. 150). Ericksonian therapy attempts to avoid labels
and redefine any possible stigma attached to a client’s presenting problem.
In a dramatic example of this, Erickson once had a young withdrawn
woman with a previously embarrassing gap in her teeth. He encouraged
her to learn to propel water through that gap. He eventually convinced
her to shoot water at a young man who had shown some interest in her
and whom she had avoided. The results of this interaction eventually led
to the courtship between these two young people (Haley, 1973). By allow-
ing this girl to continue to avoid contact with others, and by redefining
the gap in her teeth as something enjoyable rather than a deformity, he
was able to avoid the obvious resistances that could have been created by
an approach to therapy that wished to teach her to become assertive and
proud “despite her problem.” Ironically, she did become assertive and
proud but was able to do so without having to first consider her problems
as a negative liability she was going to have to overcome in the course of
therapy (Haley, 1973).
Therapy is directed toward helping clients contribute to a creative rear-
rangement in their relationships so that developmental growth is maxi-
mized. Accompanying the reduction of the pathology oriented assessment
is a corresponding reduction in so-called resistance.
Creating a Context for Change

Additionally, in Ericksonian therapy, the therapist is active and shares
responsibility for initiating therapeutic movement and “creating a context
in which change can take place” (Dammann, 1982). This is often facili-
tated by introducing material into the therapy session and by the use of
suggestion, metaphor, and even extramural assignments. That is, a thera-
pist may not wait until clients spontaneously bring up material but rather
may invite or challenge clients to grow and change by creating a context
in which it can occur. It would probably be most accurate to say that an
Ericksonian therapist does not consider himself or herself an expert on the
client who appears in the office, but rather tries to be an expert for creat-
ing a context for that client to change. That context can be didactic out-
patient psychotherapy, psychotherapy done in hypnosis, family therapy,
couples therapy, homework assignments, or combinations of all of the
above. But it is working with the unique client to develop a context that
works for them that constitutes another aspect of the flexibility that is a
hallmark of Ericksonian therapy.
Getting the Client Moving as Soon as Possible

Ericksonian therapy is interested in getting clients active and moving
(Zeig, 1980). This movement can begin with very small incremental
changes inside the office and later be magnified into greater behavioral
changes in their lives outside the office. Hypnotherapy and the use of
direct suggestion, anecdotes, therapeutic metaphors, and indirect sugges-
tions are ways of conversing with clients to help create the impetus during
sessions to carry out new relational behaviors or congruently engage in the
homework assignments. It’s conceivable, for example, that a client would
be taught during a session to begin moving a finger when he hears his wife
speak. This simple behavior could then be leveraged to having him turn
his head to make eye contact with his wife when she speaks outside the
session.
Assignments are often given in order to have clients carry out agreed-
upon behaviors between the sessions. It is from the learning brought by
new actions and not from insight or understanding that change develops. It
may be, in fact, that “change leads to insight” (Dammann, 1982, p. 195).
Consequently, clients’ understanding or insight about a problem is not of
central importance. The matters of central importance are the clients’ par-
ticipation in new experiences and transactions in which they congeal
developmentally appropriate relational patterns.
Present and Future Orientation

Ericksonian therapy is future oriented and is centered upon an integra-
tion of family therapy and individual hypnotherapy, though these areas are
often seen as extremes with very little convergence. The influence of
Erickson’s approach grew in these two areas independently as it provided
examples for the philosophical work of Bateson and other epistemological
thinkers who emphasized the need to depart from a model of linear causal-
ity associated with the medical model of therapy (Fisch, 1990).
The Ericksonian-strategic approach is a method of working with clients
emphasizing common, even unconscious, natural abilities and talents. This
is in distinct contrast to conventional psychotherapy approaches that place
an emphasis upon dysfunctional aspects of clients an attempt to analyze,
interpret, or develop insight for them during therapy sessions. Instead, it
works to frame change in ways that reduce resistance, reduce dependence
upon therapy, bypass the need for insight, and expand creative adjustment
to developmental demands, while removing the presenting problem and
allowing individuals to take full credit for changes achieved in therapy.
In the development of most approaches to psychotherapy, there has
been considerable effort to elaborate a theory that will guide clinical pro-
cedure. While practice needs to be informed by theory and research, the
clinical interventions developed from theory or research often are restric-

tive in the range of behaviors prescribed for the therapist. This appears
particularly true for psychoanalytically oriented therapies that until very
recently have continued to hold a position of dominance in the medical
and psychological communities.
Erickson and Rossi (2008) identified the limitations of these therapies
as arising from three general assumptions:
• Therapy based on observable behavior and related to the present and

future circumstances of the client is often viewed as superficial and
lacking depth when compared to therapies that seek to restructure
clients’ understandings of the distant past.
• The same approach to therapy (e.g., classical analysis, gestalt, Trans-
actional Analysis, or non-directive therapy) is not appropriate for all
clients in all circumstances.
• Effective therapy occurs through an interpretation and explanation of
a client’s inner life based on the assumptions of the given theory.
Change, from this perspective, occurs mainly through insight by a cli-
ent into his or her behavior.
These assumptions deny the context of the problem, the unique learn-
ings, experiences, and resources of clients, and the type of symptom pre-
sented. Most therapies require, if only inadvertently, that clients adapt to
the therapist’s worldview when it may not be in their best interests to do
so. From early in his life, Erickson began to challenge traditional notions,
expectations, and limitations placed on him.
We can see examples of this difference even in the initial contact that
Erickson has with clients. Erickson felt that focusing on childhood psycho-
social history, to the exclusion of the client’s daily life, contradicts basic
experience. Events in daily life can have a profound influence in the devel-
opment of character or personality. As Erickson & Rossi (2008) correctly
point out, these events do not need to be considered extensions of earlier
unresolved infantile traumas in order to be understood.
While people have memories, perceptions, feelings, and so forth regard-
ing their past, current realities impinge on them that affect their daily and
future interactions in the world. Preoccupation with the past and a disre-
gard of present and future needs unnecessarily prolong and complicate the
process of therapy. In fact, the phenomenon of selective recall may provide
the client with a great deal of apparent facts about the past that parallel
the present problem. While Erickson himself never said so, one might go
so far as to speculate whether or not memories of the past constitute a sort
of metaphor for the client’s present experiences.
In any event, a hallmark of an Ericksonian approach is an emphasis on
current interpersonal relationships and their influence on the development
and resolution of problems. While an individual may have developed a

symptomatic behavior in the distant past, the Ericksonian view focuses on
how the problem is maintained in the present. Thus, in this approach, the
unique interpersonal interactions in the client’s present life are of primary
importance, rather than a reliance on the application of a rigid theory and
technique.
CHANGES IN TREATMENT APPROACH OVER TIME

When considering this emphasis on interpersonal focus, it’s important to
note the difference between Erickson’s early career practices and his later
career developments. The field of psychotherapy in hypnosis has witnessed
controversy about Erickson’s approach. Some individuals would claim that
Erickson’s later students misunderstood his approach (Hammond, 1988).
Because some individuals emphasized techniques of indirection and ignored
Erickson’s use of techniques that were more direct, a schism developed. It
was clear to individuals who studied directly with Erickson, rather than those
who simply learned about him through his writings, that the schism did not
need to exist.
Individuals who studied with Erickson early in his career witnessed a
man who was highly influenced by the prevailing psychoanalytic theory
and the style of authoritarian-directed hypnosis that existed. At that point
in his career, Erickson used a great deal of repetition, redundancy, and
direct suggestion. Later in his career, Erickson evolved from this authori-
tarian approach and changed to a more ambitious style of therapy. The
more permissive and ambiguous approach to hypnosis and psychotherapy
that Erickson demonstrated in his later years was not the result of Erickson
mentally and physically deteriorating, as some have intimated (Hammond,
1984). Erickson specifically addresses the issue of his change and the
rationale for his change in his writings. He had a well-thought out and
logical reason for including more forms of interaction and permissiveness
in his psychotherapy and hypnosis. He felt that it was important to good
therapy to allow clients a greater latitude of understanding. He believed
that indirect techniques facilitated the client developing their own experi-
ence rather than complying to the demands of the therapist (Erickson and
Rossi, 1980c).
Perhaps the professional who studied with Erickson for the longest pe-
riod of continuous time was Jay Haley. Haley was witness to Erickson’s
earlier approach to change as well as his later approach to change. This
distinguishes him from those who experienced Erickson either in the ear-
lier or in the later decades of his career. Haley did not consider Erickson’s
later emphasis upon indirection in hypnosis and therapy a result of his
physical deterioration (incidentally, there was certainly no evidence of
mental deterioration in Erickson). If he did, in fact, develop the indirect
approach because he was physically ailing in his later years, readers might
take a lighthearted humor in the recognition that a reliance upon indirect
techniques may very well reduce stress on the therapist but it appears to
increase the therapist’s effectiveness with many clients! What could be
better? In any case, we can see the articulation of this evolution, from a
reliance upon direct communication to a more indirect approach to ther-
apy and an evolution from a strongly authoritarian to a more permissive
interpersonal posture in Erickson’s own words if we study the entire body
of his written work.
CHANGES IN TREATMENT DURATION

In the early 1950s, we see several cases during which Erickson took
months and years. The case of the man with a “fat lip” took upwards of
11 months (Erickson and Rossi, 1979, p. 224) and the case of the “February
Man” from Michigan took far longer—up to two years (Erickson, 1980a,
pp. 525–542). While it is true that Erickson made himself available to
clients for an indefinite period of time while he lived in Phoenix, his
published cases became shorter in duration. In 1973 we find the case of the
eight-year-old “stomper” that took two hours (Haley, 1973, p. 219). Various
cases of his “shock” technique in 1973 entailed one- to two-hour long ses-
sions (Erickson & Rossi, 1980a, p. 447). In general, the movement to brief
therapy progressed continually and became prominent in his practice in the
late 1960s and beyond.
Changes in Erickson’s Conceptualization of Symptoms

Let’s consider some changes in the view of symptoms from a psychoana-
lytic view to an interactional view. From his earliest years as a psychiatrist at
least until 1954, Erickson took a traditional analytic view of neurosis and vari-
ous symptoms. He said the development of neurotic symptoms “constitutes
behavior of a defensive, protective character” (Erickson, 1980c, p. 149). At
this early point in his career, he had not fully developed a theory that was
opposed to the prevailing traditional understanding of behavior.
By the mid-1960s, his view had become much more interactional. Perhaps
this was a result of his collaboration with Jay Haley, Gregory Bateson, John
Weakland, and the Palo Alto Communication Project. In any case, Erickson
writes, in 1966, “Mental disease is the breaking down of communication
between people” (Erickson, 1980d, p. 75). However, by the end of his career,
he had moved even further from the analytic and the communications or sys-
tems theory of disease. He states, “Symptoms are forms of communication”
and “cues of developmental problems that are in the process of becoming
conscious” (Erickson & Rossi, 1979, p. 143). His evolution of thought about
problems became less and less focused on them as pathological artifacts until,
in the end, symptoms could be seen as communication signals of desired

directions of growth. Erickson even went so far as to take such signals to be a
request for change, albeit unconscious contracts for therapeutic engagement.
However, in today’s world, Erickson would have been restricted by require-
ments and considerations of informed consent, of course.
Cure Accomplished by Reassociation of Experience

A focus on the psychosocial past can often reveal moments of learned
limitation. For example, a historical event may reveal the most intense
example of a time when a patient learned to avoid expressing a certain emo-
tion that is still lacking in the present. Exploring the past events and traumas
can be the basis for some types of psychotherapy, but that should not be ther-
apy’s exclusive focus. Ericksonian therapy is based on identifying client
strengths and increasing the possibility of new learnings and experiences that
can be used for solving problems in the client’s present life. The retrieval
or building of that missing emotional experience would be central in the
Ericksonian approach. In addition, his approach focuses on orienting clients
to solutions necessary for future developmental changes.
At least one area in which Erickson never wavered in the course of his
career was his view of what constituted “cure.” I suspect this was a result
of his personal experience overcoming paralysis. He learned as a young
adult that experiential resources created change. As early as 1948 Erickson
recognized that cure was not the result of suggestion but rather resulted
from the reassociation of experiences (Erickson, 1980e, p. 38). In the later
years of his career, we find this theme repeated again and again (Erickson &
Rossi, 1979; Erickson & Rossi, 1980b, p. 464; Erickson & Rossi, 1981).
Changes in Use of Hypnotic Suggestion

As mentioned, professionals who studied with Erickson early in his ca-
reer purport a different orientation to therapy than those who studied
with him during his later years. In a 1957 transcript of induction, we find
Erickson’s redundant use of words like sleep as in the following quote,
“Now I want you to go deeper and deeper asleep” (Haley, 1967, p. 54). In
addition, his authoritative approach can be found in this same transcript
represented with the statement, “I can put you in any level of trance”
[italics mine] (Haley, 1967, p. 64). However, by 1976 Erickson believed
indirection to be a “significant factor” (Erickson, Rossi, & Rossi, 1976,
p. 452) in his work. Furthermore, by 1981 Erickson clearly states that he
“offers” ideas and suggestions (Erickson & Rossi, 1981, pp. 1–2) and ex-
plicitly adds, “I don’t like this matter of telling a patient I want you to get
tired and sleepy” (Erickson & Rossi 1981, p. 4). With regard to his use of
indirection, this appears to be clear evidence that it evolved to occupy a
prominent place in his practice to a point in the late 1970s when Erickson
had all but abandoned his earlier techniques of redundancy and authori-
tarianism during induction.
BASICS INTERVENTIONS OF THE APPROACH

It is difficult to categorize Erickson’s customary approach to therapy—
that is, the approach that he most commonly used. There are a wide range
of case examples where the technique used was never repeated. On the
other hand, there are some interventions that were clearly used repeatedly
such as the February Man story and commands delivered within that story.
Others include the use of reframing, the use of indirect suggestion to
induce trance and retrieve experiences, the use of confusion technique,
structured amnesia, and the use of rehearsals done through visual imagina-
tion and trance.
Speaking the Client’s Language and Matching Behavior

Erickson’s own explanations were often frustrating to many of his stu-
dents, as he insisted upon sharing wisdom in a rather folksy manner. For
instance, asked what the most important thing was in therapy, he would
comment, “Speak the client’s own experiential language.” When asked for
the next most important thing to do, he commented, “Put one foot in the
client’s world and leave one foot in your own” (personal communication,
August, 1975). Such comments seemed to side step conventional scientific
language and left one wondering if he would eventually come to add more.
He never would.
The topic of matching the behavior of the client is a logical extension
of speaking the client’s language. Certainly speaking clients’ language is
matching their verbal behavior and way of expressing themselves. There
has also been a good bit of discussion in the last three decades about
matching the client’s physical behavior. It is not accurate however to say
that Erickson would find it appropriate in his practice to mirror the behav-
ior of all of the clients he saw. There are many examples of cases that
have been published about Erickson’s work in which he clearly took an
interpersonal posture that was dissimilar than that of his clients (Haley,
1973). For example, there is a case of a woman who had very low self-
esteem and was overweight—in this case, Erickson initially took a role
that would be described as hostile and dominant. In another case, a man
who was a flute player saw Erickson because of his enlarged and swollen
lower lip. This client was extremely hostile and critical of Erickson—in
this case, Erickson took a role that would be described as submissive and
self-critical. In other cases he played a role that could be described as
bossy and told parents they were to allow him to make all of the decisions
about their son. In still another case, Erickson played a very critical role
when he turned and stomped on the feet of a young girl who felt obsessed
about the size of her growing feet. Each of these cases and more can be
found in the Uncommon Therapy casebook (Haley, 1973).
So what are we to make of the allegation that Erickson matched the
behavior of his clients in a symmetrical fashion when so many cases illus-
trate that he did not? The answer is quite simple. Once again, the key is
that Erickson demonstrated flexibility in his approach. However, there are
guidelines for matching that may not be quite so evident at first glance. In
each of the cases I cited before, Erickson took a complementary role rather
than a symmetrical role in his interpersonal posture with these clients. I’d
like to illustrate this with the following explanation. Assume a simple bell
curve that describes the range of client behavior from, on the left side,
extremely flexible or loose behavior through relatively normal behavior in
the middle and all the way to extremely rigid behavior on the far right
side of the curve. That is to say, behavior that tends to match the cultural
norm is in the middle of the bell curve. Each standard deviation to the
left-hand side describes increasingly more chaotic behavior that would
include, for example, moderate to high anxiety, histrionic behavior, hys-
terical behavior, borderline behavior, and eventually psychotic behavior.
Each standard deviation to the right-hand side from the norm would con-
tain examples of increasingly rigid behavior such as, depression, obsession,
compulsion, narcissism, and paranoia, until finally one reached a paranoid
personality type behavior. I am not concerned about the exact ordering of
these diagnostic labels. Rather, I am concerned with the notion that
behavior can be extremely chaotic or extremely rigid and that we could
look at this on a continuum in which we find culturally normative behav-
ior located in the middle of the bell curve.
Once we have constructed this mental map, we have a good way to bet-
ter understand the logic of using the concept of matching in Ericksonian
approaches to therapy and hypnosis. Using Erickson’s successful behavior
with clients as a model, the following conclusion could be drawn. Those
clients that fall, loosely, within a standard deviation both sides of norma-
tive behavior would be met with a symmetrical matching. That is, the body
posture of the therapist would match the body posture of the client. This
behavioral matching could be done with extreme attention to detail so
the therapist matches the client’s movement of limbs, legs, breathing, eye
movements, and so forth.
However, once the presentation of the client’s behavior exceeds a cer-
tain limit beyond the normative and, by comparison, is overly rigid or
overly chaotic, the therapist may be well advised to use complementary
matching instead of symmetrical. For example, if an extremely hostile and
rigid prosecuting attorney seeks therapy, matching the client’s behavior in
a symmetrical fashion may be ill advised. It’s extremely possible or likely
that such an interpersonal posture would result in a symmetrical escalation

of hostilities. Instead, taking a complementary matching position would
probably make for a better joining maneuver. The flexibility to allow one-
self to initially be in a position of receiving criticism from such a client
could be seen as an implementation of the utilization principle.
The conclusion that should be drawn from this discussion is that the
initial joining behavior frequently referred to as “matching” has to be con-
sidered as a subset to the utilization principle of Ericksonian therapy.
There are instances of matching that will establish a symmetrical relation-
ship and cases of matching that will establish a complementary relation-
ship. Finally, the therapeutic indicators that help determine which type of
matching will provide the best initial therapeutic union have to do with
the degree of rigidity or chaotic behavior exhibited by the client. In addi-
tion, the experience of the therapist in dealing with individuals who ex-
hibit a broad range of behavior, and the unique characteristic of any
particular client, are the final determinants of when the selection of com-
plementary versus symmetrical matching should take place.
Hypnosis
Hypnosis was part of Erickson’s therapy at least as early as 1934 (Haley,
1967, p. 2) and he is probably most recognized as a pioneer and proponent of
clinical hypnosis. Erickson stated that hypnosis was “primarily a state in
which there is an increased responsiveness to ideas of all sorts” (Erickson &
Rossi, 1981, p. 4). However, it should be noted that not all of the Ericksonian
therapy models that developed from Erickson’s influence have included or
emphasized hypnosis. Some practitioners of an Ericksonian approach to ther-
apy (or who borrowed heavily from Erickson’s work) emphasize strategic
assignments, therapeutic ordeals, or family therapy using paradoxical direc-
tives, behavior rehearsal, structured interactions, and direct suggestion, to the
exclusion of hypnotherapy and hypnotic indirection (Haley, 1984, 1985a,
1985b, & 1985c; de Shazer, 1985; Lankton, S., 2001).
It is certainly possible to simply have therapeutic “conversations” that
do not at first glance resemble formal trance (Matthews, 1985b). However,
hypnosis is a useful tool to accomplish certain interview management, con-
tinue diagnostic assessment, and stimulate novel thinking, feeling, and
resource retrieval within the session. There are a variety of opportunities to
introduce hypnosis in Ericksonian therapy and one of these is simply to
notice and encourage naturally occurring altered states of consciousness
that clients will automatically experience. Whether or not to formally label
the experience “trance” is sometimes a debatable issue. Indeed, one of
Erickson’s primary contributions was an emphasis on the naturally occur-
ring elements of “common everyday trance” and demystification about
trance being an unusual or vulnerable state of consciousness (Erickson &
Rossi, 1976, 1979, 1980b). It “always utilizes such naturalistic modes of

functioning; it never imposes anything alien on the patient” (Erickson &
Rossi, 1981, p. 5). His work blurred the boundaries between formal trance
and “waking” state (Erickson, 1980f). “I am not very greatly concerned
about the depth of the trance the patient is in . . .” (Erickson & Rossi,
1981, p. 3). Experiences of searching for meaning in response to an ambigu-
ous or cryptic suggestion can lead to “therapeutic receptivity”—that condi-
tion in which clients can discover relevant experiences and facilitate the
“answers” for which they are searching (Lankton & Lankton, 2008/1983).
While hypnosis is listed here as an intervention or technique, it is more
accurate to think of hypnosis as a modality for exchanging ideas and stimulating
thinking with a client and concentration on their own experience. “The essen-
tial point is that they pay attention, not necessarily to me, but to their own
thoughts—especially the thoughts that flash through their mind” (Erickson,
1981, p. 5). As a modality or context for communication, less emphasis is
placed on hypnosis itself and instead attention is focused on that which is
relevant. Too often, people think of hypnosis as something that the expert
practitioner will do to them and that it will, in and of itself, cure them or sim-
ply remove the troublesome symptom. This is a view of hypnosis Ericksonian
practitioners work to dispel in favor of asking clients what resource experien-
ces they need to retrieve while relying upon hypnosis as an aid.
Using Hypnosis with Families

It has been mentioned that not all practitioners of an Ericksonian
approach use hypnosis. However, it should be noted that many of the fam-
ily therapists who embrace an Ericksonian approach to therapy also use
hypnosis in their family therapy (Ritterman, 1983; Parsons-Fein, 2004).
While that is not the major emphasis of this writing, I offer the following
guidelines that have been observed and developed for introducing and
using hypnosis in a family session (Lankton & Lankton, 2007/1986).
• Try to initially avoid using hypnosis with the identified patient in a

family. This is because family therapists do not wish to reinforce the
possible myth that this family member “contains” the problem in the
family.
• Protect the identified patient from further exposure to discrimination.
Since hypnosis is largely misunderstood by the general public, it is
important to be certain that he or she is not seen as “so sick as to
require a formidable intervention like hypnosis.”
• Avoid playing the role that a rigid family might be assigning—for
example, “fix the problem in the ‘sick’ member.”
• Do, however, introduce hypnosis for the purpose of facilitating relief to
the person currently experiencing or communicating the most pain.
• If the identified patient also happens to be the client member who is

in the most pain, make an exception to the first guideline by offering
hypnosis to both the identified patient and the most “healthy” family
member or members.
• Hypnosis with two or more individuals at the same time provides a
context for building rapport between them (this is especially useful if
they are struggling and failing to build a relationship for various
reasons).
• Hypnotize all adults in the family. This can be done for the purpose of
a stated shared goal or, alternatively, for individual goals that are
unique to each individual. This latter type of approach requires greater
effort, concentration, and training on the part of the therapists.
Induction of Hypnosis
With regard to introducing trance, it is possible to simply notice
the naturally occurring inwardly focused attention of a client and suggest
that this experience be intensified. This is not very much different
from the often routine suggestion to someone experiencing a particular
emotion to “go with that feeling.” Though that therapeutic directive is not
usually associated with the development of hypnotic trance, per se, formal
hypnotic induction need not consist of a break in the normal flow of
communication.
This type of conversational induction is usually not considered to be an
unusual disruption in the therapeutic process. It often includes additional
suggestions for “focusing inward” and deepening absorption. Suggestions
such as, “you can close your eyes as you allow yourself to go deeper with
that feeling and that experience and perhaps notice that things outside
you can seem irrelevant for the moment” and so on. However, the word
trance or hypnosis need not be used at all. Conversational induction under-
scores the idea that hypnosis is simply a modality for exchanging ideas as
are other more familiar interventions.
Therapists use different methods of introducing hypnosis, but the two
most common approaches are methods of naturalistic induction (often
accompanying an internal fixation) and methods of formal induction (often
accompanying an external fixation). The naturalistic induction method
involves an elicitation of the unconscious material that accompanies the
conscious contract developed and shared with the therapist and usually
related to the client’s initial request for treatment. Often clients are pre-
pared to become absorbed in a contemplation of their possible gains from
therapeutic work. When that occurs, therapists can ask the subject to close
their eyes and experience some aspect of this internal resource. That is, the
client might mention that he or she would like to overcome depression and
feel as lighthearted as he or she once did. When the therapist recognizes
the slightest indicator that the client has a memory of feeling lighthearted,
it is an opportunity to ask the client to close their eyes and began to
recover both the memory and experience of feeling lighthearted. With this
very slight alteration of consciousness, hypnosis can be initiated and devel-
oped from that conversational beginning. In this case, the induction and
subsequent hypnosis represents the immediate therapeutic attempt to per-
form a naturalistic induction.
As clients increase their internal concentration, they will of course
respond in ways that signal their degree of success. In addition to head nod-
ding and head shaking (and the meaning attributed to each), search phe-
nomena are of a broader category. Behaviors in this category range from
slight to extreme changes in various reflexes, muscle tone, and skin color.
Easily recognized search phenomena indicators include slowed swallow,
blink, and breathing reflex, increased skin pallor, and increased muscle las-
situde in the cheeks and forehead. This behavior is taken to indicate that
clients are experiencing some degree of a sense of fitness between the sug-
gestions and their own personal frame of reference (Lankton & Lankton,
2008/1983, 2007/1986). However, it further demonstrates that clients are
not altogether certain that the resources they need are available. Hence,
they are searching for further connections between the goals they value
and the tools they know they have. In other words, the search phenomena
indicate the client’s willingness and perceived need to move in the implied
direction at the present time.
The nonverbal dialogue with therapists at this subtle level constitutes a
sort of unconscious contract development. Again, it occurs by means of
ideomotor response to ideas conveyed by therapists who imply successful
developmental gains. Clients can also be asked to answer verbally, of
course. In so doing, they will often indicate a further elaboration of the
presenting conscious contract. This form of gentle induction of hypnosis
illustrates that hypnosis is a natural response to communication and prob-
lem solving. It tends to demystify hypnosis and promote the notion that it
has a rightful place in the realm of natural and ordinary interventions from
which therapists can choose. Once again, trance maintenance suggestions
and suggestions of deepening are often necessary to facilitate greater inter-
nal absorption and the appearance of phenomena usually associated with
various trance depths. Although naturalist and conversational inductions
often require more skill from the therapist, they require less compliance
from the client.
The procedure for a formal induction with external fixation is similar to
that used in a traditional ritualistic induction. The subjects are asked to
set their attention on some close external object so they might become
more absorbed in the process of concentration. As they do, the therapist
proceeds with any one of a variety of instructions most suited for the par-
ticular client before them: conscious-unconscious dissociation induction,
systematic relaxation and deepening, naturalistic, traditional, guided im-

agery, and so forth. While traditional ritualistic inductions are often con-
trasted to the conversational or naturalistic induction, it should be noted
the selection of suggestions formed with permissive language, indirect
suggestions, and therapeutic binds make this sort of formalized inductions
distinctly different than those created with direct suggestions. The times-
structuring of a formal trance induction separates the trance from what fol-
lowed and that demarcation can serve to provide security and familiarity
to those clients who come to therapy with more rigid expectations of what
hypnosis ought to be like.
Often, a formal induction of hypnosis proceeds by asking clients to be
seated with their arms and legs uncrossed and their attention focused to a pro-
gressive relaxation throughout the body. As the relaxation is deepened, the
therapist may even use counting to help the client develop an expectation
that their internal focus is also going deeper. This sort of formal induction is
perfectly acceptable; however, the aforementioned methods of conversational
and naturalistic inductions may be much more consistent with an approach
that utilizes the client’s immediate presentations and concerns.
In a permissive approach, clients should be offered suggestions with an
understanding that they can follow those that are relevant, modify those
that can be modified to become relevant, and ignore those suggestions that
seem to be irrelevant. All clients, through this type of participation, are
responding to their own meaning that they place on the words from the
therapist, or in a way, hypnotizing themselves. They are in control of
engaging or disengaging from the therapist’s influence as a result. It stands
to reason, then, that clients will stay in trance as long as the material pro-
vided is relevant or appears relevant to their growth concerns.
Formal Induction Sequence Outline

1. Orient the client to trance.
This step involves making certain that the clients are physically, cogni-
tively, and psychologically prepared for the trance.
2. Fixate attention and rapport.
Most frequently clients’ attention is fixated on a visual object, story, or
body sensation such as relaxation.
3. Establish a conscious–unconscious dissociation (Lankton & Lankton, 2008/
1983, 2007/1986).
Therapists use conscious-unconscious dissociation language (Lankton &
Lankton, 2008/1983, p. 141), including the possible use of anecdote
and education about unconscious processes to assist clients in the devel-
opment of dissociated and polarized attention.
4. Ratify and deepen the trance.

Ratification of the client’s process of unconscious search is easily accom-
plished by helping focus client awareness on the many alterations that
occur in their face muscles, reflexes, respiration, and skin coloration.
Deepening may be facilitated by several means including confusion, offer-
ing small incremental steps, or indirect suggestions, therapeutic binds, and
controlled ambiguity.
5. Utilize trance to elicit experiences and subsequently associate experiences.
Therapeutic use of trance includes using those unconscious processes
stimulated by induction. The experiences needed are determined by
the diagnostic assessment and contracted therapy goals. Experience may
be facilitated by the use of indirect suggestion and anecdotes, therapeu-
tic binds, metaphor, guided imagery, direct suggestion, and so forth.
Finally, therapists help clients arrange elicited experiences into a net-
work of associations that will help them form a perceptually and behav-
iorally based map of conduct.
6. Reorient the client to waking state.
Reorientation may be rapid or gradual. At this stage, the therapist has a
final opportunity to assist clients in developing amnesia, posthypnotic
behavior, and/or other trance phenomena that are part of the treatment
plan.
Therapists trained in the Ericksonian approaches are most likely to
use a conscious-unconscious dissociation or a conversational induction
(Erickson & Rossi, 1979). Such an induction produces the groundwork for
further elaboration with ambiguity of indirect suggestion, therapeutic
binds, and therapeutic metaphor. A degree of increased dissociation begins
to occur in response to comments about unconscious experience. Language
such as the following may be used to facilitate that dissociation with the
client: “Your conscious mind can listen to the things that I say while your
unconscious begins to identify those ideas that are relevant for you.” “Your
conscious mind may be listening and sorting through your experiences
while your unconscious relates in a global fashion to the experiences that
you need.” And, “your conscious mind may be following a certain train of
thought while your unconscious reacts symbolically or follows an entirely
different train of thought that’s useful for you.”
In this manner, therapists direct the conscious mind to experiences that
are easily validated and basically true for the client at that time. Thus, the
induction is individualized and relevant. Comments regarding the uncon-
scious mind of a client are generally more global, contain a great deal more
ambiguity, and will involve an amount of vagueness. This sort of vagueness
can easily be elaborated and controlled by the use of therapeutic stories or
indirect suggestion.
Hypnotherapeutic interventions strictly aimed toward the verbally

shared contract will be understood as relevant by most clients. A clear
contract reduces clients’ surprise or possible sense of having been deceived.
With many clients, this is of concern and ought to be given serious atten-
tion. While, with other clients, this is less of a concern due to their under-
standing that they are seeking the therapist’s professional skill, regardless
of the specific form it takes.
No matter which of the chosen method of induction, what happens
before and after the trance also needs to be considered carefully. After the
trance experience is terminated, it may be useful to once again ask clients
to engage in the problem-solving communications that had preceded the
trance. In this way, resources retrieved during the trance will be further
associated to immediately relevant concerns and increase the likelihood
that the course of problem solving will be enhanced. Additionally, the
entire trance experience is logically embedded in the middle of a struc-
tured interaction that is designed to bolster changing individual personal-
ity structure and transactional patterns.
The Use of Metaphor as Indirect Intervention

In 1944, Erickson reluctantly published “The Method Employed to For-
mulate a Complex Story for the Induction of the Experimental Neurosis”
(Erickson, 1980b, p. 336). His understanding at that point was that a com-
plex story that paralleled a client’s problem could actually heighten the
client’s discomfort and bring the neurosis closer to the surface. Within a
decade, in 1954, he was using “fabricated case histories” of fleeting symp-
tomatology (Erickson, 1980c, p. 152) indicating that at least some of the
stories he told had been confabulated. Still, almost two decades later in
1973, we see that Erickson provides several examples of case stories for
making a therapeutic point (Haley, 1963) and by 1979 he actually used
the heading of “metaphor” as a class of interventions (Erickson & Rossi,
1979, p. 49). Again, this movement corresponds to his movement from
direct and authoritarian therapy to indirect and permissive therapy.
Uses of Metaphoric Stories

A therapeutic metaphor is a story with dramatic devices that captures atten-
tion and provides an altered framework through which clients can entertain novel
experience (Lankton, 2003/1980; Lankton & Lankton, 2008/1983, 1989,
2007). Metaphor is a form of two-level communication that uses words
with multiple connotations and associations so that a client’s conscious
mind receives communication at one level while his or her unconscious
mind processes other patterns of meaning from the words and develops
related experiences (Erickson & Rossi, 1979). The therapeutic intention is

to occupy, fixate, or disrupt the client’s conscious frame of reference while
generating an unconscious search for new or previously blocked meanings
or solutions. Using metaphor, the therapist can:
• decrease the conscious resistance of the client;

• make or illustrate a point to the client;
• suggest solutions not previously considered by the client;
• seed ideas to which the therapist can later return; and
• reframe or redefine a problem for the client so the problem is placed
in a different context with a different meaning (Zieg, 1980; Lankton,
2003/1980).
As a listener becomes increasingly engaged or absorbed in a story, there

is a reduction in defensive mechanisms that customarily constrain the lis-
tener to sets of common (for them) experience. That is, listening to a
story that symbolizes tenderness can lead a person who normally defends
against sadness to weep. The concept of a novel experience may need
slight elaboration. It pertains to experiences that are commonly excluded
from the experiential set of the listener. While listening to an absorbing
story, a client may, with relative ease, temporarily experience one or sev-
eral specific experiences that, if therapeutically managed, can assist the
listener in creating personal change.
The assistance in creating personal change comes about as clients reex-
amine perceptions or cognitions, emotions, or potential behaviors in light
of a recognition that these new experiences, perceptions, or cognitions
once thought to be alien actually are or can be a part of their own person-
ality and experience. In general, it could be said that the usefulness of
metaphor in therapy comes into play at any point in therapy where it is
advisable or useful for clients to recognize that experiential resources lie
within themselves rather than having to introject or incorporate them
from an outside authority (including the therapist).
The outcome of metaphors is determined by the experiences that are elicited
during the telling of the story. It can be assumed that the conscious mind
of the listener will be engaged in the actual plot and development and of
course conclusion of the story (if it is compelling). However, the uncon-
scious outcome will be the result of elicited experiences evoked by the
story. This is an important distinction to remember. The story is a vehicle
for eliciting experiences, and that is often done with tangents taken from
the storyline itself. If one thinks of the point of the story itself as the major
therapeutic intervention, the client will only gain a cognitive understand-
ing. The cognitive understanding is much like insight—and we know that
insight does not change a person’s behavior as much as a behavior change
will lead to insight.
Simple Isomorphic Metaphors

Metaphors that can be described as isomorphic, and therefore parallel
to the problem, are simple metaphors. They take the information from the
client’s life and match it one-for-one with the constructed story. That is,
every significant noun in the original problem is matched with a noun in
the story, and every significant verb in the problem is matched with a verb
in the story. The relationship between the verbs and nouns is relatively
obvious in that it is parallel to their relationship in the story.
The relationship between the problem and the story can be illustrated in
the following example. Here we see that Joseph, who had a son named Paul,
was in a car accident. The result of the accident was a serious injury of his
son that took months to heal. As a result, Joseph feels a great deal of guilt.
And as a result of the guilt, he remains jobless. He sought psychotherapy for
assistance. A metaphor that could be built in an isomorphic fashion would
be, for example, the one that follows. A building engineer who was in charge
of construction crews was working on a building. Unexpectedly, the building
collapsed and there were a great deal of injuries. One of the things that was
“damaged” was the confidence of investors. All the investors abandoned the
project. As a result, the building engineer felt helpless. As it turns out, his
ability to seek and obtain employment was severely hampered by his feeling
of helplessness, and he could not get any new investor contacts.
In graphic summary, would look like the following:
TABLE 1.1
Problem characteristics Metaphor content

Joseph Building engineer
Son Paul Construction crew
Car Building
Auto accident Collapse of building
Serious injury Investments lost
Guild Helplessness
Joblessness Can’t secure a contract
This simple form of matching the problem to elements in the story can
have a therapeutic usefulness as well as therapeutic limitations. Generally,
it is easy to match the client situation with an imaginary or real story.
However, the ending ought to be designed to be both reasonable with the
story and retrieve useful therapeutic resources. It is most beneficial to for-
mulate the ending that is the therapeutic goal before telling a story. These
simple metaphors are also a useful form for delivering information to the
client in a relative state of anonymity. That is, by the use of embedded
quotes, or embedded commands, the therapist can illustrate dialogue within
a simple metaphor. And, within that dialogue messages can be delivered to
the client. For example, the therapist might say, “I had a client come see
me this morning. And while he was on the elevator coming to my office, a
total stranger looked at him and said, ‘Get a job now and then you will start
to feel better.’” Now, even without a sophisticated ending to this story, that
client has gotten the instructional material that says something useful for
the direction of therapy. It becomes thought provoking, to say the least.
A more sophisticated way to end isomorphic metaphors is to create a
context in which the protagonist of the story retrieves useful resources to
solve his problem. These resources will of course be parallel to the resour-
ces of the client.
Clinical observation suggests that clients make sense of the content of the
metaphor because they apply their personal experience to the ambiguity in
the story. Since this is the case, a metaphor that is parallel to the problem
simply heightens their awareness of the problem. It is important for the ther-
apist, therefore, to place emphasis upon the construction of the solution.
Since the important aspect of a metaphor is the construction of the so-
lution, the entire metaphor can become parallel to the solution from the
onset. Metaphors that are constructed in this manner are comparatively
more sophisticated. These advanced metaphors are called complex goal-
directed metaphors. The following brief outlines illustrate the major archi-
tecture of four different goal-directed metaphor protocols (Lankton &
Lankton, 2007/1986).
Complex Goal-Directed Metaphor Protocols

A. Attitude change protocol
1. Describe a protagonist’s behavior or perception so it exemplifies the
maladaptive attitude. Bias the discussion of this belief to appear pos-
itive or desirable.
2. Describe another protagonist’s behavior or perception so it exempli-
fies the adaptive attitude (the goal). Bias the discussion of this belief
to appear negative or undesirable.
3. Reveal the unexpected outcome achieved by both protagonists that
resulted from the beliefs they held and their related actions. Be sure the
payoff received by the second protagonist is of value to the client listener.
B. Affect and emotion protocol
1. Establish a relationship between the protagonist and a person, place,
or thing that involves emotion or affect (e.g., tenderness, anxiety,
mastery, confusion, love, longing, etc.).
2. Detail movement in the relationship (e.g., moving with, moving to-
ward, moving away, orbiting, etc.).
3. Focus on some of the physiological changes that coincide with the
protagonist’s emotion (be sure to overlap with the client’s facial
behavior and other identifiable bodily changes).
C. Behavior change protocol

1. Illustrate the protagonist’s observable behavior similar to the desired
behavior to be acquired by the client. There is no need to mention
motives. List about six specific observable behaviors.
2. Detail the protagonist’s internal attention or non-observable behav-
ior that shows the protagonist to be congruent with his or her
observable behavior.
3. Change the setting within the story so as to provide an opportunity
for repeating all the behavioral descriptions several (e.g., three)
times.
D. Self-image thinking protocol
1. Central self-image (CSI) construction
a. Describe a protagonist who is seeing a reflection or picturing him-
self or herself accurately.
b. Explain how the protagonist recalls and experiences several desired
qualities (which may be resources retrieved earlier in the session).
c. Describe how the original visual image of the self is altered in behav-
iorally specific ways consistent with each quality being experienced.
2. Self-image scenarios process
a. Using the story of the protagonist imaging his or her CSI as a
device, describe imagined background details as follows.
b. Introduce a positive, non-anxiety producing scene and people and
describe the protagonist experiencing and thinking through
behaviors in that scene (keeping the desired resources constant).
c. Introduce other backgrounds and people in gradual successive ap-
proximations from the previous scenes to, eventually, the most
difficult and contracted therapeutic goal.
The Ambiguous Aspect of Metaphor

Unlike directive and manipulative therapies that, through implication
or connotation, tell clients how to perceive, think, feel, or behave, techni-
ques of indirection allow clients to modify verbal input from the therapist
and fit it to their own situation with a greater degree of relevance and
with an element of ego-syntonic meaning. If clients are instructed to con-
duct themselves in a certain manner or say certain sentences to their
spouse in directive couples therapy, these things may be ego-dystonic since
they come from outside as implied or denoted by the therapist as some-
thing clients should or must do. However, when clients have determined
for themselves a relevant meaning to a more ambiguous input from a ther-
apist, they are acting upon perceptions, behaviors, or feelings that truly
belong to them as a part of them.
Let’s examine this ambiguous element more closely. The degree of am-
biguity in a therapeutic story can be regulated by the teller so the story is
more or less vague to the listener. Regardless of the degree of vagueness,

listeners create their own relevant meaning in order to understand the
story. This accounts for the ego-syntonic nature of the understanding and
the lack of mere compliance by listeners. However, as the degree of vague-
ness increases, there is an exponential increase in the number of possible
meanings that listeners can give to the story. It is assumed that listeners
sorting through several possibilities at what has been determined to be
thirty items per second (Erickson and Rossi, 1979, p. 18) become increas-
ingly absorbed in weighing the best fit for these possible meanings. This
ongoing process of weighing meaning has a number of therapeutic benefits:
• there is an increase in participation by listeners

• there is a heightened valuation in any meaning that is found by lis-
teners as it has been made a deeper part of their own experience
• there is a depotentiation of normal, rigid ego controls while seeking a
best fit
• there is an increase in the duration of time given to examining possi-
ble meanings
This last element, in fact, accounts for a therapeutic effect upon the cli-
ent long after the therapy session has ended. Indeed, for a highly meaning-
ful and yet extremely vague metaphoric story, listeners may continue to
turn it over in their mind (from time to time) for years after the therapy
session and do so for events that even years later parallel the original ther-
apeutic learning incident. For this reason, the use of metaphor can be sum-
marized as follows. It increases the relevance of therapy for clients and
involves clients more highly in their own change process. It expands the
usual limiting experience that has led to a stabilization of the presenting
problem or dynamic and brought the person to therapy. It offers an engag-
ing element of ambiguity that may continue to alert listeners to their ther-
apeutic learnings for years after a therapy session. And it offers a wide
range of potentially correct responses within the therapeutic limits.
Since indirect hypnotic language offers listeners the ability to apply a
wide range or spectrum of potential understandings to what the therapist
has said, there is a corresponding reduction in listener resistance. Any
therapeutic modality that finds clients to be resistive, possibly due to the
nature of the modality itself, will be able to take advantage of metaphoric
stories providing those stories are constructed and shared in a manner
that employs the necessary components of therapeutic change. Erickson
once said:
I do certain things when I interview a family group, or a husband and

wife, or a mother and son. People come for help, but they also come
to be substantiated in their attitudes and they come to have face
saved. I pay attention to this, and I’m on their side. Then I digress on
a tangent that they can accept, but it leaves them teetering on the
edge of expectation. They have to admit that my digression is all
right, it’s perfectly correct, but they didn’t expect me to do it that
way. It’s an uncomfortable position to be teetering, and they want
some solution of the matter that I had just brought to the edge of set-
tlement. Since they want that solution, they are more likely to accept
what I say. They are very eager for a decisive statement. If you gave
the directive right away, they could take issue with it. But if you
digress, they hope you will get back and they welcome a decisive
statement from you. (Erickson, in Haley, 1973, p. 206)
ILLUSTRATION OF INDIRECT SUGGESTION LANGUAGE

Some of the most intriguing use of hypnotic language and perhaps the ori-
gins of indirect hypnotic language came from Erickson’s work. It appears that
ambiguity and relevance are the key factors to powerful therapeutic language.
Clinically, it appears that the value of long-lasting hypnotic suggestion corre-
sponds to the amount of ambiguity it conveys—while at the same time
it appears to be personally relevant. The more ambiguity that can accompany
an apparently relevant suggestion that creates a desired response, the longer
and stronger that response will be. There is a limit to the amount of ambigu-
ity each person can tolerate before a sense of relevance is impossible to main-
tain. Erickson appears to have learned this in his clinical work and supported
it in the latter decades of his career. Indeed, ambiguity often allows language
to seem more relevant. Consider the following examples.
Relaxation [direct suggestion]: “Let yourself relax. Let go of the tensions
that you experience in your arms, allowing those muscles to become more
and more relaxed . . . and let go of the tensions that you experience in
your shoulders, allowing those muscles in your shoulders and back to
become more and more relaxed . . . and let go of the tensions that you ex-
perience in your chest and belly and lower back . . . allowing those
muscles to become more and more relaxed . . . and allow the muscles in
your legs . . . to become more and more relaxed . . . your entire body . . .
relaxing . . . until you feel limp and relaxed like an old rag doll.”
Relaxation [indirect suggestion]: “I wonder if you know how it can feel . . .
after a long day of physical activity when you’ve had a lot of things to do and
you managed to accomplish everything and you get to the end of the day and
you can finally let everything go and get some sleep? . . . everyone’s had that
experience . . . the conscious mind can’t really appreciate how the uncon-
scious can bring about an alteration that slows down the body . . . and the
body for comfort maybe slowed it down for rejuvenation or for some other
reason . . . and when a person gets ready for bed, slips between the sheets and
feels those initial feelings . . . how cool and clean the sheets feel . . . what’s
the best word to describe that? . . . every child knows the feeling of comfort.”
Suggesting eye closure [direct authoritarian suggestion]: “Now . . . your
eyelids will become heavier . . . your eyelids are becoming heavier and heav-
ier . . . so heavy that you cannot keep your eyes open . . . close them now.”
Suggesting eye closure [indirect suggestion]: “Under what circumstances
do the muscles of the face seem to support the eyelids? . . . they might
become more and more relaxed or maybe just stop looking . . . I wonder
which it will be in the case of each patient or each client . . . your con-
scious mind may wonder if your unconscious mind will actually close your
eyes, or will it be the conscious mind that chooses to close your eyes so
that you can let your unconscious mind wonder about a lot of things.”
Creating Forms of Indirect Suggestion

The various forms of indirect suggestion and therapeutic binds might be
seen as different specific vehicles for introducing ambiguity. That is to say,
the different forms of indirect language are like specific different doorways
into the mind. Ironically, the manner in which one can construct ambigu-
ous indirect hypnotic language provides a great deal of therapeutic
accountability. Using indirect language, the therapist can:
• introduce or illustrate a point to the client

• suggest solutions not previously considered by the client
• seed ideas to which the therapist can later return
• decrease the conscious mind resistance of the client
• reframe or redefine a problem for the client so the problem is placed
in a different context with a different meaning
• retrieve and associate experience such as emotion, thought, percep-
tion, behavior, and expression.
In each case, just as in the case of metaphor, the ambiguity of the sug-
gestion requires that the client create personal meaning out of the words. It is
this act of creating personal meaning that gives indirect suggestion greater
power and longer-lasting effect. The client actually will get the answer
within their own experience and not comply to demands of the therapist.
Indirect suggestion can be an important part of accomplishing both the
internal absorption and dissociation. The following section will give a
brief glimpse as to what some of those forms of suggestion are and how
they are formed. Six common forms of indirect suggestion and four com-
mon forms of therapeutic binds are representative of the large number of
ways in which indirection can be codified.
Before beginning the illustrations of several forms of indirect suggestion
and therapeutic binds, it is important to emphasize the following. These
statements are intended to be formulated around a chosen therapeutic

goal. In each case that chosen goal will be related to the next desired
movement in the therapy. That is to say, if the client is seated and
relaxed, the next desired goal might be to accomplish an induction with
eye closure. On the other hand, if that has already been accomplished, the
next desired therapeutic goal might be to help the client facilitate a sense
of security or an intense memory of a desired experience. Regardless of the
specific goal, the sentence structures that will be the vehicle for expressing
that goal can be defined and delineated. This is not only useful for articu-
lating the means by which hypnosis and therapy can be accomplished and
taught, but also for carefully defining the procedures for the sake of future
empirical research. The more carefully interpersonal communication can
be specified, the more accurately empirical research can be carried out.
Irrespective of these concerns, however, professional scholarship calls for a
careful development and an earnest attempt to increase accountability of
the therapeutic process. These forms of indirect suggestions and therapeu-
tic binds, and more, were used by Erickson for both the induction of hyp-
nosis and the process of psychotherapy during hypnosis and family therapy
(Erickson & Rossi, 1980a, 1980b, & 1980c; Haley, 1963; Lankton &
Lankton, 2008/1983; & Erickson 1980f).
Open-Ended Suggestions
Open-ended suggestions take the form of increasing the degree of ambi-
guity for any element in a sentence that would otherwise be a direct sug-
gestion. In common social communication, it’s usually an open-ended
suggestion that introduces a topic. For example, an open-ended suggestion
such as, “Everyone can find a way to record information that’s important,”
could have been formed from the direct suggestion “Write this down.”
Since it’s an open-ended suggestion, the degree of compliance from the
client is irrelevant. Instead of telling the client what to do, it initiates the
client’s own search process for a discovery of what’s relevant—if that hap-
pens to be writing down what’s been said, then an exact fit between the
otherwise unstated goal and what the client decides will have been made.
But that’s unusual. Open-ended suggestions are a prime example of how
indirection is designed to be client centered and to facilitate helping cli-
ents discover their own understanding of what’s relevant and useful to
them, with the therapist still retaining an element of control, yet avoiding
an authoritarian relationship.
Implication and Presupposition

The form of suggestion called presupposition is a simple type of implica-
tion. It can be a simple or complex presupposition, which then also states
a desired goal. For example, a simple presupposition is, “After you write
this down, we’ll continue.” This example uses a presupposition syntax (the
word after), followed by the goal of taking notes by writing. Other simple
presuppositions are: “Since this is the first time you’ve been in trance, close
your eyes” and “After your trance is over, we’ll do some talking about it” or
“One of the first things you’ll want to do in trance may be formulating a
sense of comfort.” In simple presupposition, the stated goal follows imme-
diately after the presupposition syntax. It should be noted also that these
suggestions are kept quite short. The reason for that is further speaking
will begin to focus the client’s attention elsewhere and become another
form of suggestion I will discuss in a moment.
In each of those examples, simple presupposition was followed by a state-
ment of the goal. The complex version involves the form called an implica-
tion. An implication requires that the speaker link two concepts together
such that one relates to (e.g., causes) the other. And in addition, the con-
cepts must have exact opposites—that is, the concept of “eyes open” has the
opposite of “eyes closed.” The concept of tense has the opposite of relaxed.
So an implication that links “eyes open” and tension would be: “Keeping
your eyes open can help you stay tense.” Obviously the implication is that
the listener will become relaxed when they close their eyes.
Questions or Statements That Focus Awareness

Indirect language suggestions that focus awareness can take the form of
questions or statements. Statements such as, “I wonder if you’ll be going
into trance soon” or “I don’t know if you’ve discovered how comfortable
you are” have the effect of helping clients notice the portion of the sen-
tence that highlights the goal and yet offers the sentence in a manner that
seems to be rhetorical rather than strongly exclamatory. This form can
also occur in questions such as, “Have you noticed how relaxed you are
yet?” or “Do you think you’ll begin thinking about the goal that we spoke
of?” While these questions seem rhetorical, in order to consider them, the
client must focus awareness as prescribed in the suggestion. In each of
these examples a statement of the goal is presented following the question
or observation.
Truism
Truisms state something that is essentially undeniable. Such sentences
usually begin with phrases like, “All children” or “all people” or “in all
cultures.” For example, “All people have their own way of going into
trance,” “Every child uses imagination to think about ideas,” “In every cul-
ture, people problem solve in various ways.” In each of these examples, a
truism is followed by statement of the desired goal.
All Possible Alternatives

Suggestions stating all possible alternatives can take several different
forms, but have the common aspect of listing many different ways or times
in which a stated goal can be reached or experienced. For example, “Your
eyes may close suddenly or they may close slowly or you may close them
and open them repeatedly, maybe you’ll squint for some time, or it’s possi-
ble that you’ll have your eyes closed without realizing it and in some cases
even have your eyes open and think that they’re closed.” Another exam-
ple pertaining to relaxation could be, “You may relax systematically from
your head to your feet or you may relax from your feet to your head, per-
haps you’ll discover some portions already relaxed and relax adjacent parts
of your body, or it’s possible that there will be a gradual relaxation all over
your entire body at once, or possibly random limbs and muscle groups will
relax in a more spontaneous manner or perhaps it will happen differently.”
In all possible alternative suggestions, it is advisable to have one of the
alternatives state that the client will not do any of those on the list. This
is because, in fact, you are trying to list all possible alternatives including
the alternative that nothing of that nature will occur. In this form of sug-
gestion, the therapist’s list helps clients recognize that there are many ways
the goal can be achieved and that they have a choice in how they person-
ally express themselves. Therapists continue to establish an egalitarian
relationship or client-centered relationship with the client rather than
forcing an authoritarian and heightened compliant relationship.
Apposition of Opposites
This form of suggestion emphasizes that the occurrence of a desired goal
may proceed paradoxically against some behavior that is generally seen as
an opposite. For example, “The greater a degree of tension you have in
your muscles, the more profoundly you may relax,” “The longer you have
been confused about the issue, the more rapidly an idea may come,” or
“The greater your uncertainty has been, the stronger your conviction may
be.” Clients can redirect and use energy previously devoted to avoiding or
resisting to drive an equally strong, willful experience or behavior in the
direction of their change. No reason or logic should be given for this para-
dox but rather clients should be allowed to discover for themselves how it
becomes true for them. With indirect suggestion, the goal is not to make
people behave in a particular way but rather to help stimulate their own
thinking and experience in such a manner that they determine for them-
selves exactly what’s relevant and how it’s relevant for them.
Binds of Comparable Alternatives

The first of the four therapeutic binds is binds of comparable alterna-
tives. In this type, two alternatives are provided so clients may choose
which is best for them. In the process of making either choice, the actual
desired goal is accomplished because it was presupposed by both choices.
For example, “You may want to try these ideas in your family before you
go to work; however, it may be best for you to try them after work.” In this
case, the act of trying the therapeutic material with the family exists for
the client whether or not an attempt is made before or after work to
implement the behavior. “You may go into trance by closing your eyes or
you may wish to keep your eyes open” also facilitates going into trance
regardless of the condition of the eyes.
Conscious/Unconscious Therapeutic Binds

The conscious/unconscious therapeutic bind takes a form that is some-
what like an algebra expression with an x and y variable, one for the con-
scious and one for the unconscious. The form of the sentence is: The
conscious mind may do x as the unconscious mind does y. There are three
things to consider about such a sentence. The first is what goes in place of
the x. It is a good idea to place a word that refers to something that clients
can verify with their conscious mind. Also some verb of mental activity
such as wonder, discover, know, investigate, or find works very well in the
position of x. This is especially true when there is only one specific thera-
peutic goal at that moment. What goes in place of the y in the formula is
exactly what the goal is or some sub-portion of the goal at that moment.
For example, if the goal happens to be to feel more comfortable spending
time around one’s new employer, the suggestion may state: “Your conscious
mind may be surprised to discover how your unconscious will bring a
feeling of relaxation around your new employer.” If the goal is to relax
in trance and recover a memory, the sentence could be formed as, “Your
conscious mind may be relaxed while your unconscious investigates that
memory.” The third thing to consider with conscious/unconscious thera-
peutic binds is how the conscious and unconscious parts of the sentence
are connected. There are a variety of causal links such as and, as, since,
while, and because that can connect the two events. In general it is best to
use a conjunction to link the two events together and avoid strong causal
relationships.
Double Dissociative Conscious/Unconscious Therapeutic Binds

This form of bind is exactly the same as the previous one except that it
accommodates two goals by duplicating and reversing variables on the
conscious and unconscious as that phrase is repeated. An example of the
formula is, “Your conscious mind may do x as your unconscious mind does
y or, your conscious mind may do y as your unconscious mind does x.”
When x and y represent two different goals, they can or may become inex-
orably linked together by this type of verbal production. For example, if
the goal is to feel comfortable and relaxed as you visualize interacting in a

job interview, the sentence becomes, “Your conscious mind may be com-
fortable and relaxed as your unconscious rehearses how you will conduct
yourself at the job interview or perhaps your conscious mind will rehearse
how you will conduct yourself at the job interview while your unconscious
mind is comfortable and relaxed.”
Therapeutic bind is especially apparent in this sort of sentence. The cli-
ent in trying to determine whether or not the first part or the second part
of the sentence is the most true has, in fact, associated comfort and relaxa-
tion and visualizing the job interview. The only way to escape making the
bind become true is to simply pay no attention to the actual content of
the indirect suggestion used by the therapist—hence the understanding
that these are therapeutic binds.
Pseudo Non-Sequitur Binds

The fourth form of bind is a pseudo-non-sequitur bind. I refer to them
as “rephrasing binds” because a goal is stated and then renamed. A true
non-sequitur question such as “Do you walk to school or carry your lunch?”
may at first appear to be appropriately well formed as a question but
actually bears no connection between the elements provided for choice
and is therefore a non sequitur. In a pseudo-non-sequitur bind, two appa-
rently different choices are provided for the client; however, the choices
are simply the same option—spoken once and then reworded. This form
differs from the bind of comparable alternatives because either choice is
exactly the same choice. For example, “Do you think you’d like to go into
a trance or would it be better to simply achieve an altered state appropri-
ate for your learning today?” Another example is, “You could let all the
muscles in your body go limp, or, if you prefer, to just relax completely.”
USING INDIRECT SUGGESTIONS IN THE CONTEXT

OF INDUCTION
No goal is likely to be reached by the utterance of a single suggestion but
each goal can be addressed by using many of the different types of suggestion.
This probably facilitates listeners processing the data with varying and differ-
ent kinds of mental mechanisms. For example, presupposition, comparison,
contrast, generalization, checking for fitness, choice, and so on. The differing
forms of suggestions and binds require ferrying types of thought process.
Therefore, by using various forms of suggestions and binds to restate thera-
peutic goals, the therapist enhances the possibility that clients will respond
in a way that is meaningful to them. A brief example of an induction using
these suggestions follows. The suggestions in the left column are labeled by
the names of the suggestion appearing in the right column.
The suggestions in this brief induction are given as examples to facili-

tate an understanding of how trance induction might be developed using,
primarily, indirection in a client-centered fashion in the clinical setting. It
TABLE 1.2
I don’t know whether or not you’ve statement to focus awareness
been in trance. After you reorient from presupposition
trance we can discuss it. You can go truism
into trance in your own way. Everyone truism
goes into trance in a way that’s unique
for them. direct suggestion ending with deletion
Just uncross your legs, put your arms at your
side and begin. pseudo-non-sequitur bind
You might develop an altered state
that’s appropriate for learning today or suggestion covering all possible
maybe develop a deep clinical trance. alternatives
And you can do that rapidly, or
suddenly, or you can go into trance and
come out and go back in again, or you
might simply gradually drift into a deep
trance, or perhaps a medium trance, or bind of comparable alternatives
nothing at all. You can go into trance direct suggestion
with your eyes open or closed. But, go conscious/unconscious bind
ahead and close them now. And let
your conscious mind really wonder
what the first thing your unconscious question to focus awareness with an
will do as you turn your attention embedded command
inward. Did you wonder when you double dissociative conscious/
would go more deeply? You may find unconscious bind
that your conscious mind is able to
make some sense of things that your
unconscious mind focuses on as you turn
your attention inward or maybe your
conscious mind, in turning your open-ended suggestion
attention inward, will allow your
unconscious mind to find some things
that it can focus upon. Because, every acquisition of opposites
human being has the ability to orient
their experience toward that which is
relevant. And the longer time you’ve direct suggestion
spent in confusion wondering what to do,
the more rapidly you may embrace
the direction that seems right for you. direct suggestion
Take your time to select memory of a open-ended suggestion
time you felt most confident. And feel it
now. The human mind has an amazing
capability of applying previously learned
experiences in new and useful ways.
also illustrates how direct suggestion can be interspersed with indirect sug-
gestion to facilitate the desired outcome. Greater detail and study and
supervised training are always necessary for the appropriate and ethical use
of suggestion in hypnosis and therapy.
Erickson believed that the depth of trance is less important than the
relevance of the trance. He stated, “I find that one can do extensive and
deep psychotherapy in the light trance as well as in the deeper medium
trance. One merely needs to know how to talk to a patient in order to
secure therapeutic results” (Erickson and Rossi, 1981, p. 3). The relevance
of the trance will increase the degree of internal concentration and there-
fore increase the depth of trance. Each trance is individualized to the
client, and scripted inductions should be avoided as much as possible. The
state of internal absorption, the presence of some degree of ambiguity, and
dissociation of the conscious mind establish a situation of communication
with the client that is most conducive to helping that client focus upon
and amplify various experiences.
RESEARCH
Overall, the Ericksonian tradition has been a lineage of “living wisdom”
(like the passing on of martial arts skills) rather than a science. Most
therapists realize the greatest amount of Ericksonian concepts and
approaches when they are explained and demonstrated rather than from a
critical examination of data supporting the theories and perspectives on
hypnosis, the unconscious, and the nature of human experience. However,
it is clear that much scientifically based research needs to be conducted to
establish an empirically based Ericksonian body of knowledge.
The majority of articles appearing in refereed professional journals are pub-
lications of anecdotal case reports addressing many therapeutic venues and
type of problems. These include brief therapy (Battino, 2007), utilization
(Thomas, 2007; Akiyama, 2006), anxiety (Camino, Gibernau, & Araoz,
1999), depression (Young, 2006), post-natal well-being (Guse, Wissing, &
Hartman, 2006), Candida (Edwards, 1999), family therapy (Crago, 1998),
child therapy (Tennessen & Strand, 1998), solution focused (Santa, 1998),
indirect suggestion (Fourie, 1997), and geriatric therapy (Gafner, 1997).
However, there is a paucity of empirical research showing what constitutes
the effectiveness of an Ericksonian approach. Representative of what little
exists ranges from therapeutic storytelling (Parker & Wampler, 2006),
tailored and scripted inductions (Barabasz & Christensen, 2006), and visual
recall in trance (Tamalonis & Mitchell, 1997) to research conducted on the
effectiveness and subjective experience of hypnotic language and compari-
sons of direct and indirect suggestion (Alman & Carney, 1980). The follow-
ing is a brief, but certainly not comprehensive, overview of some of that
early research of indirect language in hypnosis.
Alman and Carney (1980), using audio-taped inductions of direct and

indirect suggestions, compared male and female subjects on their respon-
siveness to posthypnotic suggestions. They reported that indirect sugges-
tions were more successful in producing posthypnotic behavior than were
direct suggestions.
McConkey (1984) used direct and indirect suggestions with real and
simulated hypnotic subjects. Although all of the simulated subjects recog-
nized the expectation for a positive hallucination, half of the real subjects
responded to the indirect suggestions and half did not. He concluded that
“indirection may not be the clinically important notion as much as the
creation or existence of motivation where the overall suggestion is accept-
able such as making the ideas congruent with the other aims and hopes of
a patient” (p. 312).
Van Gorp, Meyer, and Dunbar (1985), in comparing direct and indirect
suggestions for analgesia in the reduction of experimentally induced pain,
found direct suggestion to be more effective reducing pain as measured by
verbal self-reports and physiological measures. Stone and Lundy (1985)
investigated the effectiveness of indirect and direct suggestions in eliciting
body movements following suggestions. They reported that indirect sugges-
tions were slightly more effective than direct suggestions in eliciting the
target behaviors.
Mosher and Matthews (1985) investigated the claim by Lankton and
Lankton (1983) that indirect hypnotic language created by embedding a
series of metaphors will create a natural structure for amnesia for content
presented in the middle of the metaphoric material. The authors compared
treatment groups who received multiple embedded stories with indirect
suggestion for amnesia with control groups who received multiple embed-
ded metaphors without indirect suggestions for amnesia. They found sup-
port for the structural effect of embedding metaphors on amnesia.
Matthews, Bennett, Bean, and Gallagher (1985) compared subjects’
responses on the Stanford Hypnotic Clinical Scale (Morgan & Hilgard,
1978) to subjects’ responses on the same scale rewritten to include only indi-
rect suggestions. They found no significant behavioral differences between
the two scales. However, they did report that individuals who received the
indirect suggestions perceived themselves to be more hypnotized than those
who received the original Stanford Hypnotic Clinical Scale.
Nugent (1989a) attempted to show a causal connection between sympto-
matic improvement and the notion of “unconscious thinking without con-
scious awareness.” In a series of seven independent case studies with a range
of presenting problems (e.g., fear of injections, performance anxiety, claustro-
phobia), he used the same methodological procedure and treatment interven-
tion of indirect suggestion language for change. A pretreatment baseline
response and therapeutic change relative to the intervention were all system-
atically assessed. In all seven cases, each client reported a clear, sustained
positive change with respect to the presenting problem using indirect lan-
guage. Although the individual case study has certain methodological limita-
tions, Nugent’s use of seven independent cases with a carefully followed
treatment protocol makes his conclusion of causality more convincing.
This brief overview of research results would appear to be mixed in sup-
port of an indirect approach using suggestion, binds, and metaphor as com-
pared with direct suggestion for many tasks. Direct hypnotic language was
found more effective in treating pain in one study. However, indirect hyp-
notic language was seen as most effective in eliciting movement behavior,
producing trance depth, subjective experience of relevance, amnesia, and
posthypnotic behaviors in other studies. And, when motivation was pres-
ent, indirect suggestion was also seen as most effective for more difficult
trance phenomena such as positive hallucination.
However, the reader should remember that for most of this research the
tests were done with audio taping to standardize the intervention and that it
was therefore not possible to tailor the suggestions (whether direct or indirect)
and stories to the individual. A study by Barabasz and Christensen (2006)
found that tailored inductions performed better than scripted inductions. As a
result, the majority of these studies do not emphasize the importance of adapt-
ing and using the unique responses of the individual throughout hypnosis.
Similarly, and perhaps more important, many of these tests were not
designed in a context that attempted to address the relevant (growth)
goals of individual subjects involved. Therefore, while the research gives
us some idea, it does not represent a fully accurate picture of how a clinical
client would experience the interventions when the hypnotic language is
shaped and chosen for each individual.
Finally, these bits and pieces do not adequately address the entire
course of treatment that would be considered Ericksonian in style. It is
perhaps easier to discuss techniques than to discuss the subtle but more im-
portant contributions of this overall approach. With an over-emphasis on
technique, therapists have frequently been guilty of applying a technique
without an adequate sense of how hypnotic language can develop within a
natural interaction with clients.
CONCLUSION
As Haley notes, “. . . Dr. Erickson has a unique approach to psychotherapy
which represents a major innovation in therapeutic technique” (Haley,
1967, p. 1). The therapeutic goal of an Ericksonian approach to hypnosis
and therapy is to help clients concentrate upon and increase the use of
desired experiential resources. This, in turn, is done to lead clients to change
their relational patterns and bring a cessation to various presenting problems
so they can live fuller and happier lives. Trance is a means of developing a
state of heightened internal concentration for appropriate experiential
resources that can be elicited and linked together. In turn, these gains must
be conditioned to occur in specific life situations and during certain problem
situations. Once that happens, a cure has been established.
Both of these aspects of heightened concentration and increased control
of experience can be readily available when therapists use appropriate
hypnotic language. An appropriate hypnotic language involves verbal and
nonverbal communication that is understood as relevant and ambiguous to
a certain degree. This controlled elaboration of ambiguity can be accom-
plished with utilization, reframing, indirect suggestions, therapeutic binds,
simple and complex metaphor, and direct suggestion techniques.
Erickson’s influence has grown from a seed to a forest over the last few
decades. This is in large part due to his own tireless work and, after his
death, the many dedicated faculty members who teach at professional
training events sponsored by the Milton H. Erickson Foundation, Inc., the
American Society of Clinical Hypnosis, the Society of Clinical and Exper-
imental Hypnosis, the International Society of Hypnosis, and their subor-
dinate events worldwide. Further, his work is advanced by the many books
and professional papers written by these individuals.
At the time of this writing, a search of Amazon.com for Erickson’s name
lists 132 books. A search on the Internet today reveals 272,000 entries for
Milton Erickson and 215,000 for Milton H. Erickson. There are currently
118 Erickson Institutes established worldwide for the further study and
practice of Erickson’s contributions to hypnosis, brief therapy, family ther-
apy, and psychotherapy. Nevertheless, as with any talented innovator, the
skill, perception, and capability of the originator seems to be a high-water
mark in the field that is seldom achieved by subsequent generations of
trainees. His clinically proven skill sets, like those of a complicated martial
art, require careful study and practice, and time to replicate. His docu-
mented accomplishments with the skill sets will provide the motivation for
years of material for future empirical research, evidence-based outcome
studies, and the formulation of creative clinical applications. Finally, I want
to caution readers, as did Jay Haley (Haley, 1993), on the care with which
these powerful techniques should be exercised.
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Zeig, J. (Ed.). (1982). Ericksonian approaches to hypnosis and psychotherapy. New
York: Brunner/Mazel.
Zeig, J., & Lankton, S. (1988). Developing the Ericksonian therapy: state of the art.
New York: Brunner/Mazel.
Chapter 2
Ego Psychology Techniques

in Hypnotherapy
Arreed Franz Barabasz
To paste a coping skill on the surface of an injured person is to

further remove that person emotionally from the “self.”
(Watkins & Barabasz, 2008; Watkins & Watkins, 1997)
The human personality is not a unity, although it is usually experi-

enced as such. Our personalities are separated into various segments.
Unique entities serve different purposes. This is the central premise
of ego state therapy.
The state that is overt and conscious at a particular time is the execu-
tive state. Those states that are not executive may or may not be aware
of what is going on at a conscious level. Conflicts among states take up
considerable energy, often forcing the individual into withdrawn, defen-
sive postures. A person, such as in the case of Mathew below, will not
be at peace with himself until the conflicts are resolved.
(Watkins & Barabasz, 2008)
Mathew is in a new relationship with Emma. He sees Emma playing

with a child. He feels and believes, “This is the woman for me. I love
her and I want to spend the rest of my life with her.” Later in the same
day she criticizes him about his job as a plumber. He feels defensive and
thinks, “What did I ever see in this woman? How can I get out of this
relationship?” These responses may sound extreme, but they are not
unusual, and it is not unusual for a person to bounce among several ego
states in the process of making a major decision (one state may be
in favor, one may be against, and another indifferent). In one moment
on one day Mathew may “know” he wants Emma as his partner, and in
another moment he may know “he does not.” In this example, Mathew
has an ego state that loves and dreams of a family. It is a soft, caring part
of him, and when he sees the woman he cares about playing with a
child his “loving/caring” ego state becomes executive. While in this
state, Mathew is capable of feeling very positive and interested in
Emma. These are honest feelings. It is Mathew who is feeling them. It is
Mathew’s “loving/caring” part. Later, when Emma criticized his job,
another part of Mathew is energized to become executive (comes out).
Mathew’s “defensive, don’t pick on me” ego state becomes executive.
This is not a loving, caring part of Mathew, and probably can’t even feel
love. Its role is to protect, by creating a shell and withdrawing from the
attacker. While in this state, Mathew cannot imagine life with Emma.
This too is a part of Mathew, just as valid and needed as the other.
(Emmerson, 2003, p. 2)
As shown by Mathew, in the previous case, an ego state is “an organized

system of behavior and experience whose elements are bound together by a
common principle.” However, each state is separated from other states by
a boundary that is “more or less permeable” (Watkins & Watkins, 1997,
p. 25). Each is distinguished by a particular role, mood, and mental func-
tion, which when conscious [executive] assumes the person’s identity. Ego
states start as defensive coping mechanisms and when repeated develop
into compartmentalized sections of the personality (Emmerson, 2003, p. 3).
They may also be created by a single incident of trauma such as an auto
accident, rape, or even the first day of kindergarten. Ego states maintain
their own memories and communicate with other ego states to a greater or
lesser degree. Unlike alters in multiple personalities in those with dissocia-
tive identity disorder (DID), ego states are a part of normal personalities.
THE EVOLUTION OF EGO STATE THERAPY

Hypnosis pioneer Pierre Janet (1907) seems to have been the first to
describe those covert personality segments with which we will concern
ourselves within ego state theory and therapy. Janet’s focus was on the
study of true multiple personalities (dissociative identity disorder) and was
probably the first to use the term dissociation to describe systems of ideas
that were split off, thus not in association with other ideas within the per-
sonality. He also implied that these personality patterns can exist subcon-
sciously in normal functioning individuals even though not overt and
available to conscious observation and experience.
As one of the first psychoanalysts to deviate from pure Freudian doc-
trine, Carl Jung (1969) also recognized well-established covert structures
within the “collective” or unconscious. These were termed “archetypes.”
More transient groups of unconscious ideas clustered together were referred
to as a “complex.” Although the terminology varies from that of Janet as
Ego Psychology Techniques in Hypnotherapy 51
well as our own, both Jung’s concepts of a personality “complex” as well as

the more structured “archetypes” he is best known for refer to personality
segments that are organized into unconscious patterns.
Paul Federn (1952a) was the first to systematically apply the concept of
ego states to provide a psychodynamic understanding of human behaviors.
His disciple Eduardo Weiss (1960) translated his papers, published them,
and extended many of their implications. Neither Federn nor Weiss ever
seemed to fully realize the great significance of ego states in their treat-
ment procedures, nor did they seem to understand that an alternative the-
oretical formulation was needed to comprehend its potential as a new
sophisticated form of hypnoanalysis. This endeavor became one of John G.
Watkins’s greatest contributions to the science and practice of psychother-
apy (AFB).
John G. Watkins was the first to recognize that Federn’s theory was entirely
limited to only ego-energized items. Watkins modified the conceptualization
and developed the theory of ego states with his wife Helen Huth Watkins.
This new theory includes ego-energized and object-energized elements. Thus,
when they have become organized together in a coherent pattern, the ego
state may represent an age of a relationship in the individual’s life, which may
have been developed to cope with a certain situation (Barabasz & Watkins,
2005; Watkins, 1978; Watkins & Watkins, 1979, 1981, 1982, 1986, 1997).
Let’s say your patient was severely punished as a five year old. Becoming
quiet, saying little, and withdrawing passive aggressively was a way of han-
dling the situation. Such coping patterns seemed to also work in later life.
So when in “trouble with an authority figure” the adult now finds the five-
year-old ego state returning no matter how short sighted, present oriented,
and ultimately self-defeating it may be. As Marlene Hunter (2004, p. 88)
points out, those with borderline personality disorder “still cope the way
they did when they were 5 years old.”
Thus, our conceptualization of an ego state is one that includes both
ego and object energized elements that are encompassed within a common
principle, a collection of subject and object items that belong together in
some way and that are included within a common boundary that is more
or less permeable. By “permeable” we mean that it is accessible by the con-
scious and sometimes, but not always, in subconscious communication
with other co-existing ego states.
When one of these states is invested with a substantial quantity of ego
energy it becomes the “self in the here and now.” We say that it is executive
and it experiences the other states, if it is aware of them all, as “he,” “she,”
or “it” since they are primarily invested with object energy. As ego and
object energies flow from one state to another, the behaviors and experien-
ces of the individual change, and we may assign the diagnosis of Dissocia-
tive Identity Disorder (DID; Multiple Personality Disorder). Defined in this
way, ego states subsume what we call “multiple personalities” but also
include other clusters of mental functions, which may or may not reach
consciousness and directly change behavior.
THE MOST SIGNIFICANT HUMAN EXPERIENCE:

SUBJECT-OBJECT
My leg is me. My arm is me. My thought is me, or is it, if I am halluci-
nating? Subject-object, what is within my “self,” and what is not, is perhaps
the most significant area of human experience.
Perceptions refer to mental images and sensations, which are normally
elicited by objects outside the body. But a stone in the stomach and infec-
tion in the blood are also “objects.” An arm is normally considered as
“subject,” part of me. But if it is paralyzed and devoid of feeling and move-
ment, then it, too, becomes an object. An idea, a concept is normally
subject—it is “my” thought. But a hallucination is an idea, which is per-
ceived as coming from the outside. The hallucination is not perceived as
part of me, therefore, it is perceived as object.
Clearly then, the body cannot be the criterion for distinguishing
between object and subject. The entity which does so discriminate is our
essence, “the self.” That which is perceived as outside “myself” whether it is
within the body or not is “object.” That which is experienced, as within “my
self,” hence, part of “the me,” is subject. The “self” and not the body is the
distinguishing agent, and the difference is judged by our feeling of selfness
when we are aware of it.
THE SELF
The self and what constitutes it has been the subject of numerous theo-
ries as well as scientific controversies. Freud (1933) postulated a state of
“primary narcissism,” an inherent condition in the original child. Later, he
viewed the ego as a structure within the mind, which was equated with the
self. This was apparent in his topographic conceptualization of the mind
when one looks at it as originally written in German. The ego structure
was represented as the selbst, literally translated into English as the “self.”
Hartmann (1958) regarded the ego, hence the self, as not only an inherent
structure, but partially determined by the impact of the veridical world on
the developing infant. Other object-relations analysts, such as Winnicott
(1965) saw the self and its feeling of self-existence as coming about as the
mother, who acts like a mirror, reflects back to the child his or her own
experience and gestures. The child then believes that “when I look, I am
seen, so I exist.” When the mother resonates to the child’s needs, the latter
becomes aware of them. This awareness then slowly evolves into this sense
of self. It is the “me” inside, sometimes working and serious, sometimes at
play, sometimes in pleasure and others in pain. Mahler (1972) emphasized
the maternal role in developing the child’s self through a separation-

individuation process by which he or she comes to know himself or herself.
As the child interacts with mother, the child separates himself or herself to
develop a unique identity and sense of selfness.
Similarly, Hartmann (1958) considered the “self” as an object representa-
tion or experiential construct, but Kernberg (1976) extended this formula-
tion to reserve the term self to “the sum-total of self-representations.” By this
he apparently meant that certain experiences, feelings, and images were
endowed with self-feeling that interacted with other images and sensations
that were felt as “not me,” but were also represented within the mind. This
interaction is embedded within the ego and constitutes “the self.”
I (J.G.W.) proposed a similar view (Watkins, 1978, ch. 6) that “exis-
tence” occurred only when an object, “a not-me,” impacted a subject, “a
me.” This is consistent with Fairbairn’s conceptualization (see Guntrip,
1961) that ego and object are inseparable. An object is not significant
(e.g., does not exist to its perceiver) unless it has some ego energy in con-
tact with it.
The classical theory developed by Freud in its original form posited that
the individual was born with innate drives, sexual and aggressive, and that
it was in the satisfaction or frustration of these that personality structure
and neurotic conflicts developed. Analysts operating from this basic
assumption became known as “the drive model analysts.” These theorists
and psychotherapists were considered the original members of the rela-
tional school who increasingly emphasized the role of interpersonal rela-
tionships as a basis for shaping all human development. As the relational
branch of object relations theory developed, opposition to the drive/libido
theory grew. Harry Stack Sullivan (1968) highlighted the interpersonal
dimension arguing that Freud’s theory could be better understood on the
basis of interpersonal processes. Sullivan’s elaborate conceptualization of
psychopathology emphasized a person’s behaviors that are intended to min-
imize or avoid anxiety that was rooted in dreaded thoughts of rejection and
derogation by parents, others, and eventually oneself. Sullivan explained
that particular aspects of the child, such as crying or whining, result in
parental rejection or ridicule (e.g., telling a boy to “stop acting like a girl”).
Integrating that these parts represent an anxiety arousing “bad self,” these
aspects are “split off or disowned.” What Sullivan overlooked is that
although they may be split off they are not killed off; disowning by repres-
sion assures they remain as covert ego states that continue to affect behav-
ior in less-than-ideal ways given that their overt expression has been
denied. Our ego state conceptualization suggests such split-off unexpressed
child fixed ego states are likely to become malevolent. However, Sullivan
did recognize that the child develops coping mechanisms to preclude being
subjected to anxiety-arousing rejection again (Teyber, 2000, p. 6). Unfortu-
nately, in adulthood these responses become characterological as the child
now grown to adult size anticipates that new experiences with others will
repeat the relational patterns of the past.
Eventually, patients’ childlike attempts to contain their bad aspects will
lead to frustration. The self-effacing patient will not win approval of every-
one they need, the aloof patient will be forced by situational demands to
compete with others, and the expansive (histrionic) patient will not
always succeed at manipulating others to defer to their demands. When
such a student receives anything less than 100 percent approval from an
instructor or mentor, they will feel completely defeated and overreact with
great drama toward a significant person and may engage in storytelling in
an effort to seek attention from others. Therapists who fail to recognize
this expression of an often repressed ego state (the “narcissistic wound” in
Kohut’s [1977] interpersonal process terms) will question this overreaction
and provide a rational appraisal of the situation. This attempt at reality
grounding might well result in a transference reaction toward the therapist
who has missed entirely the deeper meaning to the client coming from the
frustrated childish ego state. The therapist must grasp the patient’s point
of view that this seemingly minor rejection indicates once again for the
patient that no matter how great their efforts they cannot get it right.
Rather than reject the ego state that is expressing such desperation, the
therapist should reflect compassion for the burden of perfectionism that
the client has suffered from since childhood. This resonant understanding
will strengthen the therapeutic alliance and create, especially with the aid
of hypnosis, a safe place for the patient to explore collaboration of their
ego states.
Kohut (1971, 1977) departed most from “drive theory.” In his Psychology
of the Self (1977), Kohut assigned the classical functions of ego, super-ego,
and id to the self. He hypothesized that this entity was developed by the
infant’s internalization of “self-objects,” meaning the significant people in
the child’s world, usually his or her parents. Through their empathic
responses to his or her needs, they provided the experiences necessary for the
development of the child’s “self.” This is an extension of Mahler’s concepts,
but unlike her, Kohut broke more definitely with the drive theory approach
since he perceived the self as almost entirely a product of interpersonal rela-
tions. Kohut felt that the self expresses a need for contact with others as its
basic motivational apparatus rather than sexual or aggressive drives.
Because of loyalty to Freud, and their own wish to be identified with the
body of classical psychoanalysis, the object-relation theorists and to a lesser
extent the interpersonal process theorists kept trying to reconcile their new
concepts, derived from clinical experience with classical drive theory
(Greenberg & Mitchell, 1983). All of these practitioners were inhibited, at
least to some degree, in proposing concepts of personality development,
which departed too widely from accepted theories. Innovative psychological
theories that deviated too radically from Freud’s, such as Alfred Adler’s
(1948), Carl Jung’s (1916), and Otto Rank’s (1952) had all resulted in the
past with their author being rejected from membership within classic psycho-
analysis. Kohut’s views, which were probably the most progressive of the
object relation theorists, were most likely more closely aligned than the other
three to the earlier views of Paul Federn, who was a friend and close associate
of Sigmund Freud.
PAUL FEDERN’S EGO PSYCHOLOGY

Federn was one of the first to join Freud’s group and developed innova-
tive techniques for treating psychosis. As early as 1927, Paul Federn had
proposed many of the concepts advocated later by the object relations and
interpersonal process theorists. His work was almost completely ignored in
the controversies between drive model and relations model theorists as
he remained all but unreferenced by those credited with the development
of object relations theory. One gets the impression that they never read
Federn, and it remained to Eduardo Weiss (who was analyzed by Federn
and trained by Freud) to publish an English compilation of Federn’s papers.
The ignorance of Federn’s contributions may stem from three primary
problems. First, Federn wrote in what almost any upper-level graduate stu-
dent would view as complex, long-winded, German sentences. Weiss, who
was John G. Watkins’s analyst, once said to J. G. W., “Federn is very diffi-
cult to understand. That is why I had to write an introduction to his book
to explain him.” At that time, J. G. W. was in analysis with Weiss. J. G.
W. noted, “I had not acquired the courage to say, ‘But Dr. Weiss your writ-
ings are also hard to understand’ ” (Watkins & Barabasz, 2008).
Another reason may have been that Federn used alternative terminol-
ogy to refer to psychoanalytic structures and processes that were then cur-
rently in normal usage. Federn himself was not fully aware of the extent to
which his view departed from Freud’s. At any rate, his theories have not
been widely read nor understood by the few that have attempted their
reading. Federn’s theories, however, provide a foundation for Ego-State
Therapy as a unified theory, which integrated the use of hypnosis to dra-
matically speed psychoanalytic processes and its extensions. After more
than a quarter century of development by John and Helen Watkins as the
primary formulators of the theory and therapy, Ego State Therapy is now
considered established. The first “World Congress of Ego State Therapy”
was held March 20–23, 2003, in Bad Orb, Germany, with the recognition
and sponsorship of both the German and European Hypnosis Societies.
Ego State Theory was again a central focus of the European Society of
Hypnosis Congress held in Gozo, Malta, September 18–23, 2005, and most
recently at the International Tagung Ego – State Therapy: Hypnosis,
Trauma and Psychotherapy, Kathmandu, Nepal, May 4–8, 2008, and in
Pokhara, Nepal, May 12–14, 2008.
EGO STATE THEORY

As is well known, Freud based much of his theory on the displacements
of a single energy, libido, which originated in the id. He later hypothesized
the need for two variants of libido: narcissistic libido and object libido. Yet
this still represented only two different allocations of the same energy
source rather than two different kinds of energy. Hartmann originally
(1955) referred to “a primary ego energy,” which was not derived from
instinctual libidinal energy. Later, Jacobsen (1964) supported an initial
state of undifferentiated energy, which then acquires libidinal or aggressive
qualities. Kohut (1971), while attempting to appear loyal to Freud’s drive
theory, proposed that libidinal energy could be divided into two separate
and independent “realms,” including narcissistic libido and object libido.
All of the psychodynamic object-relations and interpersonal process theo-
rists recognized that Freud’s single energy theory, libido, was not adequate
to account for the phenomena, which they observed in their patients.
Their tortured writings show numerous efforts to force these phenomena
into a single energy (libido) mold.
Federn had broken with that position much earlier and had clearly for-
mulated a two-energy theory that resolved many of the conflicts in under-
standing psychodynamic processes and thus provided a rationale for more
effective therapeutic interventions (see Federn, 1952a). It also provided a
rationale for hypnotherapy and hypnoanalysis, a consequence not envi-
sioned by either Federn or Weiss.
EGO AND OBJECT ENERGY

Federn hypothesized different energies: “ego energy and object energy.”
The term libido, as formulated by Freud, meant an instinctual sexual energy
emanating from the id. It was also an object energy, since it could be dis-
placed to various objects such as the patient’s mother, who then became
an object of erotic interest further extended by Jung (1966), who regarded
it as life energy to differentiate it from that of purely sexual energy. To
avoid the confusion, let us follow both Federn’s and Weiss’s later terminol-
ogy and use only “ego energy and object energy.”
Energy can be defined as an investment of a quantum of energy to acti-
vate a process. A motor is “energized” with electricity and then runs. Ego
energy is the energy that cathects or activates the ego. It is the energy of
the self. In fact, it is the self. Ego energy is what you are, it is the “you” in
you. Self is an energy, an organic, life energy, not a compilation of feelings,
thoughts behaviors, and so forth. Ego energy has but one basic quality, the
feeling of selfness, of me-ness. If an arm is invested or energized with this
ego energy, then I experience it as “my” arm. If a thought is invested or
activated with ego energy, then I experience it as “my” thought. It has
become part of “the me,” and, therefore, I regard it as within “myself.” By

calling it “ego energy” and not “ego libido,” we will no longer confuse it
with the instinctual, sexual, and object energy.
Federn’s second energy was “object energy.” It is qualitatively very differ-
ent, being a nonorganic energy, much like electricity, radiation, and so on. It
has but one basic quality. Like ego energy, it can activate or make a process
go, but any process or body part object energized is not experienced as “me.”
It is sensed or perceived as an object, hence, outside “my” self. Patients suf-
fering from borderline personality disorder (BPD) ascribe only such object
energy to other humans in their life space. To them, people serve a purpose
but do not have selfness.
Kohut and other object relations–interpersonal process theorists were
apparently unaware of Federn’s work and did not seem prepared to chal-
lenge Freud’s drive theory to the point of recognizing that the concept of a
single kind of energy called libido had to be eliminated to bring the theo-
retical structure to fruition in the treatment of patients. Instead, Kohut
and the others continued to modify the concept of the manner of cathect-
ing by a single energy, which determined whether a representation became
a “true object” or a “self object.” It seemed that at some level Kohut recog-
nized the need for a two-energy approach but could never bring himself to
such a conceptualization.
Federn’s concept of two different kinds of energy directly challenged
Freud’s basic views regarding a single, unitary “libido.” As such, it was ignored
by many psychoanalysts until the advent of Ego State Therapy.
Neither ego energy nor object energy should be equated in any way
with consciousness. If my arm has been hypnotically anesthetized, para-
lyzed that is, and removed from my self-control, its ego energy has been
removed (dissociated). The arm is now experienced by me as an “it,” an
external object and entirely outside of “myself.” If the paralysis is hypnoti-
cally removed and the “feeling of selfness” restored, that is because we
have invested it again with ego energy. From this perspective, hypnosis is
clearly the modality of choice for directing the various displacements of
ego energies and object energies.
Existence is impact between object and subject, so consciousness in ego
state theory is an economic matter. When the impact of an object-energized
element on an ego-energized boundary exceeds a certain magnitude, we
become aware, hence, conscious of it. This depends both on how highly
energized the object is and how highly energized the ego boundary is. We
can become aware of strongly energized (energized objects) even if the ego
boundary is lightly energized and the impact of a low-energized object may
become conscious if the receiving ego boundary is highly energized. If you
stroke my hand lightly, I may not feel anything. If you slap it strongly,
I become aware of the touch. As you develop a highly tuned listening, ego
boundary, hence, a sensitive third ear (Reik, 1948), you may become quite
aware of an unconscious and symbolic communication from your patient,

which the more obtuse practitioner will completely miss.
Introjection and identification depend on the allocation of object or ego
energies. When I introject an outside person—perhaps my father—I have
erected a mental image, a replica or representation of my father based on
my perceptions of him. This introject is an object because at this time it is
invested with object energy. If my father was a critical person, at the time
that I introjected him, I will feel (perhaps unconsciously) the lash of his
criticism within which I may simply experience as depression. It, a “not-
me,” is critically and harmfully impacting “the me.” There may also be an
introject of a partner, or friend. These are always persons who are, or least
have been, meaningful at some time in your patient’s life. The patient is
frequently astounded at the emotions they experience while an introject is
executive, yet by such experiencing in the first person the patient develops
a better understanding of that introject and their limitations.
Introjects are not ego states. They are not part of the patient’s personal-
ity, yet, they can be treated in much the same way as an ego state is and
perhaps most importantly they can change to bring greater health to the
patient’s adaptability and functioning in life. Introjects can be scary, abu-
sive, and threatening, or kind and helpful. As Emmerson (2003, p. 12)
points out, when the significant person in the person’s life was benevolent,
an introject will then also be benevolent. However, an introject that had
been internalized as cold and scary may, through ego state negotiation,
become warm and caring. Thus, as we will discuss later, it is frequently
helpful for ego states to be encouraged in therapy to express themselves as
introjects. The hypnotized client can express feelings toward the malevo-
lent introject by being encouraged to speak to those interjected emotions
and told, “What you did to me was wrong!”
No doubt you will have at one time heard the phrase, “If you can’t beat
’em, join ’em.” Psychodynamically, we call it “identification with the
aggressor.” For example, let us say you are employing ego state therapy to
treat a borderline personality disorder. You know the disorder was developed
in your patient due to abandonment of a significant other, usually a parent.
The child fixates at the age at which the abandonment occurred and inter-
nalizes the concept that they deserve to be abandoned as they must have
been bad. Accordingly, to escape from the internal criticism, which as in the
previous case may have been expressed as depression, I may “identify” with
my father. Hence, a common choice in borderlines is in choosing a series of
psychologically or physically abusive, controlling significant others. What
happens here is that I remove the object from this representation and invest
it instead with ego energy. I infuse the representation with the feeling of self-
ness. The introject is no longer a “not-me” object but instead has become
part of “the me.” I experience it within myself. I am no longer depressed by
my father’s introjected criticisms; but I am now critical of my own children.
The content of the “introject” has not been changed. It has now become an
“identofact,” a part of “my” self. I have become like my father, and the
neighbors say, “He is just like his father.” In so identifying with such a signifi-
cant other, your patient becomes sicker and less able to adapt in any overall
sense, thus, mature functioning and healthy adaptation is precluded. In
object relations terminology we might note that what had been an “object
representation” has now become a “self representation.” (At first, the patient
sees the serious problems in the individual and then becomes just like that
individual.) This same maneuver is possible with hypnotic intervention
through hypnotic suggestion. Ego and object energies can be manipulated
therapeutically to the benefit of the patient (subject-object techniques are
reviewed in Barabasz and Watkins, 2005, pp. 49 and 177, and elsewhere in
that volume).
The object relations and interpersonal process theorists are sometimes
difficult to understand because they often confuse introjects and identifica-
tions. Kohut (1977), for example, appears to define the term of what ear-
lier analysts called introjects of significant others, which at first are objects
but later are changed into identifications. He believed that such entities
are necessary even in adaptive mature adults.
In Federn’s Ego Psychology, the term self-object is contradictory. A repre-
sentation of a significant other constructed within the individual will either
be activated by object energy, like an introject, as previously discussed, or
energized by ego energy, like an identification. The child’s “merger” with
such “self-objects” may be gradual; a “representation” cannot be both “self”
and “object” at the same time since this is determined by the quality or na-
ture of the activating energy. It cannot be experienced as “me” and as “not
me” at the same time.
HYPNOSIS AND ENERGIES

Hypnosis emerges as the key modality for moving and changing of ener-
gies when formulating treatment plans for your patients on the basis of
object and subject energies. One hypnotically suggests to a patient that he
or she is now able to move a hysterically paralyzed limb—this may happen
because ego energy has now been invested in it, changing it from object to
subject, hence, bringing it within the self and back to the patient’s volun-
tary control.
Similarly, by hypnotically moving more object energies into a circum-
scribed repressed memory, it becomes strong enough to impact the ego bound-
ary so as to render it conscious. Energies can also move into an object or
process whenever we simply pay attention to it.
Federn did not employ hypnosis in his treatment, yet he foreshadowed its
use in Ego State Therapy. Eduardo Weiss, in his introduction to Federn’s book
(Federn, 1952a, p. 15), wrote, “Ego states of earlier ages do not disappear, but
are only repressed. In hypnosis, a former ego state containing the correspond-
ing emotional dispositions, memories, and urges can be re-awakened in the
individual.” This was a rather profound statement for that era.
If a hypnotized participant’s hand is made to wag up and down (Barabasz
& Watkins, 2005) without conscious control, we have simply removed its
ego energy. It is anesthetized and apparently not within the control of the
amused subject. Its movement is now object energized. The wagging can
become voluntary only if it is ego energized. Hypnosis thus becomes a very
powerful therapeutic modality for altering ego and object energy changes
within our patients.
PSYCHOSES AND EGO ENERGIES

Federn’s most significant contribution stemming from his two-energy
theory was in the understanding of psychotic symptoms and the psychothera-
peutic treatment of the psychoses (see Federn, 1952a, chs. 6–12). Federn char-
acterized a hallucination as a pseudoperception. The schizophrenic actually
sees, hears, or otherwise senses something that does not really exist in the
outer world. To the psychologically ill patient these perceptions appear to be
quite real, as can be well verified by the clinician who tries to persuade the
client otherwise. Yet, the stimuli from these pseudoperceptions arise from
within the patient—that is, the patient’s own inner cognitions. They repre-
sent ideas that are normally experienced as subject—that is, as stemming from
one’s self. The psychotic, however, experiences them as object and similar to
other outside objects that he or she sees, hears, or otherwise senses.
How can thoughts be turned into perceptions? Federn hypothesized that
psychotic patients sense the contents of their delusions and hallucinations
as real because they originate from repressed mental stimuli that entered
consciousness without obtaining ego energy, not because of faulty reality
testing as graduate students are frequently taught and many in our field
assume. The problem is in the weakness of the ego boundary. Like a geo-
graphical boundary, such as that between two countries that is inadequately
patrolled by border guards, citizens can be mistaken for aliens and vice
versa. In the psychotic, the inability to test reality adequately results from
an energy deficiency—a lack of sufficient ego energy to patrol the ego
boundaries, where the differentiation must be made for normal adaptation
to the outside world. Federn’s approach was intended to help the patient
build more ego energy. That, of course, is precisely what we do with rela-
tionships, supportive therapy, exercise, and so forth. In the implementation
of such an approach, Federn often (please consider the era of the mid-
1900s) used a nurse, a mother-surrogate, who could provide the nurturing
relationship normally received from one’s mother (Schwing, 1954).
The mother figure is critically important because her nurturing in develop-
ing self-identity and stable object representations, which Federn and Schwing
had been emphasizing, has currently begun to receive more attention. The
significance of mothers as “transitional objects” in the development of self
structures in infants has been increasingly recognized (Baker, 1981; Barabasz
& Christensen; 2006 Christensen, Barabasz, & Barabasz, 2009).
Baker (1981), Copeland (1986), and Murray-Jobsis (1984) have employed
many of these same concepts in treating psychotics within the hypnotic mo-
dality with remarkable positive and lasting outcomes.
REALITY A REALITY B
Now what was happening here is that Federn, and especially his disciple
Weiss (1960), stressed the distinction between reality testing and the sensing of
reality. We “sense” reality as something outside our self whenever an object-
energized item impacts an ego boundary. However, to “test” reality we need to
use our eyes, ears, and body and note that the sensed object moves its relative
position accordingly. The schizophrenic, for example, fails to take this action,
relying instead entirely on his or her weakened ego boundary in a desperate
attempt to distinguish real from unreal, thoughts from perceptions. Federn
reported that there is a felt difference between an impact of an object on the
“inside” of the ego’s boundary and its “outside,” that which interacts with the
external world. If this is also true, there would have to be a change in the magni-
tude of the impact. The psychotic then would be able to experience this “reality”
of his or her reported experience when it is explained to the patient that there
are in actuality two kinds of reality, “reality A” and “reality B.” The idea here is
to enlist the patient’s cooperation rather than the patient’s antagonism when
being confronted with reality as if they were being accused of “lying.”
What might said to the patient is, “When you see me here I want you
to label that ‘reality A.’ When you see or hear those people who are perse-
cuting you, I want you to please call that ‘reality B.’ Now ‘reality A’ is a
kind of experience you can share with others around you because they,
too, are aware of ‘reality A.’ However, ‘reality B’ is a private reality, which
they cannot share. If you talk to them about ‘reality B’ they will think you
are crazy! Please do this, when you describe to me any experience, tell me,
at least for now, whether it is ‘reality A’ or ‘reality B.’ ”
Testing this remarkable intervention with numerous psychotic patients,
Federn concluded that psychotic patients could, indeed, distinguish between
reality A and reality B even though both were experienced as real. By teach-
ing these patients to make this discrimination, he was exercising, strengthen-
ing, and re-energizing their ego boundaries. In time, these patients made this
distinction. By not reinforcing reality B, the hallucinated “reality” was de-
energized. Reality B was then returned to the world of nocturnal dreams,
wherein lie the consciously inactive “hallucinations” of normal people. By
reducing the energy in reality B, its impact with self-boundaries became
lower than the threshold necessary to become conscious.
By positing a two-energy system, Federn provided a new rationale to

explain many psychological processes that cannot be satisfactorily accounted
for by Freud’s one-energy (libido) system. For example, if a thought of my
dead mother crosses my mind and reaches consciousness, but is activated
with object energy, I will experience it as a perception of my dead mother.
I will “see” her. And, if I report this perception as real, others will say I am
psychotic and hallucinating.
Years ago, John G. Watkins was trying to explain the mechanism of
projection to a paranoid patient. As we all know, that is usually a futile
task. Much to his surprise, the patient smiled and said, “Well doctor, if
you are trying to tell me that those men who persecuted me were a product
of my own imagination, you don’ t have to. I arrived at that conclusion
my self over the weekend.” In utter amazement, Watkins spent some time
evaluating him before accepting that his delusions and hallucinations had
disappeared. The patient’s own unconscious hatreds externalized into a
perception of “men out there” who were persecuting him, had been de-
energized of object energy, and were now energized with ego-energy. He
experienced them as his thoughts and not his perceptions. The critical
point I am trying to make here is that a one-energy system would not give
us an adequate explanatory rationale even though psychodynamically we
are still unaware of just what caused this energy shift.
Psychologists and psychoanalysts frequently confuse subject and object.
Thus, an introject is supposed to be an internal object. Yet, analytic writ-
ers portray a patient as “introjecting” another person when they describe
that individual as acting and talking like the other person. The image of
the other, when internalized, is at first invested with object energy. That is
why it is an internal object. An introject is like that submarine sandwich
you ate one late evening that lies in the stomach ready to resurface at mid-
night. It is within the self but not part of it, ingested but not digested.
For the individual to act and talk spontaneously like any other, the
object energy must be withdrawn and ego energized. In object-relations
theories, we would simply say that the object representation has changed
into a self-representation. Then we no longer have an introject; we have
an identofact. The internalized has become part of “the me.”
For example, a teenage girl “in love” imitates the behavior of her boy-
friend, eating what he eats and regressing to earlier behaviors by acting as
immaturely as he does. This action is at first an introject of that same-age
immature boyfriend’s behaviors. Eating like him, behaving like him, and
taking on his views are simply internal representations of the boyfriend, cop-
ied but not part of her own self. However, in the course of time, it may
become automatic. The behaviors have become egotized—that is, invested
with ego energy. It is now part of her own self. Her same-aged but now more
mature girlfriends watch her behaving like her boyfriend does and are
amazed. If he lacks future goal directed plans, she too loses focus; if he is
opinionated, bitter, or selfish, she is too. She has identified with her boy-
friend. An identification with a previously introjected other may be minimal
or significant, depending on how much of the other’s physical attributes
and or psychological behavior, as in the present example, is taken over.
As Watkins (1978a) points out, an introject is the result of the process of
introjection, and a new term is needed to distinguish between the process
of identification and the result of that process. Consider our use of the
word identification when referring to the process, and the term identofact to
indicate the internal, ego-energized image that has been created by identifi-
cation. The girl described herein has changed the introject, and object repre-
sentation, of her “boyfriend” into an identofact, a self-representation. This
distinction between what is subject (ego-energized) and what is not self
(object-energized) in physical and psychological processes is crucial. The
movement from one to the other is fundamental to the practice of ego state
therapy, as well as many other treatment approaches.
PERSONALITY DEVELOPMENT: INTEGRATION AND

DIFFERENTIATION
Personality develops through two basic processes, integration and differen-
tiation. By integration, a child learns to put concepts together, such as cow
and horse to build more complex units called animals. By differentiation, he
or she separates general concepts into more specific meanings, such as discrim-
inating between a cat and a rabbit. Both processes are normal and adaptive.
Normal differentiation permits us to experience one set of behaviors at
a party Saturday night and another at the office Monday morning. When
this separating or differentiating process becomes excessive and maladap-
tive, we call it dissociative identity disorder.
When we differentiate two items, both of which are consciously in
mind, we can compare them and note their differences. In dissociation,
the two items are so separated from each other that comparison is not pos-
sible, since only one is within consciousness at any given time. Both differ-
entiation and dissociation involve the psychological separating of two
entities, but differentiation is lesser in degree, generally adaptive, and con-
sidered to be normal. Dissociation, on the other hand, is considered to be
pathological. It may be more immediately adaptive to cope with the stress
of a specific situation, but often at the future expense of greater maladap-
tiveness. Differentiation and dissociation may be considered as simply
resulting from different degrees of the separating process.
EGO STATES
To understand the nature of ego states one must consider their origin.
Most frequently, they were first created when the individual was quite
young. They think concretely like a child. Because of the emergence of

primary process thinking as produced by hypnotic age regression (Barabasz &
Christensen, 2006; Christensen, Barabasz & Barabasz, 2008), adult logic,
therefore, may not reach them, even though they often talk in an adult
voice. It is as if they were frozen in time. Covert ego states, unlike the
alters in a true multiple personality (DID), require hypnosis for their acti-
vation. But, if they first originated when the patient was a child, then one
should think of them like a small girl who is dressed up in her mother’s
clothes and pretending to be an adult. The ability to think concretely like
a child has been lost by the majority of adults, and thus we are at a disad-
vantage in dealing with child ego states, especially when they are not so
clearly differentiated as true multiple-personality-like alters. States that
were created during the patient’s teens will still think like a teenager,
rejecting and suspicious of grown-ups and very defensive of their own
(pseudo) independence; they do not want to be told what is right or what
they ought to do. This characteristic is illustrated in the case excerpts (see
Watkins & Barabasz, 2008).
When working therapeutically with child and adolescent states, one
should conceptualize to whom one is talking and conduct the interaction
accordingly. The clinician or counselor who resonates well will have the
greatest probability of success.
Be mindful that a child ego state was developed to adapt to the conditions
of days gone by, not today. Its attempts to function today result in maladap-
tive behaviors (short-sighted present rather than future-oriented actions). As
one inquires and secures information about the time and circumstances when
an ego state first appeared, one’s approach can be modified accordingly, even
though one is confronted ostensibly with a full-grown adult. This modification
can be done, without embarrassment, by the use of hypnosis. The psycho-
therapist interacts as one would with a child when the patient is hypnotized.
Bear in mind that an ego state was most likely developed to enhance
the individual’s ability to adapt and cope with a specific problem or situa-
tion in the past. Thus, one ego state may have taken over the overt, exec-
utive position when dealing with parents, another on the playground,
another when dealing with a significant other, and yet another when par-
ticipating in a sporting event, and so on.
In the case of dissociative identity disorder, which is manifested by the
presence of true multiple personality alters, the specific situation is usually
some very severe trauma such as child abuse or traumatic abandonment.
The ego state forms to help in dissociating the pain from the primary alter
or to make it easier for the major personality to deal with an abuser (con-
troller) without inviting retaliation. It is to be expected that these specific
ego states will be reactivated in the transferences of the present, such as to
teachers, employers, supervisors, mentors, colleagues, and, of course, thera-
pists (Watkins & Barabasz, 2008).
A common trait is that once created, ego states are highly motivated to
protect and continue their existence. The clinician who tries to eliminate
(kill off) a maladaptive state will find to his or her dismay that the entity
probably does not want to disappear, but that one’s intervention has now cre-
ated an internal enemy who resists therapeutic intervention. Part-persons
seek to protect their existence, as do whole-persons. This tendency also has
important implications in the treatment of dissociative identity–disordered
patients. Perhaps the most important point to remember is that it is much
easier to modify the motivations of malevolent and maladaptive ego states
and their behavior constructively than to attempt to eliminate them.
Persistence in existence is to understand that the original ego state
came into being to protect and facilitate the adaptation of the primary per-
son. It remained because it had a certain amount of success. It was posi-
tively reinforced, first for coming into existence, and then for continuing
its presence. It makes no difference whatsoever that now its efforts may be
contra productive to the person. The earlier adaptations, which are now
maladaptive, will hold precedence.
First, we must familiarize ourselves with the differences in the environ-
ment of the patient’s past and that of the present. We cannot generally
induce a state to change into an adaptive stance toward current adult prob-
lems when the treating counselor or clinician does not understand its earlier
struggles. Recognition of these traits is essential in the planning and conduct
of effective therapeutic maneuvers such as abreactions (Barabasz, 2008a,b,c).
When working with ego states, the internal equilibrium of the patient
will change in such a way that a new ego state, or one that has been long
dormant, will be energized and make itself known. This state may first
manifest itself by slight changes in posture, mannerism, or voice pitch.
Using the explanatory value of Federn’s two-energy theory makes it eas-
ier to understand. The nature of the past problems helps us to determine
the creation and energies of the various states. The adaptational needs of
the present must be met with the appropriate dispositions of object and
ego energies assisted by an understanding and accepting therapist. Hypno-
sis is the key modality that facilitates this allocation of subject and object
energies. This treatment goal can be reached from a variety of orientations
according to the clinician’s primary training including behavioral, psycho-
analytic, cognitive-behavioral, Rogersian, and existential therapies. Any
such approach constitutes ego state therapy when the goal is appropriate
dispositions of object and ego energies.
Ego states that are cognitively dissonant or have contradictory goals often
develop conflicts with each other. When they are energized and have rigid,
impermeable boundaries, multiple personalities (DID) may result. However,
many such conflicts appear between ego states only covertly, and these are
often manifested by anxiety, depression, or any number of neurotic, maladap-
tive, and childlike behaviors.
Ego states may be large, encompassing broad areas of behavior and ex-
perience, or they may be small including very specific and limited reac-
tions. They may also overlap. For example, a six-year-old child ego state
and a “reaction to father” ego state both speak the English language. They
can range from minor mood shifts to true overt multiple personalities, the
difference being the permeability of their separating boundaries.
EGO STATE BOUNDARIES: THE DIFFERENTIATION-

DISSOCIATION CONTINUUM
Psychological processes do not exist on an either-or basis. Anxiety,
depression, immaturity, and so forth all lie on a continuum with lesser or
greater degrees of intensity. So it is with differentiation-dissociation. On
one end of the continuum, the boundaries are so permeable that they are
almost nonexistent. The individual’s behavior is very much the same from
time to time. The difference that does occur is generally adaptive, and we
call it normal differentiation. As the ego state boundaries become increas-
ingly rigid, intrapersonal communication is impeded so that behavior
becomes less and less adaptive. When we approach the end of the contin-
uum, the boundaries are very rigid and impermeable, the behavior is malad-
aptive, and we call it “dissociation.” At this extreme end of the continuum,
the various ego states no longer interact or communicate with one another
and the individual suffers from a true multiple personality (dissociative
identity disorder) if more than one becomes energized enough to assume
the overt executive position temporarily.
In between these extremes lies a body of ego states that may act like
“covert” multiple personalities, but which do not spontaneously become
overt. However, they can be activated hypnotically.
The various states are conscious of the existence of one another but
refer to the others as “he, she” or “it,” and not as “me.” This position on
the differentiation-dissociation continuum represents a bordering (almost
true) multiple personality and is not to be confused with the diagnosis of
borderline personality disorder. The in-between ego states, because of the
lesser degree of rigidity in the semipermeable boundaries, retain partial
communication, interaction, and sharing of content. In general, they
remain covert and do not spontaneously appear overtly, but they can be
activated into the executive position by hypnosis. In this region, a conflict
between the states may be manifested by headaches, anxiety, withdrawal,
passive aggressive, and other maladaptive behaviors, such as are found in
the neuroses and in the psychophysiologic disorders. It is in this area where
the most productive contributions of ego state concepts to psychotherapy
have occurred. We are, therefore, concerned with a general principle of
personality formation in which the dispositions of the activating energies
and the impermeability of the boundaries separating the organized ego-

state patterns have resulted in relatively discreet personality segments that
may alternate in assuming the executive position, experienced as “the self”
in “the here and now.” The extreme form of this separating process, as
noted before, can result in true dissociative identity disorders.
For some time, true multiples were considered to be extremely rare. How-
ever, as recognized in the Diagnostic and Statistical Manual of Mental Disorders-
IV (APA, 1994) and in the more recent text revised (TR) edition, many
reports of cases meeting full diagnostic criteria are now being presented. The
disorder is still uncommon but it can no longer be considered rare. For exam-
ple, borderline multiples are frequently misdiagnosed as borderline personal-
ity disorders. This is fairly common and particularly prevalent among
females, and may be due to the higher frequency of abuse of females as chil-
dren as well as gender-specific maladaptations to abandonment.
CHARACTERISTICS OF EGO STATES AND

DISSOCIATIVE IDENTITY DISORDER
Ego states should be regarded as part-persons. Except in the case of true
multiple personality (DID), they do not normally appear overtly unless hyp-
notically activated. There is far too much evidence to the contrary to impute
to them simply as therapist-created artifacts since they often differ widely
from therapist expectations. Some act like complete “persons.” Others appear
to be very limited personality fragments, perhaps created for a specific defen-
sive purpose. They may have quite differing interests, purposes, and values,
even as do the various alters in a true dissociative identity–disordered person-
ality. Obviously then it is not surprising to find them often in intra-personal
conflict with one another, creating tension, anxiety, psychosomatic symp-
toms, the desire for flight, and other maladaptive behaviors. As one ego state
put it, “I make her eat because if she is over-weight men (who are dangerous)
will not be attracted to her.” Covert ego state conflicts may create headaches
just like the quarreling of multiple personality alters who struggle to emerge
and take over executive control of the body.
EGO STATE THERAPY

Ego state therapy is the utilization of individual, family, and group ther-
apy techniques for the resolution of conflicts between the different ego
states that constitute a “family of self” within a single individual (Watkins &
Watkins, 1997, p. 35). Therapy involves a kind of internal diplomacy that
may employ any of the cognitive-behavioral, psychoanalytic, Rogersian, or
humanistic techniques of treatment but almost always uses hypnosis. These
techniques are directed toward the part-persons represented by the ego
states and not toward the whole individual. While it is possible to practice
ego state therapy in the conscious condition (Emmerson, 2006), the use of
hypnosis is the method of choice for most practitioners. This is because
ego states, unlike true dissociative identity disorder (DID) alters, do not
usually become overt spontaneously. Most of the time they require hyp-
notic activation. Through hypnosis we can focus on one segment of per-
sonality and temporarily ablate or dissociate away other parts. In fact,
since hypnosis is itself a form of dissociation, it is not surprising to find
that good hypnotic participants often manifest covert ego state segments
in their personalities even though they are not mentally ill. Hypnosis offers
access to levels of personality that in classical psychoanalysis require much,
much longer periods of time to contact. Since ego state therapy is an
approach involving inter-part communication and diplomacy, hypnosis
generally becomes an essential for practicing it when the states are covert.
At times an ego state may be exerting an influence as “object” on the
primary individual—in which case we might say, “I would like to talk to
that part” (we don’t use the term ego state with the patient) of Mary Anne
who has been compelling her to overeat (or who knows about her overeat-
ing). A communication back from such a “part” commonly is the result.
The content of this “part” is often at considerable variance with the thera-
pist’s expectations, contradicting the notion that ego states are only arti-
facts created to please the therapist (a common argument posed by those
who incompletely understand ego state therapy).
Only being “part-persons,” ego states often think concretely like a child
and must be communicated with accordingly. Sometimes ego states appear
during sleep or in hypnosis-like dream figures. The same general strategies
and tactics used in treating DID patients apply when working with the
more covert ego states except that they must be preceded by a hypnotic
induction.
EFFICACY RESEARCH
Much of the recognition of the efficacy of ego state therapy has been
based on clinical experience rather than controlled research as evidenced
by the acceptance of this approach at the First World Congress on Ego
State Therapy held in Bad Orb, Germany, in 2003, and most recently in
Kathmandu, Nepal, in 2008. Nonetheless, controlled research, although
still in its infancy (Frederick, 2005), thus far indicates that ego state ther-
apy is effective in assisting clients with both psychological and somatic
symptoms. Using a time series analysis as the experimental procedure,
Emmerson and Farmer (1996) found that women with menstrual migraines
were able to experience not only a significant reduction in headaches, but
also a reduction in depression and anger. This occurred following a four-
week treatment with ego state therapy. The monthly average number of
days with migraine went from 12.2 to only 2.5. Consistent with this
decline in headaches was a statistically significant decline in levels of

depression and anger. The ego states text (Watkins & Watkins, 1997)
reports on 42 clients who had received ego state therapy for a median of
only 11 hours total treatment and those who had received other types
of therapy with a median of 145 hours. Twenty-four clients said ego state
therapy met their expectations, while only seven clients said the other
therapies met their expectations. Gainer (1993) also reported very positive
effects of ego state therapy. When trauma held by a child ego state was
processed, there was complete remission of Reflex Sympathetic Dystrophy
(Ginandes, in press).
EGO STATES AND HIDDEN OBSERVERS

Little more than a quarter of a century ago, Ernest R. Hilgard was dem-
onstrating hypnotic deafness before a class of students at Stanford Univer-
sity. As Barabasz and Watkins (2005) explain, to dissociate something one
must first be aware of it at some level, or as Martin Orne’s trance logic
conceptualization would dictate, “you have to hear it or see it before its
presence can be negatively hallucinated away.” Given that understanding,
let us get back to Hilgard’s fascinating demonstration. As he was about to
invoke hypnotic deafness, a student in his class asked whether some part
of the apparently deaf subject might be aware of what was going on.
Hilgard then said to the hypnotized subject, “although you are hypnoti-
cally deaf, perhaps there is some part of you that is hearing my voice and
processing the information. If there is I should like the index finger to rise
as a sign that this is the case.” Much to Hilgard’s surprise, the finger lifted!
Later, he discovered that individuals similarly reported being aware of pain
(but without its sensation) in a hypnotically anesthetized hand. Hilgard
ascribed this phenomenon to a cognitive structural system, which he called
“the hidden observer.”
Watkins and Watkins (1979–1980) conducted a set of experiments in
which they activated hidden observers in former ego state therapy patients
using the same procedures and verbalizations employed by Hilgard in his
studies, repeating with both hypnotic deafness and hypnotic analgesia.
What emerged were various ego states with which they had dealt in treat-
ment over a year earlier. They hypothesized that hidden observers and ego
states are, therefore, the same class of phenomena.
To conclude this discussion, let us note the differences between Federn’s
original conception of ego states and Watkins’s view of them. To Federn,
the ego remained a constant. Different contents could pass in and out if it
by being ego-energized, which were then organized by the ego into the ego
states. When an ego state was de-energized of self-energy, it retained its
organization and continuous existence as an object representation. An
ego state consisted only of self-energized items. In our view (Watkins &
Barabasz, 2008), the self consists of pure ego-energy, not contents, such as
motivations, affects, ideas, and so forth. This energy is not the energy of
the self, it is the self.
When this ego energy passes into contents, these are then experienced
as part of the self; in other words, they are experienced as “me.” The
movement is on the part of the self energy as it passes into and out of vari-
ous organized behavior and experience patterns we call ego states. Such a
state may contain both object and self representations, which on repres-
sion, removed from consciousness, still retain their respective and relative
structures. Thus, this ego state, whether self or object-energized, is the unit
to be dealt with in therapy. It takes on the character of the major amount
of energy within it, ego or object, and is experienced by the individual as
such, “the me” or less frequently as the “it.” Looking once again at the fig-
ure showing the differentiation-dissociation continuum, it is worth noting
that hidden observers and other partially separated personality segments
exist as ego states within the middle range.
EGO STATE THERAPY TREATMENT

The ego state therapy session typically resembles family therapy in that
one member speaks, another is asked to respond, and an exchange of com-
munications begins. Sometimes it is necessary to call on specific states to
come out and speak. At other times they will emerge spontaneously so
long as the hypnotic state has been adequately established. Sometimes no
one will abdicate if pressed too hard, and another will appear. The impor-
tant point is that the therapist thinks of it as talking to a multiplicity and
not a unity. There is a single body in view but you are dealing with a fam-
ily. What one says to one ego state may well be heard by others who can
take offense and oppose one’s treatment efforts.
The counselor or clinician operates like a group therapist. Any therapeu-
tic maneuver, such as reflection, ventilation, desensitization, abreaction,
free association, interpretation, reinforcement (approval), clarification, and
so forth that is part of your armamentarium may be employed. These can
be used within the basic theoretical orientation that you have been trained
in. However, they are to be applied with the use of hypnosis and to the var-
ious personality segments rather than to the patient viewed as a unity.
Sometimes the awareness of what has been done with an ego state may
be brought to the attention of the conscious person. At other times, efforts
will be made to strengthen some of the more constructive ego states. Occa-
sionally, an ego state can be found that may serve as an assistant therapist,
consulting with the clinician about strategy, advising of the effects of
earlier maneuvers, and helping in planning future steps. We (Watkins &
Barabasz, 2008) have taught ego states, who at first were destructive, to become
constructive. It is our job to try at all times to discover and meet the needs
of each ego state. Where they are conflicting, negotiation and compromise are
indicated. Your role as a psychotherapist is frequently that of a communicator
and a mediator between the clashing states. For example, “George” (a teenager
ego state) was asked, “Would you be willing to do your homework during the
week if “father” (a parental ego state) doesn’t bug you about playing on the
weekends?”
Remember that ego states, like dissociative identity disorder alters, origi-
nated for defensive adaptive purposes during the person’s critical develop-
mental years and/or in response to trauma such as faced by soldiers in the
Iraq wars, so they may no longer now be adaptive for the individual. As
they were developed when the individual was a child and/or for immediate
survival defense mechanisms, they do not serve well for normal functioning
adults. It is, therefore, unwise to eliminate “bad” ego states. Rather, one
can avoid much resistance if you treat all the ego states with the utmost
courtesy and respect, secure their cooperation, try to meet their needs, and
play the role of a good friend to each. Attempts to eliminate a state mobi-
lizes much resistance that can sabotage treatment.
SUMMARY
Ego state therapy was derived from the study of multiple personalities
and experiments with normal, hypnotized subjects within the general theo-
retical structure of hypnoanalysis. Hilgard’s “hidden observers” and the
theories of Paul Federn served as an origin for its conceptual structure.
However, we (Barabasz & Watkins, 2008) have elaborated on its original
formulations and altered them in certain significant areas based on our ex-
perimental studies and clinical experiences.
It is essential to recognize that the “separating function” in the forma-
tion of personality structure, like almost all psychological processes, exists
on a continuum ranging from normal, adaptive differentiations through
defensive operations to maladaptive dissociation as exemplified in true dis-
sociative identity disorder.
Ego state therapy may use any of the directive, cognitive-behavioral,
analytic, or humanistic approaches in treatment. But it applies these to per-
sonality segments, that is, part-persons, and not to the entire individual.
Generally, it does so with the use of hypnosis since covert ego states do not
typically appear spontaneously without having been hypnotically activated.
The orientation here is hypnoanalytic ego state therapy. However, a
therapist with a different theoretical orientation might prefer to practice a
hypnocognitive ego state therapy, applying his or her interventions to
part-persons (ego states) rather than to the entire individual.
Ego state therapy is a very potent treatment procedure because it focuses
on the specific areas of the personality that are most relevant to the pre-
senting problem. This tactical advantage is valuable not only in dealing
with the occasional true multiple personality, but extending to the vast
array of neurotic, psychosomatic, and behavioral disorders ranging from
simple stop smoking and weight reduction problems to severe phobic and
anxiety cases. When used with skill, ego state therapy can provide
approaches for handling borderline conditions in ways well beyond the
scope of other therapies currently available or, for that matter, in any case
where some measure of dissociation, mild or severe, is found.
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Chapter 3
Hypnotic Dreams
Deirdre Barrett
Hypnosis and dreams have much in common, as is reflected in our lan-

guage about them: “Hypnosis” is named for the god of sleep, phrases such
as “dream-like” are scattered through hypnotic inductions and dream ac-
tions are sometimes described with words such as trance. Most references
to non-pathological “hallucinations” refer to one or the other of these two
states (Barrett, 1995). What they have in common is the coming together
of the two major human modes of cognition:
1. The emotional, visual, irrational, hallucinatory, and intuitive mode of

thought that Freud called “primary process,” recently termed “right
brain” thought in popular literature (with only the loosest relationship
to actual hemispheric specialization).
2. Logical, verbal, linear reasoning that Freud called “secondary process,”
now popularized as “left brain thinking.”
In deep hypnosis and lucid dreams (dreams in which the dreamer knows
he or she is dreaming), these two processes are strongly manifested and
integrated with each other. In deep hypnotic trance, the coexistence is
achieved by starting in the logical waking state and introducing hallu-
cinatory imagery; in a lucid dream it is achieved by starting in the pri-
mary process/hallucinatory mode and introducing secondary process logic.
Although lighter hypnotic trances and normal dreams are characterized by
more secondary process and more primary process respectively, they still
involve a degree of coexistence of both modes not seen in most other
states of consciousness—normal waking is mostly secondary process, psy-
chosis is mostly primary process, and non-dreaming sleep shows very little
of either. So hypnosis and dreaming already share much in common, but
there is one area of interaction that is especially rich for these overlapping
of modes of thought.
THE HYPNOTIC DREAM

A variety of hypnosis-related phenomena are sometimes referred to as
“hypnotic dreams” including nighttime dreams influenced by posthypnotic
suggestions and fantasies occurring spontaneously under hypnosis. This
chapter will reserve the term for its most common usage—the result of an
explicit direction to have a dream while in a hypnotic state. However, I’ll
return to some of these other potential relationships between dreaming
and hypnosis in the last section.
The hypnotic dream was advocated as a therapy technique by many early
psychodynamic hypnotherapists such as Milton Erickson, Jerome Schneck,
Merton Gill, Margaret Brenman, and Erika Fromm. Erickson (1958) de-
scribed a procedure he called “the rehearsal technique” in which he had a
patient repeat over and over again a dream with the implied freedom of re-
dreaming it in different ways. He believed that this served the dual purpose
of progressively deepening the trance and of gaining insight into, and work-
ing through of, unconscious conflicts as the dream is reissued in less and less
censored versions. For example, Erickson cites the case of a patient who had
reported a dream in which he was in a pleasant meadow among comfortable
warm hills. At the same time, the patient experienced a strong desire for
something unknown and a paralyzing feat. On further elaborations, the lo-
cale changed to a valley with a little stream of water flowing under a horri-
ble poisonous bush. Again the dreamer continued to look for something,
while feeling terribly frightened, and getting smaller and smaller, as he was
terrorized by the unknown that was pushing closer.
In the next repetition, the dreamer was a lumberjack picking up logs
flowing down the river, and every time he obtained a log, it turned out to
be just a skimpy little rotten stick compared to the big logs of other lumber-
jacks. In the next dream, he was fishing, and while everybody else caught
big fish he only succeeded in obtaining a little sickly looking one that he
was finally forced to keep.
Further repetitions eventually resulted in the disappearance of extensive
amnesias and conscious blocking, and thus enabled the patient to reveal
without further symbolism his inferiority feelings connected with stunted
genital development and to discuss strong homosexual inclinations.
Sacerdote (1967a) describes a similar use of hypnotic dreams for rapid ther-
apy, but stresses the experience of the dream as inherently therapeutic aside
from any interpretation or insights gained from it. Some of his examples are very
analytic and similar to Erickson’s usage, while others involve an interpretation
or breaking down of defenses. In the case of an obese elderly woman, she was
told during the first and only hour of treatment under hypnosis: The dream will
now start; you will be telling me all about that dream. In the dream you will see
yourself having some very pleasant experiences, nice and slim as you want to
be. What the dream will really be all about, it will be your own affair.
Hypnotic Dreams 99
She reported the following dream: “I am in Paris, and then on the Riviera,
and I am dancing and dancing; and then I went shopping, and ho! It is so
wonderful; to get into clothes, size 10, and I had such a wonderful time.” A
second dream the same hour ran: “Oh, it is so wonderful, so wonderful; to be
thin! Now I am on the beach and people are saying, ‘What happened? Who
are you? I don’t recognize you.’ I am just walking up and down on the
beach and it is such fun; it is wonderful! Oh, I love the bathing suits!! I never
could wear a bathing suit! Oh, that man! I do so want to go dancing tonight”
(Sacerdote, 1967a, pp. 116–117). While the therapy was not quite limited to
this one hypnotic session, it was after this one hour that she began to lose
weight, becoming and remaining slim.
In a further article, Sacerdote (1972) reported the successful treatment
of a long-standing case of insomnia that was apparently due to a fear of hav-
ing nightmares by carefully inducing controlled dreams that let conflicts
be expressed more gradually than in a full-blown nightmare.
Gill and Brenman (1959) described the use of hypnosis both for the
production of original dreams and for the continuation of night dreams.
In their technique the patients are told that they will continue a dream
where it left off and that its meaning will become clearer. They gave the
example of a young soldier discharged from the army in a state of depres-
sion and anxiety. He reported a dream of walking up a mountain path
leading to a cave and trying to look inside, but waking up before he could
see in. Under hypnosis, the patient looked in the cave and saw a witch
who then becomes his mother, someone who was still somewhat frighten-
ing. Eventually, he was able to climb up on her lap and rest there like a
young child. He then got up and walked away as a grown man. This dream
was accompanied by great emotional expression and seemed to relieve his
depression and anxiety greatly, the authors seeing the abreactive effect of
the dream in this instance being the main component.
Berheim (1947) also stressed the abreactive effect of hypnotic dreams
and offered an example in which he obtained good results by having a vet-
eran go through a hypnotic dream about a real past traumatic memory of a
battle and being wounded. He spoke out loud for himself and everyone else
present as he reenacted the scene cathartically.
Lecron and Bordeaux (1947) described how hypnotic subjects could be
instructed to dream on any specific topic. In a therapy setting, they believed
that two of the most useful specifics were to have a person have a dream
about their attitude toward a significant person or to have a dream about
why resistance had appeared in an analysis. They report that an interpretable
dream usually results from these suggestions that frequently speed up the pro-
gression of therapy.
Crasilneck and Hall (1975) reported helping a woman to find a lost
locket by suggesting she would have a dream under hypnosis that would
reveal its location. She had a dream in which she was looking at rows of
books. Upon awakening, she remembered she had been reading a specific
book the night the locket was lost, went to her bookcase, and found the
locket marking her place.
Sacerdote (1968) described a group dream induction technique that he
found helpful with patients who had trouble developing hypnotic dreams
at first. He hypnotized a group and began with the people who easily pro-
duced dreams and they reported them out loud. He found that those who
have had more difficulty dreaming can then, after hearing other dreams,
begin their own dreams, which at the outset incorporate elements of the
other patients’ reports but go on to represent the dreamer’s own unique
material.
COMPARISONS OF HYPNOTIC AND NOCTURNAL DREAMS

These linear descriptions of the use of hypnotic dreams illustrate that
it can be both an illuminating projective device for discovering conflicts
and a helpful mode for working through these conflicts. How much the
hypnotic dream resembles a more common therapy tool—the nocturnal
dream—is a more difficult question.
An early review of the hypnotic dream literature (Tart, 1965) observed,
at that time, that there was a lack of research concerning the equivalence
or differences of hypnotic dreams from nocturnal dreams. Tart’s review
covered 34 publications in the area, only 10 of which he characterized as
recognizing a need for some comparison of hypnotic dreams to nocturnal
dreams. Of 14 studies drawing conclusions about this issue based on either
anecdotal observation or theoretical assumptions, 10 asserted that hypnotic
and nocturnal dreams are the same and 4 indicated differences.
It is quite clear that hypnosis is physiologically a waking state of con-
sciousness rather than true sleep, although S. Kratochvil and H. MacDonald
(1969) did find that posthypnotic suggestions could be carried out during
sleep, suggesting that hypnosis can be superimposed with physiological sleep
if explicit suggestions are given for this. Chapter 4 of this volume reviews
neurological correlates of hypnosis in detail. However, there are several
physiological findings specific to the hypnotic dream rather than character-
istic of hypnosis in general. Two studies (Schiff, Bunney, & Freedman,
1961; Barrett, 1979) have reported that in highly hypnotizable subjects,
hypnotic dreams are accompanied by movements that look indistinguishable
from the Rapid Eye Movements (REMs) that accompany dreams during
sleep. This raises the question of whether hypnotic dreams share any physi-
ology with REM sleep. There is one physiological study comparing hyp-
notic dreams with other periods of hypnosis. De Pascalis (1993) reported
Fast-Fourier spectral analyses of EEG readings from frontal, middle, and
posterior electrodes placed on each side of subjects’ scalps during hypnotic
dream suggestions and during a resting trance state. With posterior scalp
Hypnotic Dreams 101
recordings, during hypnotic dreams, high hypnotizables displayed, as com-

pared with the rest-hypnosis condition, a decrease in alpha 1 and alpha
2 amplitudes. This effect was absent for low hypnotizables. High hypnotiz-
ables during the hypnotic dream also displayed in the right hemisphere a
greater 40-Hz EEG amplitude as compared with the left hemisphere; this
effect was also absent in low susceptibles.
The majority of clinical writings on the use of hypnotic dreams are
much more concerned with the degree of similarity of content and the psy-
chological significance of hypnotic and nocturnal dreams than with their
physiological correlates. Sacerdote (1968), the leading proponent of the
use of the hypnotic dream stated: I have accepted on the basis of my expe-
rience that dreams hypnotically or post-hypnotically induced are psychody-
namically equivalent and at times physiologically identical to natural
dreams and therefore therapeutically valuable (p. 168).
Most of the clinicians dealing with this issue tended to agree on this
equivalence; some state the assumption perfunctorily while others made
elaborate arguments. Several theorists saw the equivalence as logically fol-
lowing from their theoretical concept of hypnosis. Fromm (1965) described
their equivalence as resulting from both being primary process thought
productions; she began her article “Dreams are ‘the Royal Road to the
Unconscious.’ Freud was referring to ordinary nocturnal dreams but the
same is true for the fantasies and dreams produced by hypnosis” (p 119).
Gill and Brenman (1959), while not arguing for an exact equivalence
between hypnotic and nocturnal dreams, stated that since both hypnosis
and dreaming are regressive states, this would facilitate switching easily
from one to the other. They believed a person would be able to state uncon-
scious conflicts more sharply via hypnotic dreams than in a waking state.
Schneck (1959) detailed his observations on the points of similarity
between hypnotic and nocturnal dreams, stressing that all the same pri-
mary process mechanisms are employed:
Hypnotic dreams may bear such close structural resemblance to noc-

turnal dreams as to be essentially indistinguishable from them. They
may be simple or complex in concordance with the manner in which
the patient tends to express himself in this fashion and in keeping of-
ten with the form and content of his spontaneous nocturnal dreams.
The variety of dream mechanisms employed in the latter are evident
in the former and the analysis of hypnotic dreams are often therapeu-
tically beneficial. . . . Symbolizations, condensations, displacements
and substitutions, representations by the opposite and a broader array
of mechanisms are readily discernible. (pp. 156–157)
In another article, Schneck (1966) discussed the frequent arguement

that hypnotic dreams are short, simple, and non-symbolic compared to
the stereotype of intricate nocturnal dreamwork. He pointed out that in
actuality, real nocturnal dreams also show this wide range of complexity.
Schneck (1974) gave examples of the same individual’s hypnotic night-
mares (which occurred merely at the request for a dream under hypnosis)
together with his nocturnal nightmares. Schneck concluded that both were
structurally and dynamically equivalent, and that both dealt primarily with
oedipal conflicts the patient was working through in an analysis with the
author at that time. Both types of nightmares seemed to yield an equal
number of associations and interpretations by the patient.
In two other studies, Schneck compared hypnotic dreams and nocturnal
dreams with yet another category, the self-hypnotic dream, in which the
subject would put himself into autohypnosis and suggest to himself that he
would dream. Schneck found all three types of dreams were indistinguish-
able with respect to degree of activity, extent of embellishment, and na-
ture of symbolizations. Furthermore, he found that all categories include
sudden changes in locus, cast of actors, and types of action (Schneck,
1953). In another article, however, Schneck (1954) did allude to a differ-
ence he observed between hypnotic and self-hypnotic versus nocturnal
dreams. He reported that in contrast to the nocturnal dreams, the two
types of hypnotic dreams for one specific patient typically included lengthy
conversational situations during which the patient spoke for herself or pro-
jected onto other various characters’ different points of view about imme-
diate problems.
Sweetland and Quay (1952) found that initial attempts at hypnotic
dreams sometimes differed from nocturnal dreams but that after some prac-
tice, all subjects were able to produce dreams that they, the subjects, could
not distinguish in any way from their night dreams. Mazer (1951) experi-
mented with 26 subjects, giving them suggestions to dream while in hyp-
nosis that specified that the dream would be “symbolic, with a disguised
meaning.” He concluded that while all hypnotic dreams were not exact
duplications of nocturnal dreams, differences were minimal.
Mazer gave examples not only of the hypnotic dream but also of exten-
sive associations and interpretations by the patients. He also reported a
relationship between depth of the hypnotic trance and dream quality, find-
ing that the more deep hypnotized the subject, the more symbolic and the
more exactly like night dream was the hypnotic dream.
Domhoff (1964) reviewed studies near the same time as Tart (1964)
pointed out that all empirical studies up to that time had looked only at
hypnotic dreams, making unsupported assumptions about nocturnal
dream content. He argued that not all nighttime dream content fit the
stereotype. Domhoff suggested that hypnotic dreams likely differ no more
from that stereotype than a representative group of nocturnal dreams
from the same subjects might, and that the two categories could be
equivalent.
Hypnotic Dreams 103
Shortly after that, Moss (1967) conducted a survey that shows a nar-
row majority of diplomates in Clinical and Experimental Hypnosis (cre-
ated by the American Board of Examiners in Psychology) equated
hypnotic and nocturnal dreams. He received 46 replies from 52 diplo-
mates canvassed in response to the question of whether they viewed hyp-
notic dreams as “similar in essential respects to nocturnal dream.” The
disagreement and uncertainty of these experts on the question is illus-
trated in the following distribution of his answers despite the majority
agreement:
Some authors did propose specific differences between hypnotic and
nocturnal dreams on theoretical grounds. Kanzer (1953), on a theoretical
basis, argued that the setting of the hypnotic dream is bound to make it
different from a spontaneous night dream. He stated: “On such induced
dreams, the voice of the hypnotist takes the place of the day’s residues, his
ideas shape the latent thoughts, his comments give rise to the dream wish”
(p. 231). Kanzer observed that dreams induced under hypnosis showed
greater censorship than did spontaneous dreams. He also found that the
form and imagery of the hypnotic dream were more typical of preconscious
than unconscious mental activity.
Brenman (1949) also assumed that the context of hypnosis must have a
significant effect on the dream. She stated: “In spite of the many similar-
ities to night dreams in the formal structure of the hypnotic dreams, it
must not be forgotten that while the primary function of the night dream
is to guard sleep, the motive power for the hypnotic dream derives from
the need to comply, in so far as possible, with the expressed wishes of the
hypnotist; thus to guard an interpersonal relationship” (p. 458).
She belittled the assumption that hypnotic instructions to dream will
result in a “real” dream, saying this employed the same logic as assuming
that a hypnotic instruction to fly will result in real flight. She examined
responses to the suggestion “You will now have a dream” and observed: “By
and large, these productions employ ‘primary processes’ more than does nor-
mal conscious, waking thought but less than does the ‘typical’ night dream
described by Freud. It might be said that often the hypnotic dream is a kind
of second-rate poetry compared to this tight, complex outcome of the
dreamwork. Thus, although a wide range of phenomena appears, it may be
said, for the point of view of the formal qualities, that the average hypnotic
dream takes a position which is intermediate between the conscious waking
day-dream and the night dream” (p. 457).
Barber (1962) and Walker (1974) took a more extreme position—that
the hypnotic dream is exactly the equivalent of a conscious waking day-
dream. Barber asserted: the “hypnotic dream: is typically an unembellished
imaginative product containing very little evidence of ‘dreamwork.’ In
some instances it consists of straightforward previous happenings or of
former night dreams; in the majority of instances, it consists of banal

verbal or marginal associations to the suggested dream topic” (p. 218).
While Baber admitted he had occasionally seen hypnotic dream accounts
that appeared to resemble nocturnal dreams, he offered the following three
explanations for this resemblance:
1. They came from sophisticated subjects having great familiarity with Freud-
ian dream theory who were likely to apply this to conscious productions.
2. Hypnotic dreams published in the literature were a few atypical ones
selected from a large sample of failures.
3. The experimenters either implicitly, or explicitly, have given the ex-
pectation that they want their subjects to come up with elaborate
symbolization.
Barber concluded by saying: “even with dreams suggested to deeply hyp-

notized subjects, it is difficult if not impossible to differentiate these
from the imaginative productions of non-hypnotized controls who are
instructed to imagine scenes vividly or to make up dreamlike material”
(p. 219).
Walker (1974) wrote: “A more useful way of conceptualizing the hyp-
notic dream may be to see it as qualitatively no different from the response
a person gives when simply asked to have a fantasy. . . . It is time that the
knowledge about the hypnotic dream be integrated into the broader area
of fantasy.” Walker did not believe the hypnotic dream can be appropri-
ately used in therapy in the manner a night dream would be interpreted.
Instead, she suggests it be employed more in the manner of Desoille’s
(1965) “Directed Daydreaming,” that is, as a kind of guided fantasy with sys-
tematic relaxation.
Tart (1964) found a difference in how easily nocturnal and hypnotic
dreams could be influenced by topic. He had good hypnotic subjects listen
to a tape-recorded narrative and told them to dream about it upon falling
asleep that night and to have a dream about it immediately under hypno-
sis. Hypnotic dreams were found to conform much more closely to the nar-
rative, although sleep dreams were also influenced.
Several researchers enumerated different types of “hypnotic dreams” of
which only one type resembled the night dream. Tart (1966) and Gill and
Brenman (1959) both suggested four such divisions. Tart categorized responses
to suggestions as: (1) simply thinking about something, (2) daydreaming, (3)
vivid hallucinations like watching a film, and (4) feeling “bodily located in a
dream world.”
He gave dream suggestions to both waking subjects and to those who
had been through a hypnotic induction routine and then had them rate
their own dreams as falling into one of these categories. A minority of
Hypnotic Dreams 105
subjects rated their experiences as feeling bodily located in a dream world

even with hypnotic induction.
There was also a positive correlation of dream vividness to depth of
hypnosis as measured by response to other hypnotic suggestions. However,
there was no correlation between dream vividness and having gone through
the induction routine. Tart criticized other studies on hypnotic dreams for
defining hypnosis as having gone through hypnotic induction procedures; he
believed it was more rightfully judged by the subject’s state of consciousness.
Gil and Brenman (1959) distinguished four different types of produc-
tions issuing from the hypnotic instruction to dream. They were:
1. The embellished reminiscence.

2. The static pictorial image.
3. The quasi-allegory (which they described as resembling a conscious
daydream but including in a rather obvious and primitive fashion some
elements of unconscious symbolism).
4. The quasi-dream (which they said taken out of context is often indis-
tinguishable from a night dream).
They found that analyzing all categories of productions was helpful in

therapy, but did not conclude that even the fourth category is the exact
psychodynamic equivalent of a night dream.
Spanos and Ham (1975) studied the characteristics of hypnotic dreams,
working largely from a Barber-style theoretical orientation. They used
49 female student nurses at Medfield State Hospital (where Barber taught)
as their subjects. All subjects were administered the Barber Suggestibility
Scale (Barber, 1969) in a group setting. Their hypnotic dream reports, one
per subject, were transcriptions of their verbal responses in an individual
hypnotic session.
Following the “dream” session, all subjects rated the extent to which they
(1) became involved in their imaginings, and (2) experienced their imagin-
ings as an involuntary process. Furthermore, two judges independently rated
the transcribed “dream” protocol of each subject for imaginative involve-
ment. Judges also rated the “dream” protocols of 30 subjects for implausibil-
ity, fearfulness, and fragmentation. (The remaining 19 subjects had reported
that nothing happened in response to the suggestion to “dream.”) Subjects’
self-ratings of “dream” protocols for involvement correlated highly with one
another. Both involvement measures also correlated with self-ratings of
involuntariness of imaginings and with Barber Suggestibility Scale scores.
The main emphasis, however, was upon how little dreamlike quality
was involved in the hypnotic dream reports. Nineteen subjects experi-
enced nothing, and of the remaining 30, the authors noted that: “for the
overwhelming majority of these subjects a ‘hypnotic dream’ consisted of a
plausible, non-fragmented, non-fearful, imaginary story” (Spanos and Ham,

1975, p. 47). The authors did mention that a few subjects reported
“imaginings” that were implausible, fearful, and/or fragmented—another
experimenter might have said more like nocturnal dreams, although they
did not put it in those terms.
Spanos and Ham concluded by stressing a significant point: the often
overlooked vast individual differences in response to the same instruction
to “dream.” They also concluded that hypnotic dreams were much like
waking thought processes, without taking into account the brevity of the
induction and instruction procedures or the biases of the people involved.
The experimenters, and quite possibly the nurse-subjects, were already firm
believers in Barber’s idea that hypnotic phenomena should not viewed as
something different from waking consciousness—the opposite bias of most
researchers in other studies.
The one study that did in some way compare hypnotic and night
dreams empirically was one by Hilgard and Nowlis (1972), however, they
used different groups of subjects for the two categories of report. They col-
lected hypnotic dreams in the course of administering the Stanford Hyp-
notic Susceptibility Scale, Form C (Weitzenhoffer and Hilgard, 1962).
One step on this scale is an instruction to have a dream about the mean-
ing of hypnosis specifically. Once the dreams were collected, Hilgard and
Nowlis had subjects rate their own dreams on a three-point scale of vivid-
ness, counted the number of words in the dream accounts, and using Hall
and Van de Castle’s (1966) system, scored the number and categories of
human characters in the dreams. They found 63 percent of their subjects
rated their dreams as vivid as night dreams, 33 percent rated them like
watching a movie, and 4 percent rated them like thinking or daydreaming.
In order to compare these results to night dreams, Hilgard and Nowlis used
the data of Hall and Van de Castle (1966) who had collected nocturnal
dreams from a variety of subjects, including university undergraduates and
prisoners. They were not well matched with Hilgard and Nowlis’s subjects
on age, geographic region, hypnotic susceptibility (on this potentially cru-
cial variable, Hilgard and Nowlis’s subjects were selected to score higher
than the general population), or most other variables. The specification of
the dream topic of the hypnotic dream only also negatively affected com-
parability. Hilgard and Nowlis acknowledged this as a rather unsatisfactory
procedure, but characterized it as a pilot study that might indicate any
gross differences among hypnotic and nocturnal dreams.
Hilgard and Nowlis did report several marked differences. Their hyp-
notic dreams were much shorter—a range of 13 to 238 words as compared
to 50–300 for nocturnal dreams (though they failed to note that Hall and
Van de Castle had tossed out dream reports under 50 words as too short to
meaningfully score). The hypnotic dreams averaged 1.3 characters instead
of the 2.6 Hall and Van de Castle reported for nocturnal, and the hypnotic
Hypnotic Dreams 107
dreams had fewer relatives as characters. The hypnotic dreams were also char-
acterized by the authors as having more “Alice-in-Wonderland, psychedelic-
type distortions.” They did feel they were quite similar to nocturnal dreams
in many ways and concluded that they are best considered as projective
products falling somewhere between the Thematic Apperception Test
(TAT) stories and night dreams.
A comparative study by Mixer (1961) reported no differences on
“reality orientation” of deep trance subjects’ hypnotic dreams versus night
dreams. In his study, experienced clinicians independently rated the degree
of reality orientation expressed in each dream as “impossible,” “improbable,”
or “probable.” Mixer interpreted the lack of significant differences in the
two sets of data as indicating that “there is not difference in the degree of
realism shown in hypnotic and nocturnal dreams of the same subjects, when
their hypnotic dreams occur in a deep trance under conditions which dupli-
cate night dreaming as closely as possible.” Mixer did not use a medium
trance group or draw any conclusions about whether hypnotic and nocturnal
dreams would show the same reality orientation for them.
CONTENT OF HYPNOTIC, NOCTURNAL, AND

DAY DREAMS FROM THE SAME SUBJECTS
This author undertook a study to explore how the content of hypnotic
dreams, nocturnal dreams, and daydreams from the same subjects re-
sembled or differed from one another and what depth of trance might play
in this (Barrett, 1979). Sixteen university undergraduates, equally divided
by both gender and capacity to achieve a medium versus deep trance by
Davis and Husband (1931) criteria, were selected. No light trance group
was included, as Hilgard (1965) has determined that a successful response
to a suggestion to have a hypnotic dream falls near the beginning of the
medium trance ranking. Subjects’ ages ranged from 18 to 26 years.
During a six-week period, subjects were asked to write down the first
three nocturnal dreams they remembered each week and their first three
fantasies of daydreams in as much detail as they remembered. Once a
week, the subjects were hypnotized and instructed three times during the
session to have a hypnotic dream. After theses sessions, they were asked to
write down everything they remembered of the hypnotic dreams. A few
subjects failed to remember some of their dreams, so the total collected
was 285 hypnotic dreams, 285 daydreams, and 277 nocturnal dreams.
All types of dream accounts were rated on scales from the Hall and Van
de Castle rating system developed for nocturnal dreams. These included a
three-point scale for setting—predominantly indoor, approximately equal,
more of dream outdoors—and two-point scales for presence of certain
types of characters—males, females, family, acquaintances, and strangers.
Characters were recorded only for categories on which they were scorable.
For instance, “someone” appeared only in the total, not by gender and
acquaintanceship categories. “A relative” would appear in the family cate-
gory but not in the gender categories.
Other Hall and Van de Castle categories scored were two-point scales
for hostility and friendliness on the part of other characters, and themes of
anger, fright, sadness, happiness, or sexuality on the part of the dreamer.
Reports could be scored as having none, any, or all of these characteristics
present. For example, the following hypnotic dream report was rated by
both raters as containing anger, fright, and sadness on the part of the sub-
ject: “I was in a boat alone on the lake. I was mad about something and
was trying to drive away from it. I drove the boat until I saw an old man
on the shore. I stopped and we went into his cottage and ate. We laughed
until I was no longer mad. When I left it was dark. I couldn’t see my way
home so I stopped the boat. I looked straight up. The boat began to spin
one way and I spun the other way. What little light there was closed in to
a tiny circle and shot over to the left and disappeared” (Barrett, 1979a).
Other variables in addition to the Hall and Van de Castle system were
used. Since the distinction of logic versus primary process thinking was
often written about in the hypnotic dream literature, all categories of accounts
were rated on a three-point scale of “distortion and illogical sequence” ver-
sus “coherence of story line.” The following hypnotic dream was rated at
the distortion end of the scale by both raters:
I am standing on a beach or an island in the South Pacific. I turn

around and notice that a group of people are chasing me. They chase
me all over the island until I am trapped at the edge of a cliff which
faces the ocean. I know that if I jump I will not be killed but still
there is some fear of dying. Finally I jump off the cliff and into the
water. Upon hitting the water I slowly float to the bottom of the
ocean. When I get to the bottom I see a big orange fish which asks
me what I am doing there. I tell the fish that I have come to learn.
The fish then tells me that I am not ready and that I should go back.
I then begin to float back up to the surface. [The dream ends.]
The following hypnotic dream was rated by both raters at the straight
story line end:
I was somewhere with my girlfriend and we were talking about her

going away to that school. I was mentioning that I didn’t want her
to go away to that school. But I told her that I understood that she
had to go where she’d be happy. And she turned all emotional and
started crying and told me she was glad I was so understanding. And then
she kissed me on the cheek and left to go inside. (My girlfriend was, in
fact, up looking at this school the weekend I had the dream.)
Hypnotic Dreams 109
Dream reports were rated on a three-point scale of activity versus pas-

sivity on the part of the dreamer. Passivity sometimes involved the
dreamer being present in the dream but inactive, as in the following hyp-
notic dream scored “passive” by both raters: “I’m at a striptease show. The
main ‘attraction’ comes out, and my friends and I cheer. She comes out
dancing and wiggling about. Suddenly she pulled out a gun and began
shooting people in the audience, yelling about ‘male pigs’ and getting
revenge. We are all in a daze under chairs, but then she lays down her gun
and finishes the dance.”
Also rated as passive were dreams with the subject absent such at this
nocturnal dream: “There were some horses running in a field. They were
being led by a white stallion. This Stallion was very big and powerful. He
kept running faster and faster. Until he began to fly. Then all of them were
flying. They flew to the north till I couldn’t see them.”
As an example of a dream rated as very active by both raters was the fol-
lowing nighttime dream: “I’m lying in my bed—and hear sudden screams
outside on the dimly little street. Being on the second floor, I jumped up
and looked out and saw a woman being raped by a gorilla. Thinking I was
awake, I ran outside and threw a paper cup at him and he fell over dead.
I then jumped back up into my window and went back to bed.”
The presence or absence of two other characteristics, unembellished
memory and realistic planning, were rated on a two-point scale. An exam-
ple of a report scored as unembellished memory by both raters was this
hypnotic dream: “Images from a more recent event, spring break. Flying
with my uncle in his Cessna Cardinal, four-seater aircraft. Vivid image of
him, some feel of the place, interesting, exciting. Could look out the win-
dow and see the ground below clearly. Farms, wooden, white farm houses,
roads, woods, ponds, fields, fences.”
An example of a daydream report scored as realistic planning by both
raters was: “The thought of getting a new stereo system has loomed across
my mind quite often. Since I had never owned one, I was excited about
getting one. It would be a Marantz or Pioneer cassette player-receiver.
I seldom think of any other kind.”
These ratings were done by two raters who did not know what type of
dream a given report was. One rater did all 847 dream reports; the second
rated one-third of the dream reports, equally distributed over subjects, style
of dream, and week of experiment. Rater reliability was calculated for these
285 reports. High reliability was obtained, with rater agreement ranging
from 92 to 100 percent for the different characteristics. The first rater’s
scores were then used for the statistical analyses. In addition, length in
words was counted for all types of accounts by rater 1.
In two pre-experimental sessions, consistency of trance depth and rater
agreement on visual observation of REM were checked. Subjects were
found to be consistent in depth of trance reached, and raters agreed
100 percent on whether rapid eye movements were present for these 96
hypnotic dream periods (16 subjects 2 sessions 3 dreams). During the
experimental period, the presence or absence of REM accompaniment dur-
ing hypnotic dreams was noted by the experimenter only.
The ratings of each type of dream were averaged for every subject.
Wilcoxon matched pairs signed ranks tests were done for all characteristics
between the three types of dreams. In accordance with standard procedures
for less than 25 pairs, Wilcoxon T scores were converted to Z scores for
purposes of assessing statistical significance levels.
Table 3.1 presents mean ratings on each variable for the total group of
subjects. Tables 3.2 and 3.3 report the mean ratings for deep and medium
trance subjects, respectively. The categories of characters found in night
dreams and hypnotic dreams were quite similar, and both differed from the
characters found in daydreams. Table 3.4 presents Wilcoxon scores trans-
formed to Z scores for these differences, which shows them to be significant.
The greatest difference was that there were many more family members found
in hypnotic and nocturnal dreams. There were also more strangers in them
than in daydreams. There was a tendency for daydreams to average more
acquaintances and fewer total characters, but neither of these trends achieved
high statistical significance. In terms of the total number of dreams that
had any characters, the only significant difference was that daydreams were
slightly more likely to be totally without characters than were night dreams.
Emotional themes were similar between nocturnal and hypnotic dreams
and different for daydreams (see Table 3.5). In the medium trance group,
there were some differences between nocturnal and hypnotic dreams too.
Hypnotic and nocturnal dreams got significantly higher ratings on anger,
fright, and sadness—whereas daydreams were higher on happiness. Night
dreams received somewhat higher ratings on fright and sadness than did
hypnotic dreams. However, this trend on the total scores reflected only the
medium trance subjects; the deep trance subjects’ fear and sadness scores
did not differ significantly between hypnotic and night dreams. There were
no significant differences for the sexuality theme; it occurred about equally
in hypnotic, night, and daydreams.
Attitudes of other characters showed similar trends to the subjects’ emo-
tions (see Table 3.6). Hostility of other characters was more common in
nocturnal and hypnotic dreams than in daydreams. For medium trance
subjects only, hostility was more common in nocturnal than in hypnotic
dreams. Friendliness of other characters showed no significant differences
among types of dreams.
The only significant difference in settings of dreams was that hypnotic
dreams were more likely to be set outdoors than were nocturnal dreams.
Distortion was much more common in hypnotic and nocturnal dreams
than in daydreams (see Table 3.7). Action ratings were significantly higher
for hypnotic and nocturnal dreams than for daydreams. For medium trance
Hypnotic Dreams 111
TABLE 3.1 Means of Variable Ratings for Total Subjects
Dream Type
Variable Hypnotic Day Night
Female family .16 .04 .21
Male family .22 .03 .13
Female acquaintances .44 .43 .30
Male acquaintances .54 .46 42
Female strangers .39 .34 .50
Male strangers .30 .23 .51
Distortion 1.49 1.07 1.48
Anger .14 .04 .17
Fright .24 .04 .38
Sadness .10 .09 .23
Happiness .41 .68 .26
Sexuality .04 .12 .11
Hostility .30 .13 .40
Friendliness .36 .43 .30
Setting (1 ¼ indoors, 3 ¼ outdoors) 2.22 2.01 1.85
Any people present? .69 .56 .78
Length in words 78.05 62.60 98.72
Unembellished memory .21 .35 .12
Planning .24 .49 .11
Activity ¼ 1, Passivity ¼ 3 1.72 1.51 2.20
subjects only, nocturnal dreams had a higher action rating than did hypnotic
dreams. Planning and memory were both more common in daydreams than
in nocturnal or hypnotic dreams. For the medium trance subjects only, they
were both more common in hypnotic than in nocturnal dreams. Length in
words for the total group was greater for hypnotic and nocturnal dream
reports than for daydreams and greater for nocturnal than hypnotic dreams.
There were not significant differences by gender in any of these trends.
REM was completely consistent for a given subject: it was observed as
either 0 percent or 100 percent of their hypnotic dreams. All eight deep
trance subjects and one medium trance subject exhibited REM accompani-
ment to dreams. The other seven medium trance subjects did not.
Thus, the clearest finding was the relation between depth of trance and
the characteristics of hypnotic dreams. It is certainly possible that some
characteristic not included in this study would show some differences
between deep trance subjects’ hypnotic and nocturnal dreams. However, it
is clear the two categories have very much in common for this population.
In psychotherapy, symbolic interpretation of deep subject’s hypnotic dreams
just as one would use on nighttime dreams is appropriate. Hypnotic dreams
have the obvious advantages of ability to direct the topic of the dream and
recall in patients who seldom remember nocturnal dreams. For medium trance
TABLE 3.2 Means of Variable Ratings for Deep Trance Subjects
Dream Type
Male acquaintances .45 .58 .36
Anger .14 .01 .21
Fright .32 .07 .36
Sadness .11 .04 .27
Length in words 77.64 58.82 83.88
subjects, the content differences between hypnotic and nocturnal dreams

found in this study were great enough to indicate that hypnotic dreams cannot
be used interchangeably in techniques designed for nocturnal dreams.
The distortion versus straight story line continuum in the present study
bears a rough similarity to the psychoanalytic distinction between uncon-
scious, primary process material versus conscious, secondary process thought.
On the basis of the distortion scores, the medium trance hypnotic dreams
can be viewed as having less primary process content than either nocturnal
dreams or deep trance hypnotic dreams. The lower scores on negative themes
of fright, sadness, and anger also support a conceptualization of the me-
dium trance dreams as more closely aligned with normal waking conscious-
ness than one’s nocturnal dreams, although not as much as daydreams.
These medium trance hypnotic dreams should not be used with the pre-
sumption that they are yielding predominantly unconscious material.
This awareness that hypnotic dreams are not really night dreams is
implicit in many clinical hypnotic dream articles, though alternate sugges-
tions, such as Walker’s (1974) that hypnotic dreams be used more like
guided fantasies are not completely appropriate either, as even the medium
trance dreams still differ significantly in context from daydreams. The
approach most indicated by the present study’s findings on medium trance
Hypnotic Dreams 113
TABLE 3.3 Means of Variable Ratings for Medium Trance Subjects
Dream Type
Male acquaintances .63 .34 .49
Anger .13 .08 .13
Fright .17 .02 .36
Sadness .10 .14 .19
Length in words 78.46 66.36 113.55
subjects would be to use their hypnotic dreams in a therapeutic medium

designed specifically for them. In fact, this is what many clinicians seem to
do. Approaches from Sacerdote’s 1967a book onward advocate gaining
insight from the projective qualities of hypnotic dreams in a manner that
is not predicated on the basis of their being exactly like nocturnal dreams.
This makes much use of the unique potential to request that the hypnotic
dream be on a specific topic—which is possible with much more reliability
than when using pre-sleep suggestions to influence nocturnal dreams.
These techniques also use suggested repetitions and elaborations of hyp-
notic dreams that would not be possible with nighttime dreams. For me-
dium trance subjects who do show major differences between night dream
content and that in hypnotic trance, this type of technique would seem
most useful. The one finding of my study that is inconsistent with the Hilgard
and Nowlis (1972) study is in terms of comparing amounts of “distortion”
between hypnotic and nocturnal dreams. I used a scale of distortion in
terms of a break in logical sequence similar to the characteristics discussed
as primary process. Hilgard and Nowlis had an “Alice-in-Wonderland, psy-
chedelic distortion” scale that consisted largely of things changing size
unexpectedly. I had assumed they would overlap, but on closer thought,
this is not much like any characteristics of real nighttime dreams. It is
TABLE 3.4 Z Scores Between Average Frequencies of Types of Characters in

Dream Reports
Total Deep trance Medium trance

Type of character Subjects Subjects Subjects
Total
Hypnotic with day 1.86 .70 .98
Day with night 1.14 .28 1.12
Hypnotic with night .05 .84 1.18
Family
Hypnotic with day 3.18** 2.37* 2.20*
Day with night 2.82** 1.57 2.20*
Hypnotic with night .71 1.15 .41
Acquaintances
Hypnotic with day .11 1.26 2.03*
Day with night .62 1.26 1.26
Hypnotic with night 1.66 1.36 .84
Strangers
Hypnotic with day 2.02* 1.40 1.40
Day with night 2.43* 12.24* 1.40
Males
Hypnotic with day 1.81 .70 1.54
Day with night 1.29 .42 1.54
Hypnotic with night .21 .28 .56
Females
Hypnotic with day 1.19 .14 1.12
Day with night 1.34 .70 .98
Hypnotic with night .21 .70 1.12
Any characters present
Hypnotic with day 1.62 1.44 1.54
Day with night 2.35* 1.40 2.03*
* p<.05, two-tailed. ** p<.005, two-tailed.
more characteristic of films and hallucinogenic drug experiences. So it

makes sense that there is more from the otherwise-less-like-nocturnal-dreams
medium trance subject’s hypnotic dreams. Since the deep trance dreams were
so similar in all measured content to nocturnal dreams—including amount of
irrational distortion and unpleasant affect intruding—it might seem reasona-
ble to utilize more of the techniques developed for nocturnal dream while
remaining aware that physiologically they’re not from the same state.
A final note of interest in the content of the three categories of dream
reports is that the group averages do not give any sense of the range of
content; standard deviations offer a rough outline, but individual reports
make clearer. As already discussed in this chapters, not all nighttime
dreams fit the stereotype of distortion and primary process. But this was
true for differences in daydreams. A few examples were extremely full of
Hypnotic Dreams 115
TABLE 3.5 Z Scores Between Average Frequencies of Types of Emotional

Themes in Dream Reports

Emotional theme Subjects Subjects Subjects
Anger
Hypnotic with day 3.06 2.52* 1.83
Day with night 2.54 2.37* 1.18
Fright
Day with night 3.41** 2.37* 2.52*
Hypnotic with night 3.08** .67 2.37*
Sadness
Hypnotic with day .97 1.05 .25
Day with night 2.61* 2.52* 1.18
Hypnotic with night 3.08** 2.11* 2.37*
Happiness
Hypnotic with day 2.02* 2.52* 1.12
Day with night 2.43* 2.52* 2.52*
Hypnotic with night 1.58 .61 1.86
Sexuality
Hypnotic with day .92 1.28 1.78
Day with night .51 1.46 .84
Hypnotic with night 1.84 .91 1.48
primary process—or other rare categories like fear and sadness. These dif-
ferences are best illustrated with examples of the atypical dreams, so first,
this is a nocturnal dream from one deep trance subject:
Our fraternity was having a basketball game at Alumni Gym, and I was
in the team. I was sitting on the end of the bench, and when one of
our players was hurt, Steve decided to put me in. It took me awhile to
get going, but finally I began moving pretty good. I wanted to score
badly, so when I got the ball I shot and made it. The next time down
court, I put a great move on my man and scored easily. Then when the
opponent came down the court, and I dived after the ball, someone else
dived after it too. He landed on my legs. His legs and mine became
intertwined and he twisted my ankle. I had to be carried off the court.
In contrast to this narrative, which could pretty much describe a waking

basketball game, the following daydream was reported by another deep
trance subject—the first two sentences identifying type of account were
stripped off for the raters but are printed here for relevance:
This daydream occurred in Special Ed. Class. I wasn’t actually asleep,

but I was definitely in another world. I dreamed that I was in my
TABLE 3.6 Z Scores for Attitudes of Other Characters and Settings

of Dream Reports

Variable Subjects Subjects Subjects
Hostile Characters
Day with night 3.35** 2.37* 2.38*
Hypnotic with night 1.36 .00 2.24*
Friendly Characters
Hypnotic with day .83 .56 .70
Day with night 1.29 .91 .98
Hypnotic with night .67 1.79 .17
Setting
Hypnotic with day 1.29 1.12 .84
Day with night 1.29 .28 2.10*
Hypnotic with night 3.01** 1.52 2.52*
house, upstairs, getting ready to go somewhere. My sister came to get

me and bring me downstairs. I seemed to recognize the two visitors
waiting downstairs. All I can remember is their big floppy hats cov-
ered most of their faces and their flowing dresses. I think that I was
excited over their visit and I was about to go and greet them, but my
instructor spoke to me.
REMs during hypnotic dreams also had a clear relationship to dream

content. However, they corresponded so closely to whether the subject
was from the medium or deep trance group that presence or absence of
REM during hypnotic dreams was virtually synonymous with trance depth.
Therefore, it’s hardly a useful measure in research where experimenters are
already assessing formal hypnotic depth by established scales. However, it
may be very useful to observe REMs or lack thereof in clinical settings,
where formal trance depth is rarely assessed, as this may indicate how
deeply hypnotized the patient is and give a sense of how primary process
the dream content is.
OTHER UTILIZATION OF HYPNOSIS WITH DREAMING

There are two other major ways in which hypnosis has been employed
in combination with dreaming. The first—continuing or interpretation of
a nocturnal dream in the hypnotic state—is much like the hypnotic
dream. Hypnosis has been employed much like Jung’s technique of “active
imagination” to return to, continue, or elaborate on parts of a previous
nocturnal dream. Hypnosis, as compared to doing these exercises in a usual
Hypnotic Dreams 117
TABLE 3.7 Z Scores for Distortion, Action, Planning, Memory, and Length in
Words of Dream Reports

Variable Subjects Subjects Subjects
Distortion
Day with night 3.41** 2.36* 2.52*
Action
Hypnotic with day 1.98 2.38* .21
Day with night 3.52** 2.52 2.52*
Hypnotic with night 2.67** .11 2.52*
Planning
Day with night 3.30* 2.37* 2.37*
Hypnotic with night 1.73 .21* 2.20*
Memory
Hypnotic with day 2.56* 2.52* 1.18
Day with night 3.30** 2.52 2.20*
Hypnotic with night 2.17* .31 2.37*
Length in words
Hypnotic with day 2.33* 1.68 1.68
Day with night 3.52** 2.52* 2.52*
Hypnotic with night 2.53* 1.40 2.24*
waking state, may heighten the experiential vividness of such experiences.

With hypnosis, therapists sometimes give clients suggestions to reenter the
dream and replay parts of it that are vague or forgotten. Some assume this
is the actual nocturnal dream being recalled, but of course others suggest
that new material might as easily be substituted. However, most agree
that it provides interesting material for therapy whichever may be the
case. One can also take a dream that seemed to terminate prematurely and
suggest that it continue. This will result in an experience much like
the “hypnotic dream” except that it begins with a topic determined by the
dreaming mind the night before rather than by the waking ego of the
dreamer or hypnotherapist.
Hypnosis can also be employed for even more direct interpretation of
nocturnal dreams. Upon hypnotically “reentering” the dream scene, the
dreamer can ask characters, “Who are you?” “What do you represent?” and
“What are you trying to tell me?” They can look around a scene and ask:
“What is this place” or “What real-life setting does this resemble?” Often
quite unexpected yet crystal-clear answers come more directly than when
pondering these questions from the more usual conscious “left-brain”/sec-
ondary process mode.
An example drawn from a woman in a brief workshop that I conducted

illustrates some of these processes. Marge chose to work in this manner
with a brief nightmare about her husband who had died six months previ-
ously. In the dream, Marge was in her house doing minor domestic tasks
when the doorbell rang. She went to the door and opened it; there stood
her dead husband. At this point she awakened in terror. Marge suffered both
fright and intensification of grief for some time after this dream. Many
bereaved people dream of lost loved ones, but usually these dreams are any-
where from bittersweet to deeply comforting to the dreamer (Barrett, 1991).
The few frightening dreams about someone who has been much loved often
contain some obvious element of the deceased beckoning the dreamer to
join them in death. Marge’s nightmare did not seem to have this element,
and she did not immediately know what it was about the dream image or
her feelings about her husband that had made it so terrifying.
In trance, I directed Marge to reenter the dream and instead of waking
up at the crucial point, to ask the dream character who he was. Despite
the obvious identification as her husband (characters usually give a rich
array of answers that augment rather than replace the obvious identity),
Marge’s husband said, “I am joy.” She was then instructed to ask what he
had come to tell or show her and he said, “You can be joy, too.” I then
suggested she could interact with him or continue the dream in another
way until it felt concluded. She proceeded to dance with him and then,
bidding him goodbye, to go on dancing by herself before the dream ended.
Marge woke up smiling and began to relate a group of associations to
the dream content to do with having always thought of her husband as the
carefree, easy-going one in the marriage who knew how to enjoy himself
and brought joy into her life. She realized that, in addition to the immense
loss of him, she had been feeling that her own capacity to have fun had
gone with him. She felt that the dream’s image had given her the ability
to have fun for herself in the future.
The other way in which hypnosis has been utilized in working with
dreams is to use it to influence the content or recall of nocturnal dreams.
Research by Charles Tart (1964) has found that hypnotic suggestions can
influence future dream content. Hypnosis can be used to augment the same
type of dream incubation procedures that are used without trance to shape
dreaming toward solving a specific problem or for creative inspiration,
however, the probability of achieving the desired content on a given night
seems to be higher with hypnotic suggestion (Barrett, 1995). For example,
a painter in one of my hypnosis and dream workshops found that with self-
hypnotic suggestions to herself at bedtime, she could reliably produce
dreams of paintings that she then replicated awake—phenomena that had
occurred spontaneously but rarely for her previously.
Joe Dane (1985) demonstrated that hypnotic suggestions can increase
the frequency of laboratory-verified lucid dreams. Zadra (1996) applied this
Hypnotic Dreams 119
to inducing lucidity to alter the content of recurring nightmares or help

the dreamer wake from them.
I have found that it is easier to help someone alter recurring nightmare
content toward other forms of mastery via hypnosis than it is to induce lucid-
ity. With trauma patients who have nightmares that replay, at least partially,
real events, rehearsal of changes in the dream during hypnosis can be very
effective. In trance they practice a different ending to the dream in which
they thwart a violent attack, tell off an abuser, remind themselves “this is
not my fault” at some crucial moment, or say “this doesn’t have to happen
any more,” and wake up. This hypnotic visualization, combined with the sug-
gestion that at night the dream will happen much as it was “dreamed” in
hypnosis, is often effective in altering even long-standing nightmares.
Many people have also utilized hypnotic and self-hypnotic suggestions
for increased dream recall. Hypnotherapists often use this process with
patients who begin as low dream recallers, using hypnosis both for direct
verbal suggestions, such as, “You will find yourself remembering dreams
easily and clearly when you wake up in the morning,” and for imagery—
picturing oneself finishing a dream, waking up with it clearly in mind as
one reaches for a notebook, and watching oneself writing it down, and per-
haps sketching images from it also. My patients and students have also had
good results with learning self-hypnosis and using it for such suggestions to
themselves at bedtime.
CONCLUSIONS
Combining hypnosis and dreamwork—especially for the majority of
people who do not come by either lucid dreams or deepest trances easily—
may more completely realize the interaction of primary and secondary
process thought. I believe the potential therapeutic effect of this is not
that primary process/“right brain,” intuitive thinking is inherently wiser
(although I realize there are psychology theories, especially dream theories,
that do espouse exactly this idea). Rather, I believe that it is a function of
how completely this mode is usually ignored, whereas logical thinking is
employed ad nauseum in attempts to solve the problems of an individual’s
life. The primary process made need only become equally valuable in order
to contribute significantly to what the rational mode has not yet achieved.
And when they are working together, there is a feedback loop where the
intuitive images are then evaluated by the rational process.
There may also be limited specific ways in which primary-process im-
agery can be uniquely beneficial by itself and for which secondary process
has no equivalent: vivid emotionally connected imagery, as opposed to
other forms of suggestion or ways of thinking about problems, seems to
have special ability to instigate change, training waking behavior and even
the body’s physiological processes to follow what has just been imagined.
Hypnosis and dreams both supply this powerful rehearsal of alternative

ways of being. The combination of both yields the most flexibility for
directing this imagery in the direction of desired change.
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Chapter 4
The Merits of Applying Hypnosis

in the Treatment of Depression
Michael D. Yapko
OVERVIEW
Depression is a serious and already widespread problem warranting the sub-
stantial attention it receives from the mental health profession. Currently,
nearly 20 million Americans are known to be suffering with the disorder,
and the rate of depression in the United States is on the rise in every age
group (National Institute of Mental Health, 2002). Each depressed indi-
vidual directly affects many others (family, friends, co-workers), multiply-
ing the number of people touched by depression to many tens of millions.
Ultimately, we are all affected by depression, even if only indirectly, by
having to share in the hurtful consequences of the many negative behav-
iors (such as drug abuse, poor parenting, and diminished productivity) that
often have their origin in badly managed depression (Weissbourd, 1996).
The primary purposes of this chapter are twofold: First, to highlight
some of what we already know about the nature of major depression
(i.e., Major Depressive Disorder) and what seems to be effective in its
treatment, and second, to draw attention to ways clinical hypnosis can fur-
ther enhance aspects of the treatment process. This chapter considers the
merits of hypnosis as part of a greater psychotherapy regimen for major
depression only. It does not address either antidepressant medication issues
or other forms of depression (such as bipolar disorder, depressed phase).
When psychotherapy is clinically indicated, whether in combination with
antidepressant medications or as a sole intervention, hypnosis may sensibly
be employed as a means for helping facilitate the therapeutic goals. The
treatment literature makes it quite clear that treatment for depression is
best thought of as an active, skill-building process (Martell, Jacobson, &
Addis, 2001). Hypnosis can provide a strong foundation for motivating
people and empowering them with structured processes of experiential
learning (Yapko, 2001, 2003, 2006). Given the reach of depression into
our pockets, our personal relationships, our communities, and our very
lives, addressing this complex disorder in a variety of timely and effective
ways is an especially urgent challenge we as health care professionals face.
Hypnosis is not meant to be a “magical” means of suggesting that symp-
toms simply disappear. Rather, hypnosis is a means of absorbing people in
new ways of thinking about their subjective experience, thereby potentially
altering it in meaningful ways. Since the most common symptom of depres-
sion that people complain about is a sleep disturbance, after first describing
general aspects of depression as a problem and hypnosis as a solution, I will
focus specifically on the use of hypnosis in addressing insomnia associated
with depression.
SOME OF WHAT WE KNOW ABOUT MAJOR DEPRESSION

Depression has been and continues to be heavily researched. The amount
of data generated by clinicians and researchers thus far has been impressive
by any standard, and has led to some firm conclusions:
• Major depression has many contributing factors, not a single cause.

The three primary domains of the contributing factors are biological,
psychological, and social. Hence, the so-called “biopsychosocial model”
predominates (Cronkite & Moos, 1995; Thase & Glick, 1995).
• Depression has many underlying risk factors and a variety of comor-
bid conditions likely to be associated with it (Stevens, Merikangas,
& Merikangas, 1995). In fact, numerous medical (e.g., cancer, heart
disease) and psychological conditions (e.g., anxiety disorders, sub-
stance abuse disorders) are found to commonly coexist with depres-
sion, requiring sharp differential diagnosis and multifaceted treatment
planning (American Psychiatric Association, 2000).
• Depression can be successfully managed in the majority of sufferers with
medication and/or psychotherapy (Schulberg, Katon, Simon, & Rush,
1998). While no one antidepressant has definitively been shown to be
superior in rates of effectiveness to another, therapeutic efficacy studies
show some psychotherapies (specified later) outperform others in treat-
ing depression (Barlow, 2004).
• Medication has some treatment advantages, such as a generally faster rate
of symptom remission and greater effectiveness in treating the vegetative
symptoms, for example, sleep and appetite disturbances (DeBattista &
Schatzberg, 1995). Medication also has some disadvantages, including
uncertain dosing and effectiveness, potentially negative side effects, habit-
uation and “poop-out” (i.e., the drug may eventually stop working), and
higher initial rates of relapse (Altamura & Percudani, 1993; Dubovsky,
1997).
The Merits of Applying Hypnosis in the Treatment of Depression 125
• Psychotherapy also has some treatment advantages and disadvantages.

The therapies that enjoy the greatest empirical support are cognitive,
behavioral, and interpersonal approaches (Depression Guideline Panel,
1993). The advantages include therapy’s focus on skill building and
the associated reduced relapse rate, the value of the therapeutic rela-
tionship, the greater degree of personal empowerment, and the poten-
tial to not just perform a “mop up” of preexisting problems but to
instead teach the skills of prevention (Seligman, 1990; Yapko, 1999).
The disadvantages of psychotherapy include the greater reliance on
the level of clinician competence (i.e., experience and judgment), the
greater time lag between the initiation of treatment and the remission
of symptoms compared to medications, the lesser effect in reducing
vegetative symptoms, and the potential detrimental side effects of cli-
ent exposure to a clinician’s particular theoretical or philosophical
stance (Mondimore,1993; Thase & Howland, 1995).
• The extraordinary ongoing success of the Human Genome Project has
highlighted the complex relationship between genetics, environment,
and specific disorders. Genetic vulnerabilities or predispositions exist,
but they operate in association with environmental variables that may
increase or decrease their likelihood of expression (Siever, 1997). In the
specific case of (unipolar) major depression, the genetic contribution
has been shown to be significant, with environmental factors (both
social and psychological) appearing to also have significant influence in
its onset (Kaelber, Moul, & Farmer, 1995). (In contrast, the genetic
component of bipolar disorder has been shown to be a strong one;
Dubovsky, 1997.) The relationship between neurochemicals and experi-
ence is bidirectional, meaning environmental triggers influence neuro-
chemistry at least as much as neurochemistry influences experience
(Azar, 1997; Dubovsky, 1997; Siever, 1997). There is evidence to sug-
gest that psychotherapy may be a means for directly and/or indirectly
affecting neurotransmitter levels in the brain, perhaps in some a parallel
to the effects of medication (Schwartz & Begley, 2002).
Research has yielded many other insights about depression, of course,

but the previous statements reflect a high level of general consensus among
depression experts.
Some of What We Know about Treating Depression

with Psychotherapy
Depression isn’t just “suggested away” with hypnotic suggestions. Hypnosis
has to be employed realistically by aiming at and modifying appropriate tar-
gets in treatment. Thus, this section will discuss some of what seems to matter
most in clinical intervention.
A number of important insights about major depression and suggestions for

its treatment were articulated in the depression treatment guidelines devel-
oped by the United States Agency for Health Care Policy and Research
(AHCPR), now the Agency for Healthcare Quality and Research (AHQR;
Depression Guideline Panel, 1993): (1) Three psychotherapies were shown to
have the greatest amount of empirical support—cognitive, behavioral, and
interpersonal psychotherapies. These are identified as the psychotherapies of
choice, and any or all can be applied according to the client’s symptom profile
(not the clinician’s preferred orientation); (2) Psychotherapy should be an
active process in the way it is conducted, involving active exchanges between
clinician and client that would typically involve providing psychoeducation,
the development of skill-building strategies, the use of homework assign-
ments, and the use of the therapy relationship as both a foundation and a
vehicle for exploring relevant ideas and perspectives; (3) Therapy should not
only focus on problem solving, but the teaching of problem-solving skills,
especially as they relate to symptom resolution, the guidelines’ suggested focus
of treatment; (4) Effective therapy need not have an historical focus. Accord-
ing to the treatment guidelines, the most effective therapies are goal-oriented,
skill-building approaches. None of them focus on attaining extensive histori-
cal data to explain the origins of depression. Rather, they focus on developing
solutions to problems and coping skills for managing symptoms. Hypnosis is
especially amenable to each of these psychotherapeutic applications, since it,
too, is an active and directive means of intervention. The same indications
and contraindications as articulated in the treatment guidelines (Depression
Guideline Panel, 1993) prevail when applying hypnosis, particularly the rec-
ommendation that clinicians adapt their approach according to the patient’s
symptom profile rather than a specific theoretical allegiance.
In performing an extensive review of clinical and research literature in
order to prepare the depression treatment guidelines, the panel formed the
conclusion that trying to find a specific origin for an individual’s depression
was unnecessary in promoting recovery. This sharply distinguishes what
might be termed an event-driven perspective (the view that depression has
its origin in specific historical events that must be identified and “worked
through”) from what could be called a process-driven perspective (the
view that depression has its roots in ongoing ways of erroneously or nega-
tively interpreting or managing various life experiences). Recognizing that
depression arises for many reasons of a process-driven nature accentuates
the realization that by the time depression strikes most individuals, one or more
risk factors (such as perceptual style, cognitive style, and level of social and
problem-solving skills) had already been well in place (Seligman, 1989).
The research makes it abundantly clear that depression is much more
than a biologically based problem (Joiner, Coyne, & Blalock, 1999; Yapko,
2006). Thus, helping people recognize that depression arises, in part, because
of social and psychological factors can help them to avail themselves of the
benefits psychotherapy can provide. After all, no amount of medication (or

brain stimulation or brainwave reeducation) can provide people with better
problem-solving skills, coping skills, cognitive skills, relationship skills, or a
supportive network of friends. Of the various approaches to treating depression
that have been evaluated scientifically, there is unequivocal evidence that the
therapies that actively encourage people to develop specific life-enhancing
skills perform better than other therapies that do not (Martell et al., 2001).
As our understandings of both hypnosis and depression have deepened in
recent years, the antiquated concerns that hypnosis would hurt rather than
help the depressed client have markedly diminished. We have learned, for
example, that suicidality isn’t about “inadequate ego defenses,” and that
depression isn’t really about “anger turned inward.” Instead, we have learned
that there are specific risk factors evident in one’s thinking, behaving, relat-
ing, and perceiving that can, under certain stressful conditions, give rise to
depressive episodes. As a result, there are many more immediate and well-
defined targets for hypnotic intervention than previously realized. It has
been amply demonstrated that psychotherapy can succeed, and succeed well,
when people who suffer depression are taught key life skills that empower
them to live more personally satisfying lives.
One can describe the term depression as a global shorthand, a convenient
label for a wide range of symptoms and patterns of experience. Effective
treatment must first involve identifying the salient patterns that regulate
the experience of depression in a given individual. We also know that ther-
apy, any therapy, will necessarily have to interrupt ongoing patterns of expe-
rience in some way and generate some new patterns of experience that
prove beneficial to the client’s mood, outlook, and behavior. The task for
the clinician is to absorb the client in new patterns, whether patterns of
thought as in cognitive therapy, patterns of physiology as in somatic-based
interventions, or whatever patterns are addressed in a specific style of inter-
vention. Hypnosis is multidimensional in its ability to focus anywhere and
catalyze the merits of the intervention, whatever form it might take.
As stated earlier, depression is the product of many contributing variables.
Can hypnosis be used in ways that address risk factors and the process under-
lying the formation of some forms of depression? This chapter offers both evi-
dence and clinical experience in using hypnosis in just such a manner.
THE EMPIRICAL BASIS FOR EMPLOYING HYPNOSIS

IN THE TREATMENT OF DEPRESSION
The body of literature describing the relationship between the quality of
one’s beliefs and one’s mood is substantial. It is well established that the pos-
itive, optimistic person is less likely to suffer depression. Likewise, such a
person will also benefit: (1) physically by likely suffering less serious illness
and higher rates of recovery; (2) in terms of productivity, having higher levels
of focus, persistence, and frustration tolerance; and, (3) in terms of greater

sociability and likeability, enjoying the many health and mood benefits asso-
ciated with having more close and positive relationships (Peterson, 2000;
Seligman, 1989, 1990, 2000; Yapko, 1997, 1999, 2001).
The overlap between depression as a problem and hypnosis as a means for
addressing it centers on the “believed-in imaginations” of the depressed client.
Believing “life is unfair,” or “I’m no good,” or “I’ll never be able to do that” are
just a very few of the many self-limiting and even self-injurious beliefs that
depressed individuals may form and come to hold as true. Thus, it is no coinci-
dence that cognitive-behavioral therapies, which challenge depressed individ-
uals to learn how to identify and self-correct their cognitive distortions and
behave more effectively, have been shown to be highly effective approaches
(Clarkin, Pilkonis, & Magrude,1996; Greenberger & Padesky, 1995).
It is terribly unfortunate that the scientific literature about the use of
hypnosis specifically with depressed populations is sparse because of how
long hypnosis was discouraged as a treatment tool based on misinformation
discussed earlier. However, that is beginning to change; in a recent book
edited by the author of this chapter (Yapko, 2006), many well-known
clinicians and hypnosis experts described their applications of hypnosis in
a variety of clinical populations all sharing an underlying depression.
A variety of therapeutic efficacy studies have been published attesting to
the added value of hypnosis to established treatments, especially cognitive-
behavioral approaches (Lynn, Kirsch, Barabasz, Cardena, & Patterson, 2000;
Kirsch, Montgomery, & Sapirstein, 1995; Schoenberger, 2000.) In one recent
study of hypnosis applied specifically to a depressed population (Alladin &
Alibhai, 2007), the group receiving hypnosis treatments in combination with
cognitive behavioral therapy (CBT) showed greater reduction in depression,
anxiety, and hopelessness than the group receiving CBT alone. Depression is
a global term, however. In fact, depression is comprised of many different
components, including cognitive patterns (such as attributional style), behav-
ioral patterns (such as avoidant coping styles), and relational patterns (such
as hypercriticalness). Many of these components have been addressed success-
fully with hypnosis (Kirsch, 1996; Schoenberger, 2000; Schoenberger, Kirsch,
Gearan, Montgomery, & Pastyrnak, 1997). Employing these treatments with
depressed populations for whom these cognitive and behavioral issues would
be relevant would undoubtedly improve their condition. In fact, much of
what is presented in this chapter could be characterized as cognitive-
behavioral therapy performed within a hypnotic and strategic framework
(Yapko, 1988, 1992, 1993, 2006).
WHAT IS POSSIBLE IN HYPNOSIS?

The fact that people can manifest a variety of normally “hidden” capaci-
ties in hypnosis is the reason why hypnosis offers so much as a treatment
tool. If one were to do even a cursory review of the scientific literature

attesting to the value of hypnosis in a variety of medical, dental, psychother-
apeutic, and educational settings, one would find an enormous array of high-
quality research that supports its use. More recently, newer technologies for
conducting brain scans (i.e., fMRI, CAT, PET, and SPECT) have spawned
new insights into the working relationship between the mind and brain.
Similarly, using advanced diagnostic tools to affirm measurable changes in
physiology in response to “mere” suggestions (such as influencing blood flow,
muscular tension, immunological responses, and perceptions of pain) has led
to a virtual explosion of applications of hypnosis in behavioral medicine.
In hypnosis, people are able to manifest a variety of talents that are
collectively termed “hypnotic phenomena.” These include: (1) age regression
(defined as the intense and experiential absorption in memory such that mem-
ories can be recalled in vivid detail and perhaps even relived as if occurring in
the now, allowing for the reframing of memories, for example); (2) age progres-
sion (defined as the intense and experiential absorption in expectations, a vehi-
cle for establishing positive self-fulfilling prophecies, for example); (3) analgesia
and anesthesia (the ability to reduce or even eliminate sensation, exceptionally
valuable in the treatment of all kinds of pain); and (4) dissociation (the ability
to break global experiences into component parts and selectively amplify or
de-amplify a part depending on therapeutic objective, such as encouraging a
controlled detachment from overwhelming emotions). There are many other
hypnotic phenomena that become accessible in hypnosis that are also benefi-
cial to employ in the course of psychotherapy, and the interested reader may
choose to learn more than this brief chapter can address. Suffice it to say that
as one considers what is possible in hypnosis, wherever one can influence mental
or physical processes it quickly becomes apparent that, the limits of which have
not been anywhere even close to defined yet, hypnosis will be valuable.
WAYS TO USE HYPNOSIS IN PSYCHOTHERAPY

A clinician has to be deliberate about choosing focal points for his or her
interventions. Focusing on someone’s cognitions, for example, shouldn’t be
a standard procedure as a self-identified cognitive therapist. Rather, it should
be a choice one makes to focus on the client’s thoughts because there is a
powerful depressogenic pattern operating on that dimension. But, for some-
one else, the focus will need to be on his or her relationships, and for some-
one else on his or her sleep difficulties. What a clinician will focus on and
amplify with hypnosis will, hopefully, differ according to the unique profile
of each individual client. This is one of the great strengths of being knowl-
edgeable about hypnosis: the ability to make good therapeutic choices based on
client need outweighs loyalty to a particular theory of intervention.
There are many different ways to apply hypnosis in psychotherapy. Since
hypnosis is not generally considered a therapy in its own right, hypnosis
is typically integrated with other psychotherapeutic treatments, such as

cognitive-behavioral therapy (CBT) or interpersonal therapy (IPT). Thus,
how one applies hypnosis will be entirely consistent with however one
thinks about the nature of peoples’ symptoms and the nature of therapeutic
intervention.
Hypnosis essentially amplifies experience. So, if one wants to focus the cli-
ent on his or her cognitive dimension of experience, perhaps to teach a
client to recognize and correct so-called cognitive distortions, one might
use hypnosis to help make such identification and correction a more natu-
ral and even more automatic process. (Aaron Beck, a founding father of
modern cognitive therapy, may not talk about “the unconscious” the way a
hypnosis practitioner might, but he speaks readily of “automatic thoughts.”
What about hypnosis to instill positive automatic thoughts?)
Hypnosis can be used to help manage symptoms. This is a more superficial,
yet meaningful, application of hypnosis. Using hypnosis to reduce anxiety or
rumination so an anxious or depressed client can enhance his or her sleep,
for example, is not a “deep” intervention, yet clinically it is an enormously
valuable one (Yapko, 2006). Teaching someone to manage pain is not psy-
chologically “deep,” but can literally save peoples’ lives (Phillips, 2006).
Hypnosis can be used to foster skill acquisition. As alluded to before, teach-
ing clients specific skills (e.g., social skills or problem-solving skills) is a
standard part of almost any therapy. It is well established that experiential
learning is the most powerful form of learning. Hypnosis is a vehicle of
experiential learning. It’s not just something to consider or distantly imag-
ine. It’s something to be absorbed on many different levels. There is plenty
of evidence that hypnosis generally enhances psychotherapy for this very
reason. Thus, when comparing CBT without hypnosis versus CBT with hyp-
nosis, the addition of the hypnosis enhances therapeutic efficacy. (Note that
the salient research question is not how hypnosis compares to CBT, but
how CBT without compares to CBT with hypnosis.)
Hypnosis can be used to establish associations and dissociations. What
aspect(s) of experience do we want the client more connected or associ-
ated to? What aspect(s) of experience do we want the client disconnected
or dissociated from? Someone who is lacking emotional awareness (what
might be termed “affective dissociation” in hypnotic terms) can benefit
from an emotionally focused (associative) intervention, while someone who
is hyperemotional (emotionally associative) might benefit from a more cog-
nitively based (emotionally dissociative) intervention. Hypnosis allows one
to structure interventions according to whatever aspects of experience might
best serve the client to associate to or dissociate from (or to amplify or de-
amplify). And, if one thinks in these terms, it is easy to see how any therapy
similarly focuses on or away from specific dimensions of experience, though
predictably less effectively by not using the amplified experience of the hyp-
notic condition.
Hypnosis is regarded as a tool, a vehicle for dispensing information,

building perspective, enhancing skill acquisition, and creating a context for
therapeutic change to take place. Thus, one can use hypnosis to highlight
to a patient his or her cognitive distortions, offering suggestions for more
automatically recognizing and refuting them. Thus, if one wishes to make
use of cognitive therapy techniques, hypnosis can be used to help establish
therapeutic associations in the patient for more readily identifying and clari-
fying his or her distorted thoughts and attributions (Yapko, 1992, 2003).
Similarly, if one chooses to focus on the relational dimension, using an
interpersonal model as a conceptual and practical framework, hypnosis is
also applicable. Identifying and relating skillfully to other peoples’ needs
and values, establishing and consistently enforcing one’s limits in one’s
dealings with others, and developing greater awareness of one’s own needs
and how they might best be met are all examples of skills one might wish
to help the patient build using hypnotic suggestions.
In short, the ability of hypnosis, applied either formally or informally,
to build a strong link between the troublesome context and the skilled
response desired in that context is the primary reason why hypnosis can be
so easily integrated into virtually any model of treatment.
There are many other ways to use hypnosis—to build positive expecta-
tions, to amplify and work with emotion-laden memories, to enhance cog-
nitive flexibility, to instill better coping skills, and to increase self-efficacy
are just a few applications immediately relevant to a sophisticated therapy
practice, regardless of one’s preferred theoretical orientation.
WHAT MAKES HYPNOSIS VALUABLE IN THE TREATMENT

OF DEPRESSION?
Hypnosis may be valuable in treatment because of its relationship to sub-
jective states like depression. Upon deeper reflection, the overlaps between
the separate yet related domains of hypnosis and depression become more evi-
dent. I’ll describe just a few of these: (1) Both come about and increase in in-
tensity the more narrow your focus; (2) Both are ultimately social processes,
greatly influenced by your relationships with others, whether the other is a
clinical authority describing the therapeutic merits of exposing you to an
induction procedure, or the other is a parent or spouse describing the flaws in
your character; (3) Both are a product of expectancy, whether the expecta-
tion is one of getting the benevolent corrective message “into your uncon-
scious” through suggestions received in a dissociated state, or whether the
expectation is that no amount of your effort will result in a success, thereby
giving rise to the apathy so typical of depression; and (4) Both involve what
hypnosis pioneers Theodore Sarbin and, later, Ernest Hilgard, described when
they suggested hypnosis is, in part, a “believed-in imagination,” an experience
based on the recognition that people can and do get deeply absorbed in
highly subjective beliefs and perceptions that quite literally regulate the qual-
ity of their lives (Sarbin, 1997; Hilgard, personal communication, 1988).
These beliefs and perceptions can be altered and amplified during the experi-
ence of hypnosis, well illustrating the point how idiosyncratic each person’s
sense of reality really is, especially in response to “mere” suggestions.
The notion of an individual’s personal reality essentially being a “believed-
in imagination” preceded the origin and development of cognitive therapy by
decades, even centuries, and firmly established the relevance of hypnosis in
treatment. Cognitive-behavioral therapy is, at this time, probably the most
well-researched method of therapeutic intervention. It is founded on the pre-
mise that people in general, and depressed people in particular, regularly
make identifiable errors in information processing, thinking and genuinely
believing in their mistaken notions of what truly—and depressingly—seems
like reality to them (Beck, 1997; Beck, Rush, Shaw, & Emery, 1979). This
process of becoming absorbed in one’s (depressing) imaginings is, indeed, an
instructive parallel to what occurs in hypnosis, where a clinician performs an
induction and attempts to absorb the individual in alternative ways of experi-
encing him or herself.
Through procedures employing hypnosis, the clinician creates a context
where the individual can change the direction and quality of his or her focus.
Perhaps the suggested focus is on engaging in some new life-enhancing
behavior, or perhaps on exciting and motivating glimpses of future possibil-
ities, or possibly on rewriting some of the negative internal dialogue, or some-
how altering for the better any of literally scores of depressing focal points
(e.g., cognitive styles, coping styles, relational styles). What the clinician sug-
gests during hypnosis may not be any more true in an objective sense than
what the person previously believed—it may just feel much better and serve
the person better. Hypnosis as a means of teaching people, a vehicle for get-
ting new possibilities for thinking, feeling, behaving, and relating integrated
more quickly and deeply is precisely why knowledgeable clinicians do hypno-
sis in the first place.
HYPNOSIS AND POSITIVE PSYCHOLOGY

With an increasing emphasis within the psychotherapy profession to pay
more attention to what’s right with people rather than what’s wrong with
them (Seligman, 2000), the very first lesson one learns when studying hyp-
nosis takes on a new significance: What you focus on you amplify. Do we as
mental health professionals want to focus on pathology or wellness? Is the
goal of treatment to decrease pathology or weakness, or to expand strength?
These are not merely semantic issues. On the contrary, how one responds to
a client’s distress and organizes therapeutic intervention is broadly based on
whether one strives to identify and address client weaknesses or strengths.
In this sense, hypnosis can be thought of as the original positive psychol-

ogy. Indeed, well before the term positive psychology was coined in just the last
decade, pioneering psychiatrist Milton H. Erickson, MD, as early as the
1940s, was writing about the need to pay more attention to and thereby
amplify peoples’ strengths. Erickson is often described as the most creative
and influential clinician (as opposed to theorist) of the twentieth century,
and it is hardly a coincidence that so many of his innovative contributions
directly involved insightful applications of clinical hypnosis (Haley, 1973;
Zeig, 1980).
Anyone who practices clinical hypnosis does so with the firmly entrenched
and therapeutically invaluable belief that people have many more abilities
than they consciously realize. Hypnosis engenders an entirely optimistic
appraisal of people such that therapy gets organized around the belief that
people can discover and develop the very resources within themselves they
need to improve. Hypnosis creates an amplified, energized, high-powered con-
text for people to explore, discover, and use more of their innate abilities.
Hypnosis isn’t the therapy, and hypnosis itself cures nothing. Rather, hypnosis is
the vehicle for empowering people with the abilities and realizations that ulti-
mately serve to help them. It isn’t the experience of hypnosis itself that’s ther-
apeutic, it’s what happens during hypnosis in terms of developing new and
helpful associations. The study of hypnosis, then, involves a process of discov-
ering what latent capacities are accessible in the experience of hypnosis, and
how to bring them forth at the times and places they will best serve the cli-
ent. It truly is a positive psychology in practice.
HYPNOSIS AND BUILDING REALISTIC EXPECTANCY

One of the strongest factors contributing to the viability of hypnosis as
an intervention tool is termed “expectancy” (Coe, 1993; Kirsch, 2000).
Expectancy refers to that quality of the client’s belief system that leads
him or her to believe that the procedure implemented by the clinician will
produce a therapeutic result. Positive expectancy for treatment involves
multiple perceptions: The clinician is seen as credible and benevolent, the
procedure seems to have a plausible perhaps even compelling rationale,
and the therapy context itself seems to support its application. Thus, by
the client being instructed in the value and the methods of hypnosis,
whether directly or indirectly, an expectation is established that the associ-
ated procedures will have some potentially therapeutic benefit, increasing
the likelihood of them actually doing so (Barber, 1991; Zeig, 1980).
Expectancy is an especially critical issue in the treatment of major depres-
sion. Cognitive theory in particular has viewed depression as existing on a
three-point foundation of negative expectations, negative interpretation of
events, and negative self-evaluation (Beck, Rush, Shaw, & Emery, 1979). An
individual’s negative expectancy for life experience is a cognitive pattern and

risk factor that has been associated with difficulties not only in the realm of
mood, but also in poorer physical health, poorer social adjustment, and
diminished productivity. Furthermore, negative expectancy has been associ-
ated to lowered treatment success rates (Seligman, 1989, 1990). At the
extreme, negative expectancy in the form of a pervasive sense of hopelessness
can be associated with suicidality (Beck, Brown, Berchick, Stewart, & Steer,
1990). Establishing positive expectancy in a variety of specific contexts may
be a necessary ingredient in effective treatment (Yapko, 1988, 1992, 1993,
2001). Age progression in hypnosis as a vehicle for concretely establishing a
positive and motivating view of the future may be helpful in this regard
(Torem, 1987, 1992, 2006; Yapko, 1988, 1992, 2001, 2003, 2006).
Important as it may be, however, a focus on expectancy to the exclusion
of other factors of potential therapeutic effectiveness can also be limiting.
Someone can have positive expectations yet generate no meaningful thera-
peutic results for a variety of reasons. For every client who began therapy
with high hopes that went unfulfilled, the point is clear that positive
expectations are not enough. They must be realistic and they must occur
within a larger therapeutic framework that is able to convert the promise
of expectancy into the reality of a goal accomplished. Expectancy matters,
but even positive, well-defined expectations can become a source of prob-
lems rather than a source of solutions if they are unrealistic. Thus, a clini-
cian must be able to educate the client in the process of distinguishing
realistic from unrealistic expectations, whether positive or negative. Hyp-
nosis can help in this therapeutic endeavor.
TARGETING THE MOST COMMON SYMPTOM

OF DEPRESSION: HYPNOSIS AND PSYCHOTHERAPY
FOR INSOMNIA
The time hypnosis may be of greatest benefit in psychotherapy is when
it is used as a means of teaching skills that can empower the therapy client
(Yapko, 2001, 2003). Regarding insomnia in particular, the most common
symptom of depression, there are a number of specific skills that someone
suffering insomnia can learn that will make a positive difference, such as
relaxation and good sleep hygiene. However, there is another specific skill
that is an amenable target for a well-crafted hypnotic intervention. That
target is called “rumination.”
Rumination is the cognitive process of spinning around the same thoughts
over and over again. It is considered an enduring style of coping with ongoing
problems and stressors, a coping style that can both lead to and exacerbate
depression. One’s coping style is a significant factor in one’s overall mental
health and is an especially important factor in depression. Although coping
responses may be classified in many ways, most approaches distinguish be-

tween strategies oriented toward confronting the problem and strategies ori-
ented toward reducing tension by avoiding dealing with the problem directly
(Holahan, Moos, & Bonin, 1999). Rumination can be thought of as a pattern
of avoidance that actually increases anxiety and agitation. Ruminative
responses include repeatedly expressing to others how badly one feels, ponder-
ing to excess why one feels bad, and catastrophizing the negative effects of
feeling bad (Nolen-Hoeksema, 1991.) By ruminating, the person avoids hav-
ing to take decisive and timely action, further compounding a personal sense
of inadequacy. Rumination leads to more negative interpretations of life
events, greater recall of negative autobiographical memories and events,
impaired problem solving, and a reduced willingness to participate in pleasant
activities (Spasojevı́c & Alloy, 2001). As Just & Alloy (1997) stated, correla-
tional, field, longitudinal, and experimental studies all provide evidence that
ruminative behavior is not only highly associated with depression, but serves
to increase both the severity and duration of episodes of depression. The com-
mon term analysis paralysis describes the hazard of ruminating at the expense
of taking effective action.
It is especially significant that rumination not only features in the qual-
ity of one’s depression, but it actually predicts depression. Susan Nolen-
Hoeksema of Yale University published enormously valuable research that
establishes the link clearly: A ruminative coping style that precedes
depressive symptoms predicts higher levels of depressive symptoms over
time (after accounting for baseline levels), onset of new depressive disor-
ders, greater chronicity of depressive disorders, and higher levels of anxiety
symptoms (Nolen-Hoeksema, 2000, 2003).
Thus, rumination is an especially high-priority target at which to aim
one’s interventions, hypnotic or otherwise. Rumination generates both so-
matic and cognitive arousal, both of which can exacerbate insomnia, but
the evidence suggests cognitive arousal is the greater problem. As Harvey
(2000) reported in her research on the relationship between cognitive
arousal and insomnia, insomniacs were ten times more likely to cite cogni-
tive arousal as central to their sleep difficulties, compared with somatic
arousal. Harvey went on to say that the need to aim for minimal cognitive
processing and effort toward sleep are key treatment goals.
HYPNOSIS, TARGETING RUMINATION AND

ENHANCING SLEEP
Having asked literally hundreds of individuals who declare themselves
“good sleepers” what they tend to think about when they go to sleep, their
common and consistent answer is some variation of the reply, “nothing.”
That doesn’t mean literally that they think of nothing and have an “empty
mind.” Rather, it means that the content of what they think about is so
simple and nonthreatening that it generates no significant somatic or cog-
nitive arousal to interfere with sleep. Conversely, when I ask people who
say they sleep poorly what they think about when going to sleep, they typi-
cally say some variation of, “everything.” They think of worrisome prob-
lems, unresolved situations needing to be addressed, obligations to be met,
tasks still needing to be done, and on and on. The levels of cognitive and
somatic arousal are raised to the point of interfering with sleep.
The use of hypnosis to teach the ability to direct one’s own thoughts
rather than merely react to them is a well-established dynamic and
a principal reason for employing hypnosis in any context (Lynn &
Kirsch, 2006; Yapko, 2003). Reducing the stressful wanderings of an agi-
tated mind and also relaxing the body while simultaneously helping peo-
ple create and follow a line of pleasant thoughts and images that can
soothe and calm the person are valuable goals in the service of enhanc-
ing sleep.
In order to achieve these aims, there are a number of important compo-
nents to include in one’s treatment plan. These include: (1) Teaching the
client how to efficiently distinguish between useful analysis and useless rumi-
nations. The distinction features variations in factors such as the amount of
research, if any, to be done and the timing of a decision to act (i.e., how
much information to gather and how long to contemplate what to do), but
the single most important distinguishing characteristic is the conversion
from analysis to action; (2) Enhancing skills in compartmentalization in
order to better separate bedtime from problem-solving time with the well-
defined goal in place of keeping them separate; (3) Establishing better cop-
ing skills that involve more direct and effective problem-solving strategies.
For the client that avoids making decisions and implementing them out of
the fear of making the wrong one, such as perfectionist individuals, who are
also at higher risk for depression as a result of their perfectionism (Basco,
1999), he or she will need additional help learning to make sensible and
effective, albeit sometimes imperfect, problem-solving decisions; (4) Helping
the client develop effective strategies for choosing among a range of alterna-
tives. There is evidence that having more options, an oft-stated goal for
clinicians, actually increases the anxiety and depression of those who don’t
have a good strategy for choosing among many alternatives (Schwartz,
2004); (5) addressing issues of sleep hygiene and attitudes toward sleep in
order to make sure the person’s behavior and attitudes are consistent with
good sleep; and (6) Teaching “mind-clearing” or “mind-focusing” strategies,
especially self-hypnosis strategies of one type or another that help the person
direct their thinking in utterly benign directions.
Each of the first five components listed here support the potential value
of the sixth, the actual hypnosis strategy one employs to help calm the
person to sleep.
HYPNOTIC APPROACHES
Hypnosis can be used as a vehicle for teaching the client effective ways
to make distinctions between useful analysis and useless ruminations, com-
partmentalize various aspects of experience, develop better coping skills,
develop more effective decision-making strategies, and develop good be-
havioral and thought habits regarding sleep. Such hypnosis sessions are
quite different in their structure than is a session designed specifically for
the purpose of enhancing the ability to fall and stay asleep.
The primary difference between a sleep session and a regular therapy
session employing hypnosis is that hypnosis for sleep enhancement is
designed to actually lead the client to fall asleep. In standard therapy ses-
sions involving hypnosis, the opposite is true—the clinician takes active
steps to prevent the client from falling asleep during the session. It has
been well established that hypnosis isn’t a sleep state, and that sleep learn-
ing is a myth. Thus, clinicians employing hypnosis encourage the client to
become focused, relaxed, yet maintain a sufficient degree of alertness to be
capable of participating in the session by listening and actively adapting
the clinician’s suggestions to his or her particular needs.
Another key difference between a hypnosis session for enhancing sleep
and a standard therapy session is the role of the client during the process.
In therapy, the client is defined as an active participant—actively involved
in the search for relevance for the clinician’s suggestions, actively involved in
absorbing and integrating the suggestions, and actively finding ways to apply
them in the service of self-help. Relaxation may or may not be a part of the
process. In fact, some suggestions a clinician offers during hypnosis might
even be anxiety provoking or challenging to the client’s sense of comfort.
After all, personal growth often means stepping outside one’s “comfort zone.”
In the sleep session, however, cognitive and somatic arousal are to be mini-
mized, and so challenges to the client’s beliefs (or expectations, role defini-
tion, or any other aspect a clinician might appropriately challenge) are
precluded.
The content of the strategy (e.g., progressive relaxation, imagery from a
favorite place, recollection of a happy memory, creation of fantasy stories,
counting sheep, etc.) is a secondary consideration. Thus, what specific hyp-
notic approach one uses is relatively unimportant. The primary considera-
tion is that whatever the person focuses on, it needs to be something that
reduces both somatic and cognitive arousal.
Approaches can be direct or indirect according to what the client finds
easiest to respond to. Likewise, they can be content or process oriented, again
depending on what the client finds easiest to relate to. Since sleep isn’t some-
thing that can be commanded, an authoritarian style is generally counterpro-
ductive. A permissive style is both gentler and more consistent with an
attitude of allowing sleep to occur instead of trying to force it to occur.
The use of recorded hypnotic approaches (i.e., tape recordings or com-

pact disc recordings) can be a useful means of helping the client to develop
the skills in focusing on calming suggestions. Generally, these should be
considered a temporary help in the process so that the person is eventually
able to fall and stay asleep independently using self-hypnosis. However,
recordings pose no major or even minor hazards that warrant concern they
will be abused in some way, so there seems to be no good reason to push cli-
ents to stop using the recordings for as long as they find them helpful.
Helping people learn to “slow down,” curtail their ruminations, estab-
lish stronger boundaries between their work and personal lives, and better
separate problem-solving time from sleep time are all worthwhile goals to
address in treatment. These are life skills that may be learned with clini-
cians serving as teachers or guides. Hypnosis can be an effective vehicle
for teaching such skills, even if just teaching basic relaxation skills, per-
haps even outperforming sleep medications. As one prominent sleep and
depression researcher wrote, “using deep muscle relaxation and other forms
of progressive relaxation strategies may help individuals to fall asleep more
quickly . . . controlled studies suggest effects as strong as, and with greater
durability than, those observed with sedative hypnotics” (Thase, 2000,
pp. 49–50). The quality of the symptoms a client presents can point the
clinician in the direction he or she might go if the client is to be suffi-
ciently empowered to get some control back and reduce or eliminate symp-
toms. For as long as a client feels victimized by his or her symptoms, recovery
from depression is extremely unlikely (Cohen, 1994).
The goals of therapy include not only reducing or eliminating symptoms,
but also reducing or eliminating associated risk factors for further episodes.
Depression is often described in the literature as a “recurrent disease,” and
relapse statistics confirm an ever-higher probability of later episodes the
more episodes one has (Glass, 1999). Using the previous example of insom-
nia as a target, insomnia is the symptom. But, unless the individual’s rumi-
native coping style is altered, and unless the person’s global cognitive style
is addressed by teaching better compartmentalization (boundary) skills
(e.g., to separate problem-solving time from sleep time), the mere teaching
of relaxation skills is unlikely to be of enough help to the person to over-
come depression.
A SAMPLE TRANSCRIPT OF HYPNOTIC SUGGESTIONS TO

ENHANCE SLEEP
The following abbreviated hypnosis transcript can illustrate what kinds
of suggestions might be given to someone who tends to ruminate at bed-
time. The goal is to provide a comfortable, relaxed experience in which
the person discovers he or she can clear his or her mind of the “clutter”
that interferes with sleep.
I’d like to invite you to arrange yourself in a position that is comfort-

able. I’d encourage you to listen to the recording of this session while
you are lying in bed so you can drift off to sleep and then sleep com-
fortably through the night. Unlike other kinds of sessions we’ve done
involving hypnosis or relaxation processes, with this particular hyp-
nosis session it is appropriate for you to listen to it while you’re in
bed as you’re going to sleep. After all, the purpose of this particular
session is to make your sleep easier, more satisfying, and more restful.
So, with that in mind, I’d like you to let your eyes close . . . and
notice the differences instantly as soon as you let your eyes close . . . It
means you are no longer focusing on things around you. . it means
that you have closed your eyes to the outside world . . . for now . . .
And in a way . . . you might think of that . . . simple action of closing
your eyes . . . as starting to close out . . . the world out there . . . Now,
certainly you’ll hear . . . the sounds . . . the routine sounds . . . of your
environment . . . and because they are so routine . . . whether it is a
dog barking or crickets chirping . . . or traffic . . . it doesn’t matter
what it is . . . it’s routine . . . And that frees your mind . . . to be very
present in this moment which precedes your sleep . . . you get to let
your mind . . . grow ever quieter . . . ever more comfortable . . . and
notice how good that feels . . . It’s really quite soothing to now recog-
nize that you can . . . slowly turn down . . . the rate and volume of
your thoughts . . . until you find yourself . . . thinking in a slow, quiet
whisper . . . that is barely audible . . . and what matters is that you
have the ability . . . to focus your thoughts on whatever soothes
you . . . and relaxes you . . . and makes you feel good . . . there’s so much
freedom in just relaxing and not having to think . . . you can feel the
freedom . . . of being able to . . . drift off . . . to sleep . . . slowly . . . delib-
erately . . . And, little by little . . . you may become aware . . . that you
really aren’t thinking about anything in particular . . . and how your
attention stays ever more focused on . . . the wonderfully . . . comforta-
ble . . . immediacy . . . of the safety and warmth . . . the deeply comforta-
ble warmth . . . of your bed . . . And then you can notice the subtle
sensations . . . associated with falling asleep . . . Which parts of your
body . . . seem to drift off . . . first? . . . Which parts are heaviest . . . as if
it would take just massive effort to move them? . . . And which parts are
lightest . . . and free . . . And with your breathing slowing . . . and your
mind . . . growing ever quieter . . . it can feel wonderful . . . to be drifting
off . . . so easily . . . and effortlessly . . . and there’s no need to drift off
to sleep just yet . . . unless you really want to . . . but you can allow your-
self . . . the luxury . . . of being in this . . . state of mind . . . and body . . .
for a long restful time . . . And when you wake up after this deep, restful
sleep . . . many hours from now . . . you’ll naturally feel rested . . . and
energized . . . it’s a powerful experience . . . of rediscovering . . . quite
naturally . . . that you can sleep . . . you can sleep . . . deeply . . . And
so you can . . . just enjoy . . . the comfort . . . the sense of peacefulness
. . . that you can carry with you into your dreams . . . and sleep . . . sleep
. . . So now . . . you can drift off . . . drift off . . . and sleep well . . . Good
night.
CONCLUSION
It is no coincidence that of the therapies with the greatest level of em-
pirical support for their effectiveness in treating depression (cognitive-
behavioral and interpersonal), none of them focus on the past and all of them
focus on helping depression sufferers build the skills that can empower them.
In this chapter, I have emphasized the merits of hypnosis as a vehicle for
teaching new skills, encouraging active experimentation with them in every-
day contexts, and using the feedback from life experience to continually
adapt oneself to changing demands. Such teachings directly counter the
popular psychologies that emphasize non-discriminately “trusting your guts”
or “living in the present” or thinking “you can have it all” and countless
other such global phrases that set people up to get hurt when they discover
the hard way these principles don’t apply in all (or perhaps even most) life
situations.
Hypnosis can reasonably be considered the original “positive psychology.”
Anyone who applies hypnosis does so with the firm belief that people have
more resources than they consciously realize, and that hypnosis can help
bring these resources to the fore. Empowering people in this way is a natural
component of an effective treatment for depression, for no one can over-
come depression while feeling or behaving in a disempowered manner.
Hopefully, as we continue to learn more about the many pathways into
depression, we will learn more about the many pathways out as well, includ-
ing those involving skillful applications of hypnosis.
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Chapter 5
Hypnosis in Interventional Radiology and

Outpatient Procedure Settings
Nicole Flory and Elvira Lang
OVERVIEW
Over the past decades, surgery has evolved from the traditional large-
incision technique to minimally invasive approaches, fueled by a revolu-
tion in medical imaging and device design. Skilled specialists can now
insert surgical instruments through tiny skin openings under the guidance
of X-rays, ultrasound, magnet resonance imaging (MRI), or endoscopes.
The field of interventional radiology has blossomed from these advancements,
and other specialties have adopted the minimally invasive approaches pio-
neered in radiology. Many surgeries that previously required general anes-
thesia and prolonged hospital stays are now outpatient procedures. While
patients greatly benefit from these developments, high-tech procedures still
involve considerable physical and psychological risks for patients who can
now remain alert and conscious on the operating table. In addition, indica-
tions for interventions have expanded to include more fragile patients,
who in the past would have been excluded from more traditional treat-
ment, and these patients require an even greater degree of care.
Managing procedural distress in the interventional radiology suite and
other outpatient procedure settings remains a challenge for clinicians and
patients. Treatment teams typically rely on local anesthetics and drugs to
counteract pain and anxiety. Although generally safe, these can have lim-
ited effectiveness and serious side effects. With the public’s increasing in-
terest in more holistic approaches, that is, a combination of high tech and
high touch, and mounting scientific evidence for alterative approaches, use
of hypnosis in the procedural setting shows great promise. This chapter
will touch on the specifics of the setting, and the premise, attractiveness
and challenges of using hypnosis during surgery in conscious patients.
HYPNOSIS IN THE EVOLUTION OF SURGICAL AND

ANESTHETIC APPROACHES
In the evolution of surgery, development of instrumentation, anesthesia,
and infection-free healing have been intimately intertwined. Progress in
one of these domains fuels progress in the others, and conversely, without
progress of all three, the field cannot progress effectively. In the nine-
teenth century, the Scottish surgeon James Esdaile started to use hypnotic
techniques in India mainly out of desperation for lack of other means of
pain control (Esdaile, 1946/1957). He had heard of Franz Mesmer in Vienna
who had gained fame curing mainly psychosomatic illnesses through hyp-
notic and trance-like states. Esdaile had never seen a “mesmeric” session,
but read about its use for medical procedures. He successfully used these
techniques during major surgery. He not only found that patients experi-
enced less pain, but also noticed that the rate of infection was greatly
reduced. However, with the discovery of the clinical use of ether and shortly
thereafter chloroform, clinicians gave preference to the use of pharmaceuti-
cals for pain control and the initial excitement about hypnosis in the oper-
ating room diminished. In 1846, Morton first gave ether to patients for
dental procedures and then demonstrated its use to the public in an amphi-
theater later known as “Ether Dome” at the Massachusetts General Hospital
(Skolnick, 1996). In 1847, Simpson first used chloroform on women during
child birth (Simpson, 1847), which caused much controversy and contempt
among certain religious groups (Mander, 1998). The initial enthusiasm for
ether and chloroform, however, was damped by serious side effects and deaths
following surgery (Duffy, 1964). This was mainly due to poor safety consider-
ations, over sedation, and the spread of infection—in particular, during
labor and delivery involving physicians (Mander, 1998). In 1847, Semmelweiss
contributed a milestone to the evolution of surgery (Grant, Grant, &
Lockwood, 2005). By promoting hand washing with 4 percent chlorinated
lime solution for doctors and their trainees assisting in childbirth, he was
able to reduce maternal mortality from 13–30 percent to 1.2 percent
(Nuland, 2003). Thus, he brought about one of the most important steps in
reducing wound infection and mortality. Unfortunately, Semmelweis’s
efforts were met with much hostility and hand washing was accepted only
years later, after his death, as a principle of antisepsis in surgery (Grant
et al., 2005). His experience may serve as an example that simple mea-
sures with obvious positive patient outcomes still can face great opposition
from members of the medical community who adhere to ingrained but
unproven customs.
With the progress made in the nineteenth century, surgeons of the twen-
tieth century were ready to expand to an extensive array of open surger-
ies including large abdominal incisions and chest operations with heart
lung machines. In the last decades, technical evolution has permitted
Hypnosis in Interventional Radiology and Outpatient Procedure Settings 147
less-invasive methods to address the same “plumbing needs” with speedier

recovery. Specially trained physicians can now insert miniature high-tech
devices through the patient’s skin under the guidance of various imaging
techniques. These imaging techniques include X-rays, ultrasound, computer
tomography, MRI, or endoscopes. For example, pus, kidney stones, gall blad-
ders, and tumors can now be removed without cutting patients open. Inter-
ventionalists can now open blocked arteries, veins, or bile ducts from the
inside through image-guided surgical interventions. The new subspecialty of
radiology, called interventional radiology, and subsequently, interventional
pulmonary, gastroenterology, cardiology, vascular, and general surgery have
all profited tremendously from advances in minimally invasive surgery.
In conjunction with the evolution of surgical techniques, the modes of
chemical anesthesia have also expanded. Local anesthetics with varying
times of actions have been devised, and drugs that counteract pain and
anxiety are continuously evolving. For minimally invasive surgery, general
anesthesia is no longer necessary. Interventionalists usually administer
injections of local anesthetic medication (such as lidocaine) in conjunc-
tion with analgesic agents and intravenous (IV) “conscious” or “moderate
sedation” (Lang, Chen, Fick, & Berbaum, 1998; Martin & Lennox, 2003).
While these drug regimens generally are well tolerated during proce-
dures, they are not always effective and can have side effects including car-
diovascular problems, cessation of breathing (apnea), shortage of oxygen
(hypoxia), unconsciousness (coma), and very rarely death (Martin &
Lennox, 2003).
While serious complications during minimally invasive procedures are
rare, even a very low incidence of adverse events has larger-scale con-
sequences. For example, millions of routine endoscopies are performed.
Experts estimate that 3–13 percent of patients will face complications or
other adverse outcome following their endoscopy (Mahnke et al., 2006).
About 750 per 100,000 individuals undergo endoscopies for upper gastroin-
testinal problems annually (British National Institute for Health and Clin-
ical Excellence; Web page 12/11/2006). In the United States, experts
suspect that endoscopies result in more than 70,000 serious complications
each year. Therefore, any medical intervention should be used judiciously
to provide the best care to patients (Martin, Lennox, & Buckley, 2005).
The occurrence of adverse effects not only depends on the type of
procedure performed, but also on the amount and properties of each medi-
cation as well as the patient’s susceptibility to certain medical problems
(Hatsiopoulou, Cohen, & Lang, 2003). Research findings document that
the amount of medication for the same medical procedure differs sig-
nificantly between patients, health care providers, and hospital settings
(Gracely, McGrath, Heft, & Dubner, 1977; Lang et al., 1998). The risk
associated with the use of monitored anesthesia during minimally invasive
procedures can be comparable to that seen in general anesthesia. It is thus
not surprising to see a rekindling of interest in hypnosis for the manage-

ment of procedural distress.
In the nineteenth century, the development of pharmacologic anesthesia
greatly reduced the use of hypnosis during surgery (D. Spiegel, 2006; Wain,
2004), but a small group of dedicated physicians continued using hypnotic
techniques solely or as an adjunct throughout the century. Hypnosis was
then mainly used for individuals who had a contraindication to chemical
anesthesia or purposefully requested a hypnotic intervention (Blankfield,
1991). While use of general anesthesia permitted development of extensive
open surgery, it also opened the way to minimally invasive techniques that
now no longer require general anesthesia. In the twenty-first century, we
may well have reached the point where the greatest procedural risks are
those related to the patients’ pain, anxiety, and the management of these
symptoms. Greater requests for transparency in medicine and the require-
ments of hospitals to share complication rates with the public make non-
pharmacologic methods, with their high safety profile and the potential for
high patient satisfaction, once again a very attractive alternative.
PROCEDURAL ENVIRONMENT
Despite the “minimally invasive” label, procedures in interventional ra-
diology or other outpatient settings are not free of pain and possible dis-
tress. During outpatient surgery or minimally invasive procedures, patients
typically remain conscious and immobilized on a table, sometimes for sev-
eral hours, and in cases where image guidance is necessary, the room is
darkened to permit viewing of the monitors. Instruments such as wires, cath-
eters, and endoscopes that can measure several feet in length are inserted
into various openings. If one were to design a psychological experiment to
create feelings of anxiety and despair, one would likely choose most of
the elements present in the procedure room: fear for life or health, loss of
control, uncertainty of outcome, presence of masked strangers, darkness,
immobilization, exposure and vulnerability (Flory, Salazar, & Lang, 2007).
Even for generally healthy and well-adjusted individuals, a visit to the
operating room can be a stressful experience. Patients often experience
worry and concern, such as fear about being in pain, giving up control, loss
of body image or physical attractiveness, surgical complications, adverse
reactions to anesthesia, and death (Anderson & Masur, 1983). Optimal
patient care involving heavy reliance on technology-based interventions
like radiology procedures should expand to include much needed emo-
tional support for patients (Peteet et al., 1992). Reducing anticipatory anx-
iety is not only desirable in itself but also has considerable implications for
the upcoming procedure. In a study with patients undergoing interventional
radiological procedures, pre-procedure anxiety significantly correlated with
anxiety, pain, and medication use and overall procedure length (Schupp,
Berbaum, Berbaum, & Lang, 2005). Highly anxious patients ask for and
are offered more medication during surgery, therefore exposing them to a
greater likelihood of adverse events. Pain and distress can also result in a
longer stay in the recovery room, additional medication use, delayed dis-
charge, and hospital readmission (Chung, Ritchie, & Su, 1997). Recovery
from surgery is of vital importance since all the mentioned adverse events
put additional strain on the patients and at the same time inflate health
care costs (Montgomery et al., 2007).
BASES OF PROCEDURAL PAIN MANAGEMENT

WITH HYPNOSIS
The experience of pain is a complex and highly subjective phenomenon
(Price, Harkins, & Baker, 1987). The same physical stimuli that may be
barely noticed as painful could be experienced as excruciating in a differ-
ent setting, or as David Spiegel once described the phenomenon, “the
strain in the pain is in the brain.” Focused attention and awareness are key
elements in changing perceptions of pain (Spiegel & Spiegel, 1978). For
example, intense attention toward an imagined warm and tingling sensa-
tion may modify the brain’s response to the painful signal (Spiegel &
Bloom, 1983). Pain is usually perceived in different dimensions according
to its sensory, cognitive, and affective-emotional aspects (Melzack, 1999).
Hypnosis can reduce both the sensory and affective dimensions of pain,
thereby reducing overall pain perception (Wright & Drummond, 2000).
Magnetic resonance imaging studies have demonstrated that the wording
of hypnotic suggestions can systematically alter the brain’s processing of the
same painful stimulus. Suggestions targeting the sensory dimensions of pain
resulted in a modulation of activity in the primary sensatory cortex, while
suggestions targeting the affective components of pain resulted in changes in
the anterior cingulated cortex (Rainville, Bao, & Chretien, 2005; Rainville,
Carrier, Hofbauer, Bushnell, & Duncan, 1999; Rainville, Duncan, Price, Carrier,
& Bushnell, 1997). Pain and anxiety are interrelated (Schupp et al., 2005), and
reduction of one is likely to beneficially affect the other.
Hypnotic techniques can be considered brief therapeutic interventions
changing cognitions, emotions, and behaviors of individuals. Hypnotic an-
algesia lets patients explore their own capacity to interact with a painful
or uncomfortable situation (Spiegel et al., 1989). Its benefits have been
documented for patients in various settings with no or little side effects
(Faymonville et al., 1995; Huth, Broome, & Good, 2004; Lang et al.,
2000). This is in contradiction to the purely pharmacologic approach.
While pharmacologic treatments for pain and anxiety may seem like a quick
fix, clinical experience shows that the adrenergic activation of very anxious
patients can override even large amounts of sedatives and narcotics. This
adrenergic activation does not only render chemical drugs ineffective, but is
also dangerous once the procedure is over and the full drug effect suddenly
emerges. In this context it seems much more efficient to engage in a quick
hypnotic anxiety conversion up front. On the other hand, one should not
be opposed to judicious use of drugs or place performance pressure on
patients and their hypnosis providers. It is important to offer patients the
choice of hypnosis, drugs, both, or none in what they perceive as their needs
within the realm of safety. Earlier concerns of some, that sedatives and anal-
gesics may adversely affect a patient’s ability to engage with hypnosis on the
procedure table, have not been proven in a series of clinical studies. These
have shown that procedural pain and anxiety can be well managed through
a combination of relatively small amounts of medication and hypnosis in a
wide range of medical procedures (Baglini et al., 2004; Butler, Symons,
Henderson, Shortliffe, & Spiegel, 2005; Lang et al., 2000; Lang et al., 2006;
Stewart, 2005).
HYPNOTIC TECHNIQUES
Since this book describes hypnotic techniques and general principles,
we will explain approaches that are more specific to interventional radiol-
ogy and other outpatient medical settings. The interventional procedure
suite can be noisy, sabotage prone, and buzzing with different activities.
This environment is very different from the practice of a therapist or psy-
chologist with a couch in a tranquil office setting. While an office setting
allows 40-minute inductions, the generation of patient-specific tapes, and
possibly subsequent patient practice at home, the procedure environment
requires quick action.
In the ideal case, hypnosis in the procedure room should be provided by
a person who is already part of the team (Blankfield, 1991). This person
would have had the opportunity to meet the patient on a prior visit and
used the opportunity to learn the patient’s individual responses to stressful
situations. In our experience this is highly unlikely in the current cost- and
time-conscious culture of medicine. Often, the needs and provisions for
each individual patient can only be established once the patient has arrived
in the procedure room. Rapid attention to such needs and brief interven-
tions are essential. Emphasis should be placed on building rapid rapport,
positive wording of suggestions, openness to discussion, and use of patient-
centered imagery. On the other hand, patients are highly suggestible in the
health care setting and, in particular, the acute care area (H. Spiegel,
1997), so that lengthy inductions are not necessary. Also, the approach
should not interfere with patient preparation for the surgery and surgery
itself. Although hypnosis is still highly cost effective even if it adds proce-
dure time (Lang & Rosen, 2002; Montgomery et al., 2007), it has been very
difficult in our experience to convey to procedure personnel that halting
their activity—even for a little while and contrary to the evidence—could
bring any good at all. We have learned over the years that it is very well
possible to start the hypnotic process while a patient is being “prepped”
(e.g., cleansed with antimicrobial solution), hooked up to equipment, or
even when being positioned in a mammography unit.
To guide patients into self-hypnotic relaxation, we typically use scripts;
yet these are structured such that flexibility, openness, and patient-centered
imagery are all key elements. The overpowering aspect of technology in
the procedure room is well offset by a highly permissive, responsive, and
interactive approach that conveys a greater sense of control for the patient
(Flory et al., 2007). It therefore mirrors some of the key aspects of Ericksonian
hypnosis. Some argue that a deeper explorative non-scripted approach could
produce even better results (Barabasz & Christensen, 2006), but such requires
very highly skilled hypnotists, which typically are not available on a daily
basis in the clinical setting.
Seeing a hypnosis provider sit down to read a script can reduce misper-
ceptions of hypnosis, overcome resistance, and provide comfort for both
patients and health care professionals. A script can be a safety blanket that
conveys how important the wording is when the patient lies on the operating
table. It permits the whole treatment team to learn and reinforce hypnotic
vocabulary. In addition, the use of scripts enables a greater standardization
of treatment that is essential for documentation and reproducibility. It also
permits the exchange of personnel during procedures and allows patients
to drift in and out of hypnosis as they wish.
All hypnosis should be considered self-hypnosis as patients explore their
own abilities to deal with painful or distressing stimuli. A semantic shift
from “hypnosis” to “self-hypnosis” emphasizes the patient’s active partici-
pation. Patients often feel out of control, passive, exposed, and vulnerable.
Imagery that patients used to describe this state ranged from a “piece of
red meat with a butcher knife all the way through,” to “a little mouse
being chase by huge barn cats,” or “surrounded by knights in silver armors
ready to pierce me.” In the same way that these patients can produce dis-
tressing imagery, they can also envision more resourceful scenarios if
guided appropriately. It is best to teach patients to help themselves, and
patients take pride and fulfillment in being able to produce such scenarios.
Their choices are highly individual—another reason why we do not
believe “one-size-fits-all” hypnosis tapes. What pleases some patients may
be disturbing to others as in the following examples: camping on the Mis-
sissippi, floating on the clouds with one’s deceased relatives, flying a plane
in the dark night sky, gambling in Las Vegas, or even canning vegetables
while watching TV (Fick, Lang, Benotsch, Lutgendorf, & Logan, 1999).
There are many ways to structure the hypnotic process in the procedure
room; based on our experience, we describe what we found most useful
in our setting. The approach contains two elements. The first is a set of
structured attentive behaviors that the hypnosis provider displays in the
first seconds of the patient encounter. The second element is the reading
of the script in the next section.
We have reported that hypnosis in the operating room should also
include other techniques in addition to hypnosis such as structured atten-
tive behaviors, establishing rapport, correct use of language and suggestions,
patient-initiated imagery, relaxation training, and provisions to address
patients’ worries as early as possible (Lang et al., 1999). Structured attentive
behavior consists of several behaviors, most importantly listening. Attentive
listening is the key to instant rapport building—the listener seeks to under-
stand and uses patient-generated images for the hypnosis. A second element
is matching the patients’ verbal and nonverbal behavior pattern; examples
include sitting at eye level with the patient and the removal of barriers
between the patient and the hypnosis provider in the operating room. Other
elements of attentive behaviors include provision for increasing the patient’s
perception of control by prompt responses to patient requests. Last, but not
least, encouragement presented in statements like “thank you for your coop-
eration” will empower the patient to take a more active role during his or
her medical treatment (Lang et al., 1999).
The correct use of language and suggestions is important since patients
generally present to the operating room with heightened suggestibility
(H. Spiegel, 1997). Negatively loaded suggestions such has “sharp pain
and pressure now” or “this will hurt a bit” can reinforce anxiety and mag-
nify attention to pain (Lang et al., 2005). Emotionally neutral descriptions
are preferable and may include “feeling of warmth and fullness” or “focus
on the sensation of your breath.” Positive suggestions foster relaxation, and
patient-centered imagery around successful coping will enhance the patient’s
well-being (Erickson, 1994). It is best to tap into the already existing cop-
ing strategies by using the patient’s words and descriptions.
SCRIPT
There are many options for hypnosis scripts. After having worked with
several scripts and learned from our pitfalls, Dr. D. Spiegel helped us develop
the following script, which was tested for efficacy in several randomized-
controlled trials (Lang et al., 1999; Lang et al., 2006). Over the years we
made small changes based on feedback from the hypnosis community. For
individuals who wish to develop their own scripts, we recommend that the
following elements be included: a short explanation about what is going to
happen, use of an induction that can be repeated should other personnel or
events sabotage the process and inadvertently re-alert the patient, an immu-
nization against the noise and interruptions in the room as well as unhelpful
suggestions, a simple way to engage in resourceful imagery, elements of anxi-
ety and pain conversion if needed, and a reorientation that acknowledges
the patient’s contribution.
“We want you to help us to help you to learn a concentration exercise

to help you get through the procedure more comfortably. It can be a way
to help your body be more comfortable through the procedure and also
deal with any discomfort that may come up during the procedure. It is just
a form of concentration, like getting so caught up in a movie or a good
book that you forget you are watching a movie or reading a book.
Now you may be interested to learn how you can use your imagination
to enter a state of focused attention and physical relaxation. If you hear
sounds or noises in the room, just use these to deepen your experience.
And use only the suggestions that are helpful for you. There are a lot of
ways to relax, but here is one simple way:
On one, you can do one thing—look up.

On two, two things, slowly close your eyes and take a deep breath.
On three, three things, breath out, relax your eyes, and let your body float.
That’s good, just imagine your whole body floating, floating through the
table, each breath deeper and easier. Right now you might imagine that
you are floating somewhere safe and comfortable, in a bath, a lake, a hot
tub, or just floating in space, each breath deeper and easier. Just notice how
with each breath you let a little more tension out of your body as you let
your whole body float, safe and comfortable, each breath deeper and easier.
Good, now with your eyes closed and remaining in this state of concentra-
tion, please describe for me how your body is feeling right now. Where do
you imagine yourself being? What is it like? Can you smell the air? Can you
see what is around you? Good, now this is your safe and pleasant place to
be and you can use it in a sense to play a trick on the doctors. Your body
has to be here, but you don’t. So just spend your time being somewhere you
would rather be.
Now, if there is some discomfort, and there may be some with the procedure
as they prepare you and insert the line, or as you feel the dye entering your
body, there is no point in fighting it. You can admit it, but then transform that
sensation. If you feel some discomfort, you might find it helpful to make that
part of your body to feel warmer, as if you were in a bath. Or cooler, if that is
more comfortable, as if you had ice or snow on that part of your body. This
warmth and coolness becomes a protective filter between you and the pain.
If you have any discomfort right now imagine that you are applying
a hot pack or you are putting snow or ice on it and see what it feels like.
Develop the sense of warm or cool tingling numbness to filter the hurt out
of the pain.
With each breath, breathe deeper and easier, your body is floating, filter
the hurt out of the pain.
Now again with your eyes closed and remaining in the state of concen-
tration, describe what you are feeling right now.
(1) If they are at their safe and comfortable place—reinforce it.

What is it like now? What do you see around you? What are you doing?
(2) If they are in pain—The pain is there but see if you can add coolness,
more warmth, or make it lighter or heavier.
If no longer in pain—Good, continue to focus on those sensations.
If still in pain—Try to focus on sensations in another part of your body.
Now rub your fingertips together and notice all of the delicate sensations
in your fingertips and see how much you can observe about what it feels
like to rub your thumb and forefingers together. How do you feel now?
If not in pain—Good, continue to focus on these sensations.
If still in pain—Now imagine yourself being at ________ (patient’s safe
place) where you said you felt relaxed and comfortable. What is it like
now? What is the temperature? What do you see around you?
(3) If they state that they are worried—Okay, your main job right now is
to help your body feel comfortable, so we will talk about what is worrying
you. But first, no matter what we discuss, concentrate on your body float-
ing. So let’s get the floating back into your body. Imagine that you are in
this favorite spot and when you are ready let me know by nodding your
head and then we will talk about what is worrying you. But remember no
matter what we discuss concentrate on your body floating, and feel safe
and comfortable. So what is worrying you? (Discuss)
How do you feel now? If not worried: Good, now continue to concen-
trate on body floating, and feel safe and comfortable in your favorite place.
If after discussing patient has persistent worry, then—Okay you might pic-
ture in your mind a screen like a movie screen, TV screen, or a piece of
clear blue sky. First you might see a pleasant scene on it. Now you may
picture a large piece of blue screen divided in half. All right, now on the
left half, picture what you are worrying about on the screen. Now on the
right half, picture what you will do about it, or what you would recom-
mend someone else to do about it. Keep your body floating, and if you are
worrying about the outcome, okay admit it to yourself, but your body does
not have to get uptight about it. You may, but your body does not have to.
Good, you know that whatever happens there is always something you can
do. But for now just concentrate on keeping your body floating and feeling
safe and comfortable.
Sometimes throughout the procedure say—If you feel any sense of discom-
fort you are welcome to let me know about it. You may use the filter to fil-
ter the hurt out of the pain, but by all means let me know and I will do
what I can to help you with it as well. Whatever you do just keep your
body floating and concentrate on being in the place where you feel safe
and comfortable.
When finished, say—Okay the procedure is over now. We are going to
leave formally this state of concentration by counting backwards from
three to one. On three get ready, on two with your eyes closed roll up your
eyes, and on one let your eyes open and take a deep breath and let it out.
That will be the end of the formal exercise, but when you come out of it
you will still have the feeling of comfort that you felt during it. Ready,
three, two, one.
If necessary: Three—get ready. Two—with your eyes closed roll up your
eyes. One—let your eyes open and take a deep breath, and feel refreshed
and proud about having helped yourself through this procedure.”
SCIENTIFIC EVIDENCE
For the past century, the majority of research on hypnosis has been in
the form of case reports, often based on the descriptions of the treating cli-
nician. Supporters of evidence-based medicine often frown on the lack of
thorough methodology; for example, use of anecdotal case reports, selec-
tion biases, retrospective designs, non-standardized interventions, or vague
outcome measures. As such, hypnosis had suffered from lack of availability
of such data from randomized studies (Blankfield, 1991). Nowadays, how-
ever, empirical support for the effectiveness of hypnotic techniques for
medical purposes is available from both experimental and clinical studies.
Modern developments in neuro-imaging provide insight into the physio-
logical mechanism of hypnosis. In experimental studies, hypnotic instruc-
tions have been shown to alter the way pain or other distressful events are
processed in the brain and perceived by an individual (Rainville et al.,
2005; Rainville et al., 1999; Rainville et al., 1997). For example, changing
the wording of suggestions under hypnosis affects the activation of differ-
ent brain centers during exposure to the same stimulus (Rainville et al.,
1997). Rainville et al. (1997) demonstrated that suggestions targeting the
sensory dimension of the pain (such as “you will feel a tingling sensation”)
resulted in activation changes in the primary sensory cortex. Suggestions
targeting the affective dimension of the pain (such as “you will remain
calm”) resulted in changes in the anterior cingulate cortex.
Clinical studies with superior methodology using prospective random-
ized control designs have demonstrated the effectiveness of hypnotic tech-
niques in the peri-operative domain, that is, before (Saadat & Kain,
2007), during (Lang et al., 2000; Lang et al., 2006), and after surgery
(Huth et al., 2004). To name a few examples, hypnotic techniques have
been used for various treatment of breast cancer, burn care, plastic surgery,
tumor embolization, labor and delivery, and the removal of appendices,
bone marrow, teeth, and tonsils (Butler et al., 2005; Faymonville et al.,
1995; Huth et al., 2004; Lang et al., 2000; Lang et al., 2006; Montgomery
et al., 2007; Patterson, Questad, & deLateour, 1989; Wright & Drummond,
2000; Zeltzer & LeBaron, 1982).
Faymonville et al. (2000) reviewed 1,650 various surgical procedures
from retrospective and randomized prospective studies in which hypnosis
was used as an adjunctive treatment to conscious sedation. The authors
concluded that patients greatly benefited from hypnosis as a result of greater
active participation, procedural comfort, faster recovery time, and shorter

hospital stays. To date, the literature on hypnosis documents that this
brief psychological intervention significantly reduces pain intensity, pain
unpleasantness, anxiety, nausea, fatigue, medication use, and procedure
time (Butler et al., 2005; Faymonville et al., 2000; Lang et al., 2000; Lang
et al., 2005; Montgomery et al., 2007).
Montgomery, David, Winkel, Silverstein, & Bovberg (2002) conducted
a meta-analysis of 20 randomized-controlled trials evaluating the effective-
ness of hypnotic techniques in conjunction with pharmacologic treatments
for various medical procedures. Results indicated that on average about
90 percent of surgical patients profited from adjunctive treatment com-
pared to control groups. Outcomes were evaluated according to negative
affect, pain, medication, recovery, and treatment time; hypnosis produced
better results in all of these domains. The authors concluded that hypnosis
is an effective adjunctive procedure for a wide variety of surgical patients
(Montgomery et al., 2002).
Particularly in the realm of interventional radiology, using interventions
with documented beneficial outcomes that are safe and easy to apply on the
procedure table is of prime concern. The current gold standard to assess effi-
cacy and treatment safety is evidence from prospective randomized con-
trolled trials in which patients are randomly assigned to different treatment
conditions. In the experimental group, patients receive an intervention
such as a self-hypnotic relaxation exercise. In the control group, patients
receive the standard medical care without any specific intervention or with-
out an additional person attending to them. There is an ongoing debate as
to which group of patients represents an appropriate control group. Jensen
and Patterson (2005) have argued that an additional control should be
included that does not receive hypnosis or pharmacologic treatment. How-
ever, the intervention still needs to be credible but minimally effective to
control for the social aspects and additional care through the hypnosis pro-
vider present in the hypnosis condition (Jensen & Patterson, 2005).
Lang et al. (2000) presented the most comprehensive study using a pro-
spective randomized-controlled design to establish hypnosis outcomes to
date. In this study, 241 patients underwent interventional radiology proce-
dures in the kidneys and vascular system. Patients were randomized to self-
hypnotic relaxation, structured attention, and standard care. All patients
had access to local anesthetic and IV medication if they requested it. Hyp-
nosis significantly reduced anxiety, pain, drug use, and complications. As a
result, procedure time was reduced by 17 minutes compared to standard
care. In addition, hypnosis reduced costs an average of $330 per procedure
compared to standard care (Lang & Rosen, 2002).
Lang et al. (2006) conducted another randomized-controlled trial on
236 women undergoing large core breast biopsies comparing hypnosis to
standard care and empathic attention. Large core breast biopsies are known
to often cause distress in patients and are usually performed solely under a
local anesthesia (Bugbee et al., 2005). Hypnosis and empathic attention
were administered in addition to local anesthesia; both significantly reduced
pain perception, but only hypnosis also reduced anxiety (Lang et al., 2006).
Montgomery et al. (2007) have presented the most recent randomized
study on brief hypnosis interventions in 200 patients undergoing breast
cancer surgery. Women were randomized to either a pre-operative hypnosis
session with a psychologist or non-directive empathic listening (attention
control). Hypnosis resulted in significantly less drug use for sedation and
pain management during the procedure compared to the control group.
Patients in the hypnosis group also reported less pain, nausea, fatigue,
discomfort, and emotional upset than the controls. The authors also
documented that hypnosis reduced costs by $772.71 per patient for the
institution, mainly as a result of shorter stays in the procedure room
(Montgomery et al., 2007).
In summary, there is overwhelming support for the effectiveness of hyp-
nosis to manage pain and anxiety in patients undergoing invasive medical
procedures. In addition, complications and cost can be reduced by its use.
PATIENTS RESPONSIVENESS AND ACCEPTANCE

In recent years, patients have become more educated about their health
and surgical interventions. Patients want to become more actively
involved in their care. This includes using alternative treatments to reduce
pain and distress. Western medicine has traditionally not met these needs,
and patients have therefore turned toward more alternative sources of
healing. About a third of Americans use alternative treatments for their
medical problems, and it is therefore not surprising that patients present
with their own coping strategies to the procedure suite (Campion, 1993;
Eisenberg et al., 1993). Many patients use mind-body techniques that can
reduce pain and anxiety including imagery, distraction, relaxation, hypno-
sis, and meditation (Quirk, Letenre, Ciottone, & Lingley, 1989; Astin,
2004; Astin, Shapiro, Eisenberg, & Forys, 2003).
In recent years, the Internet, books, and tapes have become valuable
tools for patients, and their authors claim extensive widespread use. It is
becoming more common to see patients checking in for their procedures
with hypnosis tapes or requests for specific coping rituals. Introduction of
hypnosis into the procedure suite may thus become a consumer-driven
event. As David Spiegel (2007) recently stated, hypnotic techniques suffered
the “disadvantage” of not involving drugs or other products that can
be purchased. If this were the case, the industry would have worked
hard to try selling this product. However, the tide may be turning in
favor of such patient-centered therapy based on patient demand and the
superior outcome profile for procedures performed under hypnosis. What
held true for Esdaile in the nineteenth century still holds in the twenty-
first century—hospitals with better outcomes will attract more patients,
and healthcare facilities would be advised to take note in order to compete
in the consumer-driven market of health care.
The question then becomes, which patients can benefit from hypnosis
during surgery? Highly hypnotizable individuals have undergone open sur-
gery solely under hypnosis without general or local anesthesia (Wain,
2004). Wain (2004) has described these talented patients as “hypnotic vir-
tuosos,” but these represent only a small percentage of patients. However,
even hypnosis-naive and moderately hypnotizable individuals can be guided
quickly into self-hypnotic relaxation during minimally invasive procedures
as described previously. For minimally invasive surgery that does not require
general anesthesia, patients can benefit from hypnosis even when their hyp-
notizability is average or low (Flick et al., 1999). A recent study showed
that in a cohort of patients aged 18–92, age had no effect on hypnotizabil-
ity (Lutgendorf et al., 2007), a finding contradictory to previous reports
(Morgan & Hilgard, 1972).
CHALLENGES
Despite the empirical support for the effectiveness of hypnotic techni-
ques, hypnosis is still underused. Reasons for the slow acceptance of hyp-
nosis into mainstream medicine are numerous and include inaccurate
perceptions of this practice. One such inaccurate perception is that hypno-
sis requires additional time and financial costs (Anbar, 2006); the opposite
has been documented (Lang & Rosen, 2002; Montgomery et al., 2007).
Another reason for slow acceptance may rest with the fact that successful
use of hypnosis in the procedure room depends on the cooperation of all
members of the treatment team. Treatments that depend on interpersonal
skills and not a technical gadget are often met with skepticism and some-
times ridiculed by more empirically trained health care professionals.
Research findings on the effectiveness of audio tapes and computerized
interventions have been mixed (Ghoneim, Block, Sarasin, Davis, &
Marchman, 2000; Hart, 1980). It appears that such interventions can be
effective for both treatment outcomes and costs, but more patient-centered
approaches with a personal hypnosis provider have resulted in more con-
sistent benefits. As attractive as it might be to give patients a tape or some
high-tech device such as virtual reality helmets developed by Patterson
et al. (2006), proceedings in the operating room are complex. Providing
patients with the best medical care including procedural hypnosis requires
that the patient’s individual preferences are respected and that the whole
treatment team is willing to go along or at least not to interfere. It “takes
a village” to attend to the patient’s needs and solicit the collaboration of
everybody in the procedural suite for a successful outcome.
Some medical providers believe that stating how painful and distressing
a procedure can be helps the patient and expresses sympathy. With good
intentions physicians and nurses often use terms with unpleasant content
such as “stinging sensation,” “is it hurting yet,” “don’t worry, it will be over
soon,” or “sharp burning pain.” It is assumed that such words help patients,
but the opposite has been shown to be true (Lang et al., 2005). Such nega-
tively loaded suggestions can create “nocebo effects” and increase pain and
anxiety (H. Spiegel, 1997). The idea that words can both heal or harm is
far from new. One of the oldest documents on medical practice, the
“Hippocratic Corpus,” explicitly states that physicians should pay attention
to both talk and silence (Jones, 1923/1972).
Compassionate and empathic communication is often considered essen-
tial for good medical practice and has become an important part in train-
ing health care professionals. However, there remains considerable debate
around what constitutes real empathy and whether it improves the patient’s
well-being. A recent study by Lang et al. (unpublished manuscript) found
that hypnosis techniques and empathic attention reduce pain, anxiety, and
medication during interventional radiology procedures. Yet, empathic tech-
niques alone, without tapping into the patient’s self-coping, resulted in
more pain, anxiety, and complications. These complications were related
not only to psychosocial well-being but also to adverse effects on blood
pressure and oxygen supply. Just providing emotional support without guid-
ing the patient into a more relaxed state seems counterproductive. Chat-
ting and touching the patient may not only be unhelpful, but potentially
harmful if not practiced with caution. Trying to be nice does not suffice in
helping patients help themselves.
PRECAUTIONS AND SAFETY CONSIDERATIONS

Safety of the patient needs to be considered first before any procedures
are implemented. Research studies on the medical use of hypnosis suggest
that it carries little risk for adverse effects, and patients are generally satis-
fied with outcomes (Jensen et al., 2006). If adverse effects emerge, these
are usually minor and transient. Possible adverse effects of hypnosis in the
experimental context include drowsiness and headaches (Coe & Ryken,
1979). Therefore, several safety precautions should be considered and the
potential for adverse effects needs to be recognized early (Barber, 1998).
Since comprehensive training in hypnosis is associated with a lesser
likelihood of adverse effects (Lynn, Martin, & Frauman, 1996) its practice
should be limited to health care professionals with adequate training.
Health care professional should use hypnosis as an adjunct for a treatment
that they are trained to deliver in the first place. For example, members of
the treatment team in the interventional radiology suite could deliver hyp-
nosis in the procedure room but should not attempt to treat post-traumatic
stress syndrome. Hypnotic techniques should also not be used as the only
tool or the last resort to manage pain, anxiety, or medical emergencies. As
a precaution, it is not recommended that hypnosis be used with patients
whose reality testing is compromised since mental health professionals are
best qualified to treat this population. However, psychotic patients typi-
cally are not very hypnotizable (D. Spiegel, Detrick, & Frischolz, 1982).
Lang and colleagues have shown that hypnotic techniques are safe and
effective in the interventional radiology setting (Lang, Joyce, Spiegel,
Hamilton, & Lee, 1996). Use of hypnotic scripts can ensure safety and
reproducibility that are particularly important in research and procedural
settings. The script used by our group places an emphasis on rapid trance
induction, patient-centered imagery, and permissiveness, and was originally
developed by Dr. D. Spiegel (Lang et al., 1999). The script is quick and easy
to apply, immune to disruptions, and also addresses fears of patients early
before these become more difficult to manage.
CONCLUSIONS
Research has demonstrated that hypnotic techniques can be safely and
effectively integrated into a medical high-tech environment. Integration of
hypnosis in modern medicine does not add costs nor time. Even hypnosis-
naive patients can learn hypnotic techniques on the operating table with-
out disturbing or prolonging the procedure. In summary, hypnosis is ideally
suited as an adjunctive treatment for modern minimally invasive proce-
dures. The union of high-tech medicine and hypnosis, the oldest form of
psychotherapy, would make for a happy marriage (D. Spiegel, 2006).
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This work was supported by the U.S. Army Medical Research and Material Com-
mand (DAMD 17-01-1-0153), National Institutes of Health & National Center for
Complementary and Alternative Medicine (RO1 AT-0002-05 & K24 AT01074-01),
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& National Institute of Cancer (T32-59367).
Chapter 6
Hypnosis in the Treatment of Smoking,

Alcohol, and Substance Abuse:
The Nature of Scientific Evidence
Kent Cadegan and V. Krishna Kumar
The Substance and Mental Health Services Administration (2007)

reported that in 2006, 72.9 million Americans (29.6 percent) aged 12 or
older were current users (past month) of a tobacco product, the largest
(61.6 million or 25 percent) were cigarette smokers. Furthermore, illicit
drug use was almost 9 times higher (47.8 percent) among youths aged 12 to
17 who smoked cigarettes in the past month than it was among youths who
did not smoke cigarettes in the past month (5.4 percent). Generally, illicit
drug use was reported by 9.6 million persons aged 12 or older. Marijuana, a
popular drug of choice of 14.8 million users, was smoked daily or almost
daily over a period of 12 months by 3.1 million persons among past mari-
juana users, aged 12 or older. Heavy alcohol was reported by 17 million
(6.9 percent) of the population aged 12 or older, or 17 million people, and
binge drinking by 57 million people (23 percent). Even more troublesome
is that in 2006, 10.2 million people (4.2 percent) aged 12 or older reported
driving under the influence of illicit drugs during the past year.
Smoking is the leading contributor to premature death, cardiovascular dis-
ease, stroke, lung cancer, and, more recently, it has been linked to Alzheimer
disease and dementia. A study of 6,868 people age 55 and older in the Neth-
erlands, followed for seven years, showed current smokers, without an APOE
e4 allele, were at increased risk to develop Alzheimer dementia, than those
who had never smoked. There was no association in whom the allele was
present. There was, however, no association between current smoking and
risk for vascular dementia, or past smoking and risk for dementia, Alzheimer
dementia, and vascular dementia (Reitz, den Heijer, van Duijn, Hofman, &
Breteler, 2007). Alcohol, cocaine opiates, other street and prescription drugs,
and gambling wreak havoc in the lives of many people and stress the health
care system, law enforcement, and employment agencies to a very high level
in many developed countries. The social costs of addictions are indeed very
high (Rehm, Taylor, Patra, & Gmel, 2006), given that there are multiple
consequences of substance abuse—premature mortality, conflicts with family,
unemployment, various psychiatric disorders, transmission of infectious dis-
eases, automobile accidents, cancer, and a host of other medical ailments
(Wagner et al., 2007).
Treatment options abound for people addicted to tobacco and illicit
and prescription drugs. These include self-help groups such as Alcoholics
Anonymous and Narcotics Anonymous; pharmacological interventions in
the form of emetics, patches, and pills; acupuncture; and, psychological
interventions that use behavioral, cognitive-behavioral, stress manage-
ment, motivational, and hypnotic strategies to beat addictions. Of course,
people often simultaneously attempt one or more interventions, for exam-
ple acupuncture, patches, and cognitive-behavioral.
The rising cost of the dominant conventional allopathic system of pharma-
ceutical antidotes appears to be driving individuals to seek alternative systems
of healing and wellness, including hypnosis. With over 300 alternative systems
of health care the world over, it is necessary to establish the effectiveness of
hypnosis as a treatment modality, particularly since it could be a very cost-
effective treatment strategy. To think a simple daily self-hypnosis practice and
timely hypnotherapy could offer significant relief begs more careful scrutiny
than given Franz Mesmer by the French Academy of Sciences.
The purpose of this chapter is to review experimental evidence on the
effectiveness of using hypnosis in the treatment of smoking and drug and
alcohol abuse. The review is restricted to experimental work and is an exami-
nation of the Cochrane Database of Systematic Reviews (2000–2005), other
past reviews, and recent individual experimental studies using hypnosis for
the treatment of smoking, drug, and alcohol abuse.
HYPNOSIS IN THE TREATMENT OF SMOKING

Excellent reviews of literature (Holroyd, 1980; Green & Lynn, 2000;
and most recently, Abbot, Stead, White, & Barnes, 2006) are already
available on the impact of hypnosis on smoking cessation. They all paint a
fairly grim picture about the effectiveness of hypnosis for smoking cessa-
tion with a minimal intervention of one or two sessions.
The reviews of Green and Lynn (2000) and Abbot et al. (2006) suggest
that the most available studies suffer from one or more methodological
weaknesses, thus failing to meet the criteria for meeting the highest levels
of evidence for evidence-based research on the effectiveness of therapy.
From a comprehensive review of clinical reports, nonrandomized/nonequi-
valent sample studies, experimental investigations with less than recom-
mended sample size, and rigorous experimental studies, Green and Lynn
Hypnosis in the Treatment of Smoking, Alcohol, and Substance Abuse 167
(2000) concluded: “giving hypnosis the stamp of a well-established treat-

ment for smoking cessation is premature, although hypnosis can, with some
justification, be regarded as a possibly efficacious, yet by no means specific,
treatment for smoking cessation” (p. 216).
In a review on the effectiveness of a variety of smoking cessation interven-
tions, Marlow and Stoller (2003) highlighted Abbot, Stead, White, Barnes,
and Ernst (2000), finding no “efficacy of hypnosis for smoking cessation”
(p. 1251), noting that the main challenges to validating the efficacy of hyp-
nosis had to do with “small sample size of most of the trials and confounding
issue of separating the impact of time spent with the therapist from the
hypnosis itself ” (p. 1251). Furthermore, they observed that “The USDHHS
Clinical Practice Guideline do not recommend hypnosis” (p. 1251).
There is little evidence that hypnosis for smoking cessation does any
better than other treatments (relaxation, behavior modification, and health
education), attention, or placebo comparisons (see also Covino & Bottari,
2001). Re-examining the data reported by Green and Lynn (2000; Table 1),
the median abstinence rates in clinical reports using 3, 6, and 12 months
time frames were found to be 29, 25, and 19 percent, respectively. Further-
more, data on nonrandomized/nonequivalent sample studies, abstinence rates
reported in Table 2 by Green & Lynn (2000) ranged from 1 month to 19
months in 5 very different studies, making it difficult to evaluate the effect of
hypnosis in terms of specific time frames on abstinence rates. The median ab-
stinence rate for hypnosis alone, for these varied time frames, was about
22 percent. The median abstinence rate was 31.5 percent for experimental
studies with less than recommended sample size, using individual and group
hypnosis conditions and using follow-up periods of 1 week to 6 months
(based on Table 3, Green & Lynn, 2000). The median abstinence rate was
21 percent for follow-up time periods of 3 weeks to 6 months in rigorous
experimental studies (estimates based on Table 3, Green & Lynn, 2000).
Abbot et al. (2006) considered only those studies that used randomized
controlled trials that reported abstinence over at least 6 months after the
beginning of the treatment. They found only nine such studies (through
search of various data bases, 1966–2005) from which they concluded: (a)
there was wide variation of results in individual studies, with conflicting
results about the effectiveness of hypnosis, relative to other treatments or
control conditions (wait listed/no treatment control, attention/placebo,
psychological treatments, rapid/focused smoking, hypnosis plus group ther-
apy vs. group therapy alone), (b) there was no evidence of a greater effect
of hypnotherapy on 6-month abstinence rates, compared to other treat-
ments or no treatment, (c) studies used a wide range of hypnotherapies,
but did not describe them fully, (d) none of the studies used biochemical
markers for determining abstinence at follow-up, (e) the increased likeli-
hood of abstinence, in studies reporting success, may be due to non-specific
factors such as contact with a therapist, and (f) the encouraging results
from uncontrolled studies may be due to the inclusion of highly motivated

participants and may not be reflective of long-term abstinence.
A recent study by Elkins and Rajab (2004) used a non-randomized con-
trol group study. The control was a consult-only group of nine patients
(who chose not to participate after session 1) who were compared with
patients who had experienced one (n ¼ 9) or two sessions (n ¼ 12) of hyp-
nosis treatment. During the second session, patients were provided with a
cassette tape (direct suggestions for relaxation and comfort) following hyp-
nosis with individually adapted hypnosis suggestions at the end of the sec-
ond session and were asked to practice four or more times per week.
Although encouraging results were reported (48 percent abstinence rate at
one year post-treatment), no results pertaining to the use of practice or its
effects were reported.
Elkins, Marcus, Bates, Rajab, and Cook (2006) noted that many of the
randomized studies have used “a minimal approach to hypnotherapy,
involving one or two sessions or group interventions” yielding “outcomes
about 20% to 25% cessation” (p. 304). Elkins et al. (2006) conducted a
prospective randomized control group pilot study, involving intensive hyp-
notherapy for smoking cessation involving eight sessions, in which hyp-
notic interventions were conducted in sessions 1, 2, 4, and 7. Individualized
suggestions were embedded in general common suggestions (across all sub-
jects) of “deepening relaxation, absorbing in relaxing imagery, commitment
to stop smoking, decreased craving for nicotine, posthypnotic suggestions,
practice of self-hypnosis, and visualization of the positive benefits of smok-
ing cessation” (p. 307). The 20 participants in the experimental group were
also provided with self-help materials from the National Cancer Institute
and brief counseling each session, plus a self-hypnosis tape recording and
tape player and instructed in the daily practice of self-hypnosis. The partici-
pants also received supportive phone calls three days after the target quit
date, and in weeks 2, 4, and 5. The 20 participants in the wait-listed group
received self-help material, were encouraged to set a quit date, and received
supportive phone calls. Using biochemical markers, they reported a 40 per-
cent continuous abstinence rate (from quitting date) for the hypnosis par-
ticipants as opposed to zero percent in the control group. Unfortunately,
again, the study did not examine either the effects of hypnotic susceptibil-
ity or the effects of practice.
Lynn and Kirsch (2006) described a two-session program approach, using
cognitive-behavioral training in conjunction with self-hypnosis training. Their
program included the following components: self-hypnosis training, cognitive-
behavioral skills, education, enhancing motivation and self-efficacy, being a
nonsmoker, relapse prevention and gain maintenance, minimizing weight
gain, and contracting and social support. They reported continuous abstinence
rates of 24 to 39 percent at six-month follow-up (n ¼ 236) across different
trainers.
HYPNOSIS IN THE TREATMENT OF ALCOHOL AND

SUBSTANCE ABUSE
Relative to smoking, very few experimental studies exist on the use of
hypnosis in the treatment of alcohol and even fewer on substance abuse,
although there appears to be a growing interest in using hypnosis for treating
alcoholism and other addictions (Potter, 2004). Early reviews by Wadden
and Penrod (1981), Wadden and Anderton (1982), and Schoen (1985) sug-
gest mixed findings. Experimental studies showed little effects of hypnosis on
alcohol abstinence, but case studies reported encouraging results. All reviews
pointed to various methodological flaws in the reviewed studies that make it
highly problematic to conclude that hypnosis qualifies as an evidence-based
approach (or even possibly efficacious) for treating alcohol abuse. Examining
more current literatures suggests that this has not changed. There have been
a few dissertations on the adjunctive usefulness of hypnosis (Chierici, 1989;
Crocker, 2004; Smith, 1988; Young, 1996) in the treatment of alcohol abuse.
Unfortunately, none of these studies say much about the efficacy of hypnosis
as an evidence-based approach, either as an adjunctive technique or as
stand-alone treatment strategy in the treatment of alcohol abuse or depen-
dence. They worked with small sample sizes, short-follow-up time frames
(1 week to 90 days), and outcomes were assessed via self-report.
As mentioned before, experimental studies with substance abuse patients
are even more rare. A recent randomized controlled trial by Pekala et al.
(2004) was a step in this direction. They used random assignment across four
conditions (hypnosis, transtheoretical, cognitive-behavioral, and attention-
placebo labeled as stress management conditions). All 261 veterans included
in the study were involved in either a 21 or 28 (dual diagnosis) substance
abuse day treatment program involving intensive group and individual ther-
apy five days a week, approximately six hours a day. The veterans received
an additional four hours of training in self-hypnosis, a cognitive-behavioral
transtheoretical intervention (based on Prochaska, Norcross, & DiClemente,
1992), or an attention-placebo (stress management) intervention program.
Thus, the treatment conditions in the study were all adjunctive to the regular
domiciliary programs. The veterans received treatment manuals in the four
conditions, which they could refer to use and use on a regular basis during
treatment and postdischarge.
The hypnosis treatment included four hypnosis protocols: self-esteem
enhancement, relapse prevention, serenity enhancement, and anger and anx-
iety reduction/management. The relapse prevention hypnotic protocol used
suggestions based on H. Spiegel (1970) and suggestions for relapse prevention
based on Marlatt and Gordon (1985). All protocols included body-scan
relaxation and mind-calming suggestions. The participants were encouraged
to practice “whatever self-hypnosis protocol they wanted, but to do so at
least once per day for the next 3 months” (p. 285). A two-month self-report
follow-up was conducted. Of the 54 percent of participants contacted,

87 percent reported total abstinence in all four groups. While there were no
significant overall differences in the four experimental conditions in relapse
rates, possibly due to the excellent residential program everyone received,
some interesting findings did emerge, “with severely addicted individuals,
practicing self-hypnosis tapes regularly (at least 4 times a week) postdischarge
was associated with increased self-esteem and serenity, and decreased anger
impulsivity” (p. 292). Additionally, “participants were more likely to be
abstinent to the extent they practiced the audiotapes, and at the beginning
of the study had lower levels of self-esteem, were already practicing counter-
conditioning strategies, and did not practice stimulus control” (p. 293).
Given that hypnotic responsivity was associated with those who practiced
the self-hypnosis tapes, the results suggest a specific mediating effect of hyp-
nosis. The study’s results can be considered encouraging as an evidence-based
adjunctive treatment strategy, in as much as it suggests the use of multiple
hypnotic protocols and the significance of self-hypnosis practice for more
hypnotically responsive patients. Although the study used random assign-
ment, treatment manuals, and had adequate sample size in each condition,
the follow-up relied upon self-reports, and the number of individuals avail-
able for final analyses were small. Unfortunately, the data on what protocols
were actually practiced were not collected, thus it is not possible to deter-
mine what mechanisms were actually at work in the participants who found
hypnosis helpful.
GENERAL DISCUSSION
Examining both extant reviews and recent experimental studies on the
use of hypnosis for smoking cessation suggests that the conclusion of Green
and Lynn (2000) of hypnosis as a “possibly efficacious, yet by no means spe-
cific, treatment for smoking cessation” (p. 216) still remains valid. If a
potential client calls and asks, does it work, we are still unable to give a
clear substantive answer as to what would be a reasonable expectation of
success. Given abstinence rates of zero to 88 percent in different studies,
even with rather gross estimates of about 20 percent success rates, it is
not clear what statement can be made to a potential client as to what
to expect. In contrast, it is noteworthy that Law and Tang (1995) reported
that an estimated 2 percent of smokers stopped smoking and did not
relapse up to a year as a result of brief unsolicited advice from their physi-
cian, leading them to conclude that although the effect is modest, this
is a very cost-effective strategy. It would be interesting to determine if
physician-referred patients for hypnosis are more successful than those
referred from other sources (e.g., friends, families, self).
The conclusion with regard to the use of treatment of alcohol and drugs
is even bleaker, despite the number of good ideas that are available in the
designing of hypnotic treatment protocols and tested in somewhat less rig-

orous studies that suggest that hypnotic strategies are valuable for at least
some clients.
Some key recommendations emerge from a review of these various studies.
There is a need to standardize the measurement of outcomes by way of using
biochemical markers. There appears to be an over-reliance on the more con-
veniently obtained self-report measures. Follow-up intervals tend to be short,
possibly because of inadequate funding of such projects and perhaps also the
increasing difficulty of maintaining contacts over time with the participants.
However, there is a need for systematizing the follow-up intervals in different
studies. Possibly the minimal requirement for such outcome studies should
use follow-up time frames of 3, 6, and 12 months. With increasingly long-
term follow-ups, there is an increasing problem for internal validity, in as
much as there is a potential for greater within-conditions variability
(Westen, Novotny, & Thomson-Brenner, 2004). Investigators should also
report whether the participants were continuously abstinent over the time
frames used in the study, along with frequency of lapses and relapses, and not
just whether they were abstinent at the single point of time at follow-up. A
study of lapses and how participants recover from lapses would be valuable.
There is also a need to evaluate the effectiveness of hypnosis for different
types of smokers—light, medium, or heavy—and chronic (hardened smokers)
versus those have smoked for a short period of time.
In designing studies, one needs to employ a hypnosis-alone condition,
along with hypnosis-plus another treatment such as cognitive-behavioral,
cognitive-behavioral alone, and an attention-placebo condition to more
accurately assess the role of hypnosis as an adjunctive technique. The ques-
tion of how many sessions do we need remains to be addressed. There is a
need to systematically examine the popular one-session approach with a
more multiple-session approach, especially in view of the popular one-large
group sessions that are offered by lay hypnotists in hotels around the coun-
try. Studies are needed to examine the effectiveness of particular sugges-
tions used in hypnosis protocols. This can be done by both asking patients
what they found most helpful in the hypnotic protocol used and more rigor-
ously by conducting controlled experiments. Yet another possibility is to
examine if stages of change (Prochaska et al., 1992) are important in the
type of suggestions used. Such analyses will be helpful in making specific
recommendations to clinicians. Currently, a wide range of suggestions are
used and it is not known what suggestions are particularly helpful and when
(i.e., in terms of stages of change). In studies where multiple protocols are
used, addressing tangential, but relevant aspects, such as improving self-
esteem, reducing anger (e.g., Pekala et al., 2004), it is important to follow
up on understanding their contribution to the treatment process.
Studies are needed to examine the effectiveness of individualizing
suggestions versus using pre-scripted versions and their association with
hypnotizability. The chief advantage of pre-scripted protocols is that they

can be administered by a minimally trained technician and/or via audio-
tapes. In contrast, individualized protocols clearly require experience and
would require individual taping. Hypnotizability needs to be routinely
assessed in treatment outcome studies, as Bowers (1984) noted “the effects
of a treatment intervention are not due to a suggestion unless treatment
outcome is correlated with hypnotic ability” (p. 444), the point of view is
referred to as the “Bowers Doctrine” (Woody, 1997, p. 227).
Pekala et al.’s study suggests the importance of self-hypnosis practice
(see also Potter, 2004). However, not much is known about the role of
self-hypnosis practice as it relates to treatment outcomes. Specifically, how
much practice is needed and for how long? Is distributed practice better
than massed practice? Is it better to use taped scripts or have the patients
practice without audiotapes on self-generated suggestions? And, is there a
role for hypnosis booster sessions in maintenance?
Since hypnosis is popularly sought as treatment of smoking cessation, it
is imperative that studies are urgently needed to not just establish it as an
effective treatment, but also to determine the essential components of a
hypnotic intervention. Thus, there is a need to know what works and what
does not work and for whom (i.e., types of suggestions, types of practice,
individual vs. group, types of adjunctive treatment, individually tailored
vs. pre-scripted versions, influence of individual difference variables; see
Spiegel, Frischholz, Fleiss, & Spiegel, 1993).
There is indeed a significant body of work (case studies, quasi-experimental
studies, and experimental studies) that suggests hypnosis is a viable treatment
option, and there is no dearth of good ideas about how hypnotic protocols are
to be designed—but there is a need for testing these ideas using experimental
methods. Eventually, it should be possible to say to a potential client that hyp-
nosis can help you control your addiction if you have certain characteristics
(e.g., hypnotizability, motivation to quit; availability of social support), and if
you are willing to practice (with specification about the nature and amount of
practice).
There is no exclusive methodology by which science progresses—there is a
place for a variety of different types of methodologies, informing one another.
On a cautionary note, it is important to realize that the randomized controlled
trials, the “gold standard” (Cooper, 2003, p. 106) of evidence-based practice,
has weaknesses. Most importantly, such trials address narrow issues, use care-
fully selected samples, use short-trial periods, and provide information about a
group, not individual treatment (see Cooper, 2003; Williams & Garner,
2002), among other problems. Williams and Garner (2002) pointed out that
even a single successfully treated patient might provide information on a
breakthrough procedure, for example, “the first surgical operation for mitral
stenosis” (p. 11). Thus, evidence that is based on randomized controlled trials
is not to be construed as a guarantee of success in practice At best, they
provide guidance and needs to combine with clinical experience for making
treatment decisions. Williams and Garner (2002) noted: “Sophisticated clini-
cal experience with regard to an individual patient needs to be balanced with
an evidence base derived from a group. Too much emphasis on a narrow range
of acceptable evidence oversimplifies the complex nature of clinical care”
(p. 11). Furthermore, even well-established medical practices do not always
work for everyone. And, what may generally not work may have extraordinary
effects in some individuals. Williams and Garner (2002) observed: “The EBM
[Evidence-Based Medicine] data on donezpil show marginal improvement in
patients with mild to moderate dementia. On the other hand, there are good
examples of individual patients showing impressive improvement in patients
(Dening & Lawton, 1998; Manchip & Morrison, 1999). Evidence of this
nature must be recognized and not dismissed as anecdotal (p. 10).”
A recent exciting finding was reported by Naqvi, Rudrauf, Damasio, &
Bechara (2007) concerning the role of the insula in controlling conscious
urges for nicotine. Damage to the insula was accompanied by “disruption
of smoking addiction, characterized by the ability to quit smoking easily,
immediately, without relapse, and without persistence of the urge to
smoke” (p. 531). A patient who had smoked “40 unfiltered cigarettes per
day and was enjoying smoking very much” (p. 534) quit smoking immedi-
ately after suffering a stroke; he stated “he quit because his ‘body’ forgot
the urge to smoke” (p. 534), suggesting that smoking serves to satisfy a
bodily need. In a media report, one of the authors of the study, Bechara,
stated: “The quitting was like a light switch turned off and he never
wanted a cigarette again” (Dunham, 2007, pp. 1–2). Naqvi et al. (2007)
suggested that “therapies that modulate the function of insula will be use-
ful in helping smokers quit” (p. 534) Well, can hypnosis practitioners
design suggestions to turn odown the insula when faced with cravings, or,
to gain greater control by being able to turn it up and down volitionally?
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AUTHORS’ NOTE
The authors thank Dr. R. J. Pekala for his comments on an earlier ver-
sion of this chapter. Reprint requests are to be addressed to V. K. Kumar,
Department of Psychology, West Chester University of Pennsylvania,
West Chester, PA 19393; e-mail: vkumar@wcupa.edu
Chapter 7
Hypnosis and Medicine:

In from the Margins
Nicholas A. Covino, Jessica Wexler,
and Kevin Miller
A significant relationship between psychological variables, most notably anx-

iety and depression, has been found to be present in a variety of medical
illnesses (Roy-Byrne et al. 2008). Psychological interventions in medicine
commonly employ cognitive-behavioral and relaxation strategies that target
the autonomic nervous system and improve social support for patients.
Behavioral medicine strategies seek to manage increases in heart rate, respi-
ration, muscle tension, and the overproduction of glucose, neurotransmitters,
and hormones that result from sustained sympathetic arousal and benefit
patients with pain, insomnia, asthma, gastrointestinal disorders, and some
others (Giardion, McGrady, & Andrasik, 2007). Cognitive processes are
thought to play a key role in the maintenance of these medical illnesses and
somewhat in their treatment (Grossman, Neimann, Schmit, & Walach,
2004; Lehrer, Carr, Sargunaraj, & Woolfolk, 1993). Social supports are pur-
ported to provide emotional and instrumental assistance for patients and
contribute beneficially to longevity (Anderson, 2003).
Hypnosis interventions with pain patients have been found, in varying
degrees, to be efficacious (Montgomery, DuHamel, & Redd, 2000; Patterson &
Jensen, 2003). Reviews of the hypnosis literature and in other areas propose
that medical illness and conditions such as insomnia, asthma, bulimia, and
irritable bowel syndrome and illness behaviors such as cigarette smoking and
hyperemesis point to opportunities for symptom reduction and illness man-
agement via hypnosis (Covino, 2008; Mendoza & Capafons, 2009; Pinnel &
Covino, 2000). Recent research with children and adults who are undergoing
painful medical procedures supports the use of hypnosis as a distraction and
pain management technique not only to decrease discomfort, but also, the use
of medication and the time required for treatment (Butler, Symons, Hender-
son, Shortliffe & Spiegel, 2005; Lang et al., 2000).
Hypnotic interventions have a long history in the treatment of the medi-
cally ill. However, apart from the role of hypnosis in pain management,
much of the research support for the use of hypnosis with the medically ill is
dated or lacks sufficient methodological rigor to qualify for recommendation
as an adjunct to medical care by mainstream practitioners. Most limiting are
the parochial experimental models and idiosyncratic treatment protocols of
hypnosis that ignore the research findings of other psychology and behavioral
medicine investigators. The hypnosis literature on pain management pro-
vides significant reason to believe that hypnotic techniques can be of benefit
to medical patients (Patterson & Jensen, 2003) and that there is some sup-
port for its extension to other illness areas (Pinnel & Covino, 2000). How-
ever, methodological weaknesses in the hypnosis literature, such as absent or
dated research, a paucity of randomized control experiments, and the com-
mon failure of hypnosis researchers to integrate the results of studies from
behavioral science investigators and other medical research, limit the accep-
tance of hypnosis as an adjunctive technique by patients and professionals.
Advancement in this area seems achievable, but greater recognition requires
the hypnosis community to update its literature, integrate findings from other
researchers in psychology and medicine, and bring increased methodological
rigor to research strategies to accomplish this.
Several medical illnesses and conditions serve as good examples of the
promise and challenge for hypnosis in medicine, and these will be reviewed
in this chapter. Since the efficacious role of hypnosis in pain management
is best established and has been the subject of several excellent analyses
(Montgomery, DuHamel, & Redd, 2000; Patterson & Jensen, 2003) we will
not discuss it in further detail in this chapter.
ABSENT RESEARCH SUPPORT: INSOMNIA

Between 40 and 70 million Americans experience at least one episode of
sleeplessness each year with chronic insomnia claiming about 20 percent of
the adult population and close to 30 percent of those in senior years (Foley
et al., 1995; NIH, 2005). Psychophysiologic insomnia is second in fre-
quency only to the complaint of pain among primary care patients (Hauri
& Linde, 1996) and it is the result of the combination of autonomic nerv-
ous system (ANS) arousal and injudicious behavior.
Consistent with a pattern of chronic ANS arousal, insomniacs use increased
oxygen during the day and at night (Bonnet & Arand, 2003); demonstrate
persistent elevations in temperature, heart rate, basal skin response, and vaso-
constriction prior to and during sleep (Bonnet & Arand, 1998; Lushington,
Dawson, & Lack, 2000); and report more frequent pre-sleep negative cognitive
activity (Harvey, 2000; Kuisk, Bertelson, & Walsh, 1989; Nelson & Harvey,
Hypnosis and Medicine 179
2003). In an effort to cope with chronic insomnia, individuals commonly

self-medicate with alcohol, establish irregular sleep habits, and engage in
behaviors such as reading and watching television in bed that are incompatible
with sleep. A repetitive cycle of arousal that includes catastrophic thinking,
increased cardiopulmonary activity, maladaptive behaviors, and the release of
hormones and neurotransmitters maintains the disorder. Sedative medications
are sometimes prescribed, but psychological treatments such as cognitive be-
havioral therapy (CBT) that emphasize relaxation, cognitive restructuring
(e.g., challenging and revising catastrophic thinking, such as “I must get to
sleep soon or I will have a terrible day tomorrow.”) and “sleep hygiene” (e.g.,
regularizing bedtime, avoiding daytime naps, leaving the bed when sleep is
delayed more than 20 minutes), are recommended treatments (NIH, 2005).
Seventy-eight adults with chronic insomnia who were randomly assigned
to receive medication (Temazepam), CBT, CBT þ medication, or placebo
reported better results for all active treatment conditions. While the best
results were obtained by patients in the combined condition, CBT not only
outperformed the medication-alone group, but, at one- and two-year follow-
up, subjects reported greater relief and satisfaction with the psychological
intervention over medication alone (Morin, Colecchi, Stone, Sood, & Brink,
1999). In a double-blind, placebo, controlled study, patients who were
offered six weeks of CBT increased their hours of sleep and reduced the time
that it took to fall asleep more than those trained with relaxation alone or
subjected to desensitization techniques (Edinger et al., 2001). When insom-
nia patients were, again, randomly assigned to treatment conditions that
included CBT, placebo, a popular sleep medication, and the combination
medicine and CBT, both of the cognitive interventions had significant effect
at six months on sleep efficiency over placebo and medication alone (Jacobs,
Pace-Schott, Stickgold, & Otto, 2004). Patients who were offered the psy-
chological intervention reported greater satisfaction with their results
than those in the medication group. Interestingly, this type of cognitive-
behavioral intervention has been found to be equally successful whether it is
administered in a group, individually, or over the telephone in a 20-minute
format (Bastien, Morin, Ouellet, Blais, & Bouchard, 2004).
A National Institute of Health expert panel, charged with reviewing the
state of the science on insomnia, concluded that cognitive and behavioral
techniques were the most effective psychological interventions for this dis-
order (NIH, 2005). Unfortunately, hypnosis was not recommended by the
committee, due to a lack of available evidence in support of it. Although
this aptly named (i.e., pnos ¼ sleep, from the Greek) technique captures
attention, facilitates absorption, alters perception, and offers suggestions
for cognitive and behavioral change, researchers have not subjected it to
empirical trials. It is easy to hypothesize that those who are blessed with
vivid imaginations could be more susceptible to sleep disruption. Further-
more, this same capacity for absorption and imaginative involvement seems
likely to permit patients with hypnosis to relax deeply and distract

themselves from arousing thoughts in a manner that would facilitate sleep.
However, only anecdotal case reports exist for hypnotic interventions with
sleep-disordered patients, making it impossible to include among the evi-
dence-based treatments in medicine.
DATED RESEARCH SUPPORT: ASTHMA,

BULIMIA, HYPEREMESIS
Asthma
Asthma is a chronic medical illness that is characterized by episodes of
inflammation and narrowing of the small airways of the lung, leading to symp-
toms of wheezing, shortness of breath, cough, and chest tightness. Approxi-
mately 22 million people in the United States suffer from asthma, and this
number has been rising significantly due to lifestyle issues such as obesity, pol-
lution, and smoking (Yeatts et al., 2006; National Heart Lung and Blood
Institute 2008). Asthma results in lost work days and health care costs that
exceed $16 billion per year and is among the most common causes of absen-
teeism among school-age children (NHLBI, 2008). Asthmatic episodes are
commonly triggered by allergens, infection, and exercise, but psychological
factors such as anxiety and panic are thought to be triggers as well (Kayton,
Richardson, Lozano, & McCauley, 2004).
For many years, bronchial asthma was regarded as a “psychosomatic” illness.
Early psychoanalysts (Alexander & French 1945; French & Alexander, 1941)
grouped asthma among seven illnesses, including ulcerative colitis and neuro-
dermatitis, where psychological conflicts were determined to be necessary and
sufficient causes of disease. The asthma patient’s signature wheeze was seen as
a symbolic expression of dependency (i.e., “a suppressed cry for help from the
mother”) that would be resolved, along with the medical illness, by psycho-
analysis. Later work in the 1970s, influenced by an understanding of asthma as
a “hyperreactive airways disease” where the smooth muscle surrounding air-
ways in the lung becomes triggered by heightened emotion, identified anxiety
as an emotional trigger for an asthma attack. Susceptible individuals would
not only be more vulnerable to increased symptoms but characterological anx-
iety was found to negatively impact the management and course of care
(Jones, Kinsman, Dirks, & Dahlem, 1979; Kinsman, Dirks, Jones, & Dahlem,
1980). More recent studies continue to find a relationship between panic dis-
order and asthma sufferers. Hasler and her colleagues found that children with
panic disorder were six times more likely to develop asthma as adults, and that
asthmatic children were found to have a 4.5-fold incidence of panic disorder
as adults (Hasler et al., 2005). The World Mental Health Survey of more than
85,000 adults found that asthma patients were 1.5 times more likely than non-
asthmatics to experience panic and related anxiety disorders (Scott et al.,
2007). The more recent medical understanding of asthma as an inflammatory

disease that is regulated by the immune system has invited researchers in the
emerging field of “psychoneuroimmunology” to examine the relationship
among psychological stress, immune response, and asthma symptomatology
(Wright, 2004).
Early research utilizing suggestion and hypnosis in the treatment of
asthma produced a rationale to include it in asthma care and some measure
of hope for its efficacy. An experimental model, developed in the mid-
1960s, measured airways resistance among asthmatics exposed to saline mist
who were given “suggestions” that they were breathing bronchoconstricting
irritants. Nineteen of 40 asthmatics reacted to the experimental situation
with a significant increase in airways resistance and 12 of the asthmatic
subjects developed full-blown attacks of bronchospasm that was reversed
with a saline solution placebo (Luparello, Lyons, Bleecker, & McFadden,
1968). A meta-analysis of 23 studies that followed this same model found
that one-third of the total 427 subjects in these studies demonstrated clini-
cally significant responses to suggestions for breathing difficulties.
Two randomized, control studies are some of the best work in this area
and each is more than 40 years old (British Tuberculosis Association, 1968;
Maher-Loughnan, Mason, Macdonald, & Fry, 1962). At 18 months, asthma
patients with hypnosis training demonstrated a significant decrease in medica-
tion use over asthma patient-controls without such training (Maher-Loughnan
et al., 1962). A large sample (N ¼ 252) randomized clinical trial examined the
efficacy of relaxation training alone versus monthly hypnosis training with
daily practice and found improvements in both groups. However, significantly
better reduction in symptoms and medication use, especially among female
patients, was noted for those in the hypnosis condition (British Tuberculosis
Association, 1968). Patients with heightened hypnotizability were found to
benefit from a supportive visit, but experienced significantly more benefit when
trained to use hypnosis to manage asthma symptoms (Ewer & Stewart,
1986). A small group of 10 patients with exercise-induced asthma per-
formed significantly better on treadmill tests when trained to use hypnosis
than when they were offered a medication, a placebo, or standard care
(Ben-Zvi, Spohn, Young, & Kattan, 1982). A more recent study (Anbar,
2002) found improvement for 80 percent of children who were offered hyp-
nosis training, but it is unclear whether these children were asthmatic or
were “pseudo-asthma” patients with a significant psychological component
to their symptom presentation.
Given the impressive results of the early work in this area and the striking
number of children and adults who suffer from asthma, it behooves clinical
hypnosis researchers to undertake further study of the impact of hypnosis
training in this population of medical patients. The number of studies
demonstrating the strong relationship between panic and asthma and sug-
gestibility and asthma offer a significant promise for the use of hypnosis as an
adjunctive resource in pulmonary care. However, the dated literature in this

area limits any enthusiasm among medical specialists to include this as a
treatment strategy.
Bulimia
While the prevalence of bulimia nervosa in the general population is very
small, estimates of women, especially young women, with eating disorders
range between 1 and 4 percent (American Psychiatric Association, 2000;
Howat & Saxton, 1987). Individuals with this disorder are often normal-
weight individuals, but they feel out of control with regard to their eating, of-
ten bingeing on large quantities of food at a time. Despite a “normal” appear-
ance, they commonly harbor a distorted body image of themselves as
overweight, and they become preoccupied with maintaining a certain physi-
cal image. Diuretics and vomiting are often employed to reduce the caloric
impact of over-eating that leads to a vicious cycle of bingeing and purging.
While these disordered eating behaviors are not life threatening per se, seri-
ous dental, gastrointestinal, and cardiovascular problems can result from
chronic bingeing and purging (Fairburn, Cooper, Safran, & Wilson, 2008).
The origin of this disorder is unknown, but symptoms of depression and
anxiety are frequently reported by those with bulimia. Cognitive-behavioral
treatments have been found to be successful at reducing the frequency and
severity of bulimic symptoms, although many women report symptoms of
this disorder throughout their lives. Dissociative symptoms of timelessness,
depersonalization, derealization, and involuntariness have been linked to
experiences of bingeing and purging (Demitrack, Putnam, Brewerton, Brandt,
& Gold, 1990).
Cognitive-behavioral treatments address several aspects of the symptom
picture in bulimia: cognitive restructuring techniques are directed at the
patient’s body image distortions and irrational ideas regarding food; behav-
ioral strategies are employed to reduce bingeing and purging as well as for
affect management. In most cases, clinicians ask patients to keep a record of
thoughts and feelings, especially those that occur prior to a binge episode. A
review of the errors of logic associated with patients’ thinking about body
image, food, and nutrition often leads to the revelation of core beliefs that
can be revised with more adaptive ideas substituted. Behavioral strategies for
relaxation, affect management, and more adaptive eating behaviors are
rehearsed in the clinical setting and applied in daily life.
Recent years have seen a number of empirical studies regarding the effi-
cacy of CBT interventions in bulimia. Keel & Haedt (2008) provide a sum-
mary of evidence-based studies in this area. Their review supports CBT as a
well-established intervention for adults and older adolescents with bulimia
nervosa. Randomized controlled trials find better outcomes correlating with
patients’ advancing age with few successful studies including children and
very young adults. Follow-up studies with adolescents and adults in this
review showed improvement at six months and one year with symptom and
social gains lasting as long as 10 years (Fairburn, Jones, Peveler, Hope, &
O’Connor, 1993; Keel, Crow, Davis, & Mitchell, 2002). Support was
found for family, interpersonal, and psychodynamic treatments aimed at
self-confidence and self-efficacy, offering promise for a more diverse app-
roach to treatment and potential lines of experimental inquiry.
Early reports of dissociative symptoms among this population (Demitrack
et al., 1990; Torem, 1986) prompted hypnosis researchers to study the
levels of hypnotizability among bulimics. First among these studies were
Pettinatti, Horne, and Staats (1985) who found that bulimic inpatients
showed elevated scores on hypnotizability scales when compared to ano-
rexic inpatients. College outpatients displayed similar scores on a variety of
hypnotizability measures in several reports (Barabasz, 1993; Groth-Marnat &
Schumaker, 1990; Kranhold, Baumann, & Fichter, 1992). Young women
with bulimia and another group of normal-weight controls who volunteered
for an investigation of taste preference were tested for hypnotizability by the
same investigator who was blind to diagnosis (Covino, Jimerson, Wolfe,
Franko, & Frankel, 1994). Bulimic subjects not only had higher scores than
the controls, but an unusual number of these individuals (p < .001) scored in
the “highly hypnotizable” range.
Despite good evidence of hypnotizability of bulimic patients with various
levels of the disorder, psychological interventions utilizing hypnosis in this
population are rare. The few studies that do exist lack appropriate controls,
employ small sample sizes, and fail to report follow-up data (Griffiths, Gillett,
& Davies, 1989; Vanderlinden & Vandereycken, 1988). Such limitations
make it difficult to be confident about advocating for the use of hypnosis with
these patients. One controlled study (Griffiths, Hadzi-Pavlovic, & Channon-
Little, 1996) randomly assigned subjects to a CBT group or one employing
“hypnobehavioral” treatment (HBT). Participants received individual psy-
chotherapy along with manualized care that delivered traditional CBT and
HBT to the relevant group. HBT subjects received suggestions for behavioral
change and self-hypnosis training with ego-strengthening techniques. Both
treatment conditions showed equal effect at nine-month follow-up, but they
followed an initial period of behavioral treatment that might have been the
efficacious element of the care. A recent study reported by Barabasz (2007)
found 14 bulimic women who were randomly assigned to a CBT or CBT þ
hypnosis group then followed for three months. Symptom measures found
comparable results for both treatments, but the hypnosis group reported sig-
nificantly less binge frequency compared to those treated with CBT alone.
While encouraging, this is a very small sample and this study is a singular
example of the kind of research that is needed in this area.
Research findings of elevated hypnotizability in this population invite
us to believe that hypnosis strategies added to the well-supported CBT
interventions for bulimia should make an important addition to medical

and psychological care in this area. Patients who are more suggestible
should be able to use trance and new ideas to assist them with managing
emotions, changing fixed ideas about nutrition and body image, revising
maladaptive core beliefs, and practicing more adaptive eating behaviors.
The paucity of recent, controlled intervention studies at this point makes
it impossible for any provider to be enthusiastic about the use of hypnosis
for bulimia. Such work is clearly needed.
Hyperemesis
Uncontrolled nausea and vomiting, also known as hyperemesis, is a com-
mon consequence of chemotherapy for cancer and, as we know, of pregnancy.
Anticipatory nausea and vomiting (ANV) usually results from the combina-
tion of behavioral conditioning and the application of intensive medication
regimens that are aimed at reducing cancerous cells (Morrow & Dobkin,
1988). ANV affects between 25 and 50 percent of patients, commonly by the
fourth session of treatment (Andrykowski, Redd, & Hatfield, 1985; Redd &
Andrykowski, 1982), with patients experiencing symptoms of nausea and
vomiting in response to hospital odors, images, or personnel or other condi-
tioned stimuli, and their symptoms are escalated by anxiety (Andrykowski,
1987; Jacobsen, Bovbjerg, & Redd, 1993). ANV is a debilitating experience
for patients, but it is, also, the most common reason that cancer patients dis-
continue treatment earlier than advised (Dolgin, Katz, Doctors, & Siegel,
1986; Sitzia & Huggins, 1998; Zeltzer & LeBaron, 1982). While most women
experience nausea and vomiting in the early months of pregnancy, a certain
number (0.5–2 percent) experience intractable vomiting leading to dehydra-
tion. This condition is called hyperemesis gravidarum (HG), and it results
from metabolic changes created by the placenta. Behavioral conditioning
can complicate this condition, as with ANV, but psychological factors have
not been found to play an etiological role in this condition.
Behavioral intervention procedures are the most widely offered psychoso-
cial services at comprehensive cancer centers due to their immediate impact
on the presenting complaint, the relative ease of application and the opportu-
nity to offer some measure of control to a disempowered patient (Coluzzi
et al., 1995; Meyer & Mark, 1995). Behavioral interventions typically include
distraction techniques such as story telling and the use of video games, sys-
tematic desensitization, relaxation training, and hypnosis. In their review of
54 published studies of the effectiveness of interventions aimed at the aversive
symptoms of cancer treatments, Redd, Montgomery, & DuHamel (2001)
report that behavioral techniques can effectively control anticipatory nausea
and vomiting along with anxiety and distress related to the medical treat-
ments. Patients treated with relaxation are able to use this skill during aver-
sive procedures to manage accompanying anxiety and to distract themselves
from the subjective experience of nausea. Numerous studies find relaxation to

be effective at decreasing the incidence of nausea and vomiting prior to chem-
otherapy (Razavi et al., 1993; Vasterling, Jenkins, Tope, & Burish, 1993).
Hypnosis has been employed by pediatric and adult clinicians to manage
pain, reduce anxiety, and manage the symptoms of nausea and vomiting.
Zeltzer, Dolgin, LeBaron, & LeBaron (1991) treated 54 children who were
randomly assigned to receive hypnosis, distraction, or placebo interventions.
Observation and interview measures of anticipatory- and post-chemotherapy
nausea and vomiting, distress, and functional disruption found that children
in the hypnosis group had the greatest reduction in symptoms. Another study
with children found that hypnosis decreased the need for antiemetic medi-
cines and reduced chemotherapy-related nausea and vomiting (Jacknow,
Tschann, Link, & Boyce, 1994). Furthermore, children in the hypnosis group
were still able to manage anticipatory nausea for several months after treat-
ment. Among adults, bone marrow transplant patients who were randomly
assigned to groups utilizing hypnosis, CBT, therapist contact, and treatment
as usual demonstrated better results with hypnosis than with CBT (Syrjala,
Cummings, & Donaldson, 1992). In a related use of hypnosis to manage
postoperative nausea and vomiting, patients undergoing breast surgery with
hypnosis training four to six days prior demonstrated less vomiting and less
need for analgesic medications (Enquist, Bjorklund, Engman, & Jakobsson,
1997).
While there is both logic and some empirical support for the use of hypno-
sis in the management of hyperemesis, especially with regard to ANV among
cancer patients, and, perhaps, surgical patients, this literature is dated, the
sample sizes are small, and the studies are very few in number. Research com-
bining hypnosis training for distraction, absorption, and anxiety management
along with the use of imagined approaches to noxious stimuli in the manner
of systematic desensitization holds a great deal of promise for the field and for
patient care.
PAROCHIAL RESEARCH: FUNCTIONAL GASTROINTESTINAL

DISORDERS AND SMOKING CESSATION
Functional Gastrointestinal Disorders
By definition, the bloating, abdominal pain, and changes in motility and
bowel movement that constitute functional gastrointestinal disorders (FGID)
are without structural or organic origin (Toner & Cassati, 2002). Disorders
such as irritable bowel syndrome (IBS) and functional bowel disorder (FBD)
impact as many as 22 percent of the population and comprise close to one-third
of the typical gastroenterologist’s practice (Drossman, Camilleri, Mayer, &
Whitehead, 2002; Whitehead, Crowell, Robinson, Heller, & Schuster,
1992). As with insomnia, autonomic hyperarousal, cognition, and behavior
play key roles in maintaining these disorders. In response to experimental

stressors, patients with FGID show increased gastric motility (Drossman
et al., 2002; Maunder et al., 1997) gastric velocity, and gastric activity
(Bilhartz and Croft, 2000; Drossman, Whitehead, & Camilleri 1997). How-
ever, dismotility is absent during sleep (Fukudo et al., 1992; Kellow, Gill, &
Wingate, 1990). FGID patients selectively attend to abdominal sensations
and maintain a persistent belief that they are seriously ill, despite medical
assurance to the contrary. Psychological factors such as a history of early
childhood abuse and chronic mood disorders are common precursors, with
a majority of FGID patients failing to see a mind-body dimension to their
disorder (Blanchard, 2001; Toner & Casati, 2002).
While controlled studies utilizing brief psychodynamic psychotherapy
have demonstrated success in reducing FGID symptoms (Guthrie, Creed,
Dawson, & Tomenson, 1991), substantial research supports the efficacy of
cognitive-behavioral interventions for this population (Blanchard, 2000).
Techniques including psychophysiological education, relaxation training,
cognitive restructuring, and behavioral rehearsal have improved FGID in
randomized controlled studies involving waitlist (Tkachuk, Graff, Martin, &
Bernstein, 2003; van Dulman, Fennis, & Bleijenberg, 1996) and crossover
(Lynch and Zamble, 1989) designs. Treatment strategies that help FGID
patients to correct a tendency toward catastrophic thinking, while acquiring
adaptive habits such as relaxation, are accepted interventions by mental
health and medical caregivers.
Whorwell and his colleagues found that as few as seven 30-minute
sessions with hypnosis were effective in reducing IBS symptoms and were
more effective than talking therapy alone (Whorwell, Prior, & Faragher,
1984; Whorwell, Prior, & Colgan, 1987; Prior, Colgan, & Whorwell, 1990).
Subsequent work from the same group found substantial improvement in
pain control, bowel movement, and rectal sensitivity (Houghton, Jackson,
Whorwell, & Cooper, 1999) and that bowel symptoms and quality of life
remained improved at three months (Gonsalkorale, Houghton, & Whorwell,
2002) and, even, five years (Gonsalkorale, Perrey, Pravica, Whorwell, &
Hutchinson, 2003). Similar symptom amelioration and improved quality of
life were effected by hypnosis through audiotapes with gains remaining at
10–12 months (Palsson, Turner, Johnson, Burnett, & Whitehead, 2002).
Unfortunately, rather than integrate the significant body of psychological
research that finds support for cognitive-behavioral interventions, hypnotic
research methods, almost universally, employ the strategy of the earliest hyp-
nosis investigators in this area who specify “gut-directed” suggestions as the
desired hypnosis intervention. This recommendation is supported by their
observation that six study subjects had prior, general, hypnotic suggestions
without relief and these improved when suggestions for warm hands that
could soothe the abdomen and bring better control to bowel function were
presented to them (Gonsalkorale, 2006; Whorwell et al., 1987). Generalized
from such a small and briefly analyzed sample, this logic is not only not com-
pelling, it ignores a substantial body of CBT research with its focus on alter-
ing cognitions and changing behavior. Only very recently have investigators
begun to integrate CBT strategies into hypnosis studies (Taylor, Read, &
Hills, 2004), although maintaining the overly specific approach. Such a re-
stricted strategy unnecessarily limits the range of therapeutic interventions
for patients with FGID and keeps clinicians and investigators, who are
involved in similar work, unnecessarily sequestered. Moreover, such an idio-
syncratic logic and clinical approach contributes to the marginalization of
our field by mental health professionals who witness the ignorance of an
evidence-based approach with CBT and by medical practitioners who think
it unconventional.
While there is some enthusiasm for the use of hypnosis in this area,
randomized control studies and a better integration of the successful ele-
ments of CBT research with this patient population are much needed.
Smoking Cessation
Cigarette smoking is responsible for 30 percent of cancer deaths in this
country and it is a major contributor to emphysema, heart disease, and stroke,
along with presenting a significant health risk for nonsmokers who are
exposed to it. Despite significant public education efforts across recent years,
the population of smokers in this country remains relatively constant at more
than 23 percent (CDC, 2006). Unfortunately, psychological factors of condi-
tioning and suggestion combine with the addictive drug nicotine to create a
complex habit disorder that undermines most smokers’ best intentions.
The elements of “suggestion” are well employed by the tobacco marketers
who place attractive people in appealing settings to sell their product. Con-
sumers are invited to become imaginatively involved in the advertisement
and open to the suggestion that a particularly disagreeable behavior is as de-
sirable as the images. Catchy phrases are so repetitiously presented that,
many years later, the general public of a certain age knows what LSMFT
means, how good Winstons taste, and how cool Joe Camel is. By contrast,
public health messages that employ cancerous lungs, a dyspneic cowboy, and
illness warnings fail to invite smokers to linger long enough on the content
of the commercial to absorb the message. While the numbers are small, about
2 percent of patients will stop when their primary care doctor suggests it to
them (Law & Tang, 1995).
The treatment of cigarette smokers has been quite challenging. Most
interventions, be they with nicotine replacement, antidepressants, or CBT,
are likely to succeed with only one of five patients. However, given the
number of smokers and the known consequences of long-term use, these
numbers represent a significant health care gain. Research finds support for
behavioral techniques such as rapid smoking, stimulus control, and skill
training, but not for aversive stimuli, contingency, and nicotine fading
(Covino & Bottari, 2001). Given the important role that nicotine plays in
fostering and maintaining addiction, it is not surprising to find nicotine
replacement almost doubles the chances of success for those who are
interested in quitting, regardless of the treatment approach used (Silagy,
Lancaster, Stead, Mant, & Fowler, 2004). Most reports on the use of hyp-
nosis for cigarette smoking follow the direct suggestion/motivational model
developed by H. Spiegel (1970). This method exhorts patients to know that
“smoking is a poison for your body; you need your body to live; and to the
extent that you want to live, you owe your body respect and protection.”
Some investigators use hypnosis to achieve relaxation, to focus on individ-
ual motivations to change, and to rehearse coping behaviors.
A popular, although controversial, theory in habit change work is the
“transtheoretical” Stages of Change model of Prochaska and his colleagues
(Prochaska & Velicer, 1997). This model posits a process of six stages that
patients with habit disorders such as cigarette smoking are likely to pass
through: precontemplation, contemplation, preparation, action, maintenance,
and termination. While there is some caution about the success of this model
(Hughes, 2000; Riemsma, Pattenden, Bridle et al., 2002), proponents believe
that tailoring suggestions and behavioral recommendations to meet the moti-
vational level and needs of the person undertaking to change behavior
will improve treatment outcome for this population (Prochaska, Velicer, Fava
et al., 2001).
The hypnosis literature on smoking cessation is a diverse one with a
large number of clinical reports dating back to the 1970s. Several quasi-
experimental designs with small, unequal, or incomparable samples and
questionably reliable outcome measures, and only three studies that meet
the criteria for evidence-based treatment comprise most of the body of work
in this area (Green & Lynn, 2000). Reviewers point to methodological
weaknesses like incomplete descriptions of the “hypnosis intervention,”
inadequate controls, and an excessive dependence upon unreliable measures
of abstinence to assess treatment outcomes (Abbot, Stead, White et al.,
1998; Covino & Bottari, 2001; Greene & Lynn, 2000; Law & Tang, 1995).
The Cochrane Review assessed nine randomized, controlled studies from
1977 to 1988 and found insufficient evidence to recommend hypnosis; they
proposed nonspecific therapist variables as the most likely contributors
to treatment success (Abbot, Stead, White, & Barnes, 1998). In a larger
review, similar methodological weaknesses were noted, along with the chal-
lenge of differentiating the cognitive-behavioral interventional elements
from those of hypnosis, but the authors saw hypnotic interventions as
superior to various no-treatment conditions (Green & Lynn, 2000). A meta-
analysis of 48 investigations found mean quit-rates of 36 percent with hypno-
sis as superior to physician advice at 2 percent (Viswesvaran and Schmidt,
1992). Most conclude that the use of hypnosis for smoking cessation is better
than no treatment, but it cannot be seen as superior, except to placebo, aver-

sive conditioning, and physician advice.
The use of hypnosis for smoking cessation is among the best examples
of what contributes to the marginalization of this technique. On the one
hand, research substantiates that it could be effective, and, indeed, that it
is more effective than no treatment at all. Thus, it is worth the work to
update and to make more sophisticated the research methodologies in this
area. However, by largely ignoring the strong evidence in support of nico-
tine replacement, failing to integrate the compatible behavioral techniques
that work and to explore the potential assistance that the transtheoretical
model offers, hypnosis researchers make it very difficult for colleagues to
take our work seriously and to include it as a component of treatment.
CONCLUSIONS
For many years, hypnosis-trained clinicians have advocated to a largely
unreceptive audience of medical practitioners that they had something to
offer their patients. The best work in this field has established a clear role for
hypnosis in the treatment of patients with pain (Patterson & Jensen, 2003).
Surgical interventions and procedures offer the similar opportunity to address
the complex interactions of anxiety, pain, treatment time, and patient com-
pliance with adjunctive hypnotic strategies. There is, as has been shown,
some real promise for the use of hypnosis with many medical illnesses and
conditions. For this technique to be better accepted, it is imperative that
researchers in the field update outdated studies, integrate promising strategies
from related research, abandon idiosyncrasy, bring appropriate scientific rigor
to investigations, and pay attention to the excellent work of colleagues in
related fields. With enthusiasm for this approach, it is clear that patients will
benefit from our skills and the field will be brought closer to mainstream
practice.
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About the Editor and Contributors
THE EDITOR
Deirdre Barrett, PhD, is a psychologist on the faculty of Harvard Medical
School’s Behavioral Medicine Program. She is the past president of both the
International Association for the Study of Dreams and the American Psycho-
logical Association’s Division 30: Society of Psychological Hypnosis. Dr. Bar-
rett has written four books: The Committee of Sleep (Random House, 2001);
The Pregnant Man and Other Cases from a Hypnotherapist’s Couch (Random
House, 1998); Waistland (Norton, 2007); and Supernormal Stimuli (Norton,
2010). She is an editor of two additional books, The New Science of Dreaming
(Praeger/Greenwood, 2007) and Trauma and Dreams (Harvard University
Press, 1996), and has published dozens of academic articles and chapters on
health, hypnosis, and dreams. She is editor-in-chief of DREAMING: The Jour-
nal of the Association for the Study of Dreams.
Dr. Barrett’s commentary on psychological issues has been featured on Good
Morning America, The Today Show, CNN, Fox, and the Discovery Channel.
She has been interviewed for dream articles in the Washington Post, the New
York Times, Life, Time, and Newsweek. Her own articles have appeared in Psy-
chology Today and Invention and Technology. Dr. Barrett has lectured at Esalen,
the Smithsonian, and universities around the world.
THE CONTRIBUTORS
Arreed Franz Barabasz, EdD, PhD, ABPP, completed his first doctoral degree at
State University of New York at Albany at the age of 23. His PhD in Clinical
and Human Experimental Psychology is from the University of Canterbury,
New Zealand, where he conducted the first studies of EEG and hypnosis in Ant-
arctica. His post-doctoral clinical fellowship was at Massachusetts General Hos-
pital and Harvard Medical School. He is the editor of the International Journal of
Clinical and Experimental Hypnosis (IJCEH) and professor at Washington State
University. He is a diplomat of the American Board of Professional Psychology;
a fellow of the American Psychological Association, the American Psychologi-

cal Society, and the Society for Clinical and Experimental Hypnosis; and past
president of the Society for Clinical and Experimental Hypnosis (SCEH) and of
APA Division 30: Society of Psychological Hypnosis. Barabasz was an associate
professor of psychology at the Harvard Medical School prior to his professorship
at Washington State University. He has published over 125 refereed research
papers and received numerous awards for his achievements in research, theory,
and practice. He is the three-time winner of the Guze Award from SCEH “for
best research paper published in the previous year,” most recently in 1999 for his
experimental research showing unique EEG ERP responses to hypnosis. His
(2005) text Hypnotherapeutic Techniques, 2E, coauthored with John G. Watkins,
was awarded the 2005 Best Book on Hypnosis by the Society for Clinical and
Experimental Hypnosis. His latest psychoanalytic text is Watkins & Barabasz
(2008, Routledge) Advanced Hypnotherapy: Psychodynamic Techniques. His most
recent edited book, also from Routledge, Medical Hypnosis Primer: Clinical and
Research Evidence (2010) has been adopted by both the Society for Clinical and
Experimental Hypnosis and the International Society of Hypnosis for distribu-
tion to clinics and hospitals worldwide.
Kent Cadegan, BSc, MD, FCFP, is a medical director at the Glace Bay Site,
Cape Breton Regional Hospital, Nova Scotia, Canada. He is also a member of
the Medical Advisory Committee of the Cape Breton Regional Hospital. Dr.
Cadegan has practiced cradle to grave, home and hospital family medicine for
over 33 years in his home town of Glace Bay, Cape Breton. He is a past presi-
dent of the Clinical Hypnosis Society of Nova Scotia, approved consultant
ASCH, Private Practice in Family Medicine, Obstetrics and Hypnosis. He is a
founding member of the Canadian Federation of Clinical Hypnosis and serves
on its executive board He is a lecturer in the Department of Family Medicine,
Dalhousie University, Halifax, Nova Scotia. He is an active organizer and
teacher of hypnosis workshops.
Nicholas A. Covino is the president of the Massachusetts School of Professio-

nal Psychology (MSPP). For twenty years, he was a psychologist at the Beth
Israel Hospital and the Harvard Medical School, where he served as director
of the psychology division and as the director of training. He is a member of
the Boston Psychoanalytic Society and Institute and maintains a small psycho-
therapy practice. Covino is past president of the Society for Clinical and Ex-
perimental Hypnosis and the author of a number of articles and chapters on
the application of clinical hypnosis.
Nicole Flory, PhD, is a licensed clinical psychologist with a private practice in

Arlington, Massachusetts, and a teaching associate in the behavioral medicine
program at Cambridge Health Alliance, Harvard Medical School. Dr. Flory is
dedicated to women’s health issues and has conducted a randomized controlled
trial on the psychosocial outcomes of hysterectomy. Her research, clinical, and
training interests are in cognitive-behavioral interventions, sex and couples

therapy, and medical hypnosis. She was born and raised in Europe and com-
pleted her initial training on the use of hypnotic techniques in 1995 at the
University of Berlin (Freie Universitaet) in Germany. Dr. Flory is the former
associate director of the Non-Pharmacologic Analgesics Program, Department
of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School,
Boston. She has published in a variety of scientific journals. Dr. Flory enjoys
teaching, writing articles, and has received numerous rewards for her work
such as the Student Research Award from the Society for Sex Therapy &
Research; a research grant from the Canadian Foundation for Women’s
Health; and the Ruth L. Kirschstein National Research Service Award from
the National Institutes of Health (NIH) and the National Cancer Institute
(NCI).
V. Krishna Kumar is a professor of psychology at West Chester University of

Pennsylvania. He is a clinical associate at the Center for Cognitive Therapy,
University of Pennsylvania. He is an elected fellow of APA as well as in two
APA divisions, Society of Psychological Hypnosis (Division 30) and Society
of Humanistic Psychology (Division 32). He is a two-time recipient of the Mil-
ton Erickson Award for Excellence in Scientific Writing on Clinical Hypnosis from
the American Society of Clinical Hypnosis. He is also a recipient of the Best
Theoretical Paper Award from Division 30 of the American Psychological Asso-
ciation. He is a past president of the Greater Philadelphia Society of Clinical
Hypnosis. He is the author or coauthor of over one hundred articles in peer-
reviewed journals and several chapters in edited works.
Elvira Lang, MD, FSIR, FSCEH, is a pioneer and leading expert in the use of
hypnosis during medical procedures. Her research-based refinement of hyp-
notic techniques has resulted in greater patient comfort, increased practitioner
effectiveness, and improved financial performance. Dr. Lang is associate profes-
sor of radiology at Harvard Medical School and founder of Hypnalgesics, LLC,
which trains medical teams in rapid rapport and quick hypnotic techniques.
She is internationally known in the field of interventional radiology; she
served as chief of interventional radiology at Beth Israel Deaconess Medical
Center, Harvard School of Medicine, in Boston from 1998 through 2006. Dr.
Lang has trained nurses, doctors, and technologists to incorporate procedure
hypnosis into medical areas from a variety of disciplines including MRI, breast
care, oncology, urology, gastroenterology, diagnostic and interventional radiol-
ogy, obstetrics, and dentistry. She held faculty appointments and leadership
positions at the University of Heidelberg, Stanford University, the University
of Iowa Hospital and Clinics, and the Beth Israel Deaconess Medical Center.
Dr. Lang takes an active leadership role in the advance of hypnosis in the
medical setting; she is past president of the New England Society of Clinical
Hypnosis and current president of the Society of Clinical and Experimental
Hypnosis. She is author of Patient Sedation without Medication: Rapid Rapport
and Quick Hypnotic Techniques. A Resource Guide for Doctors, Nurses, and
Technologists.
Stephen R. Lankton, MSW, DAHB, is a licensed clinical social worker in

Phoenix, Arizona. He is the editor-in-chief of the American Journal of Clinical
Hypnosis and a fellow and approved consultant of the American Society of
Clinical Hypnosis. He serves as secretary and treasurer of the Arizona Behav-
ioral Health Examiners Board Credential Committee. He is a diplomate in
clinical hypnosis, and past-president of the American Hypnosis Board for
Clinical Social Work; a fellow of the American Association of Marriage and
Family Therapy; and a fellow and board member of the American Psychother-
apy Association. Among his awards, Lankton is the recipient of the “Lifetime
Achievement Award for Outstanding Contribution to the Field of Psy-
chotherapy” from the Milton Erickson Foundation, 1994 and the “Irving Sec-
tor Award for the Advancement of Clinical Hypnosis” from the American
Society of Clinical Hypnosis, 2007. He is the author of 18 clinical books, with
translations in several languages, regarding techniques of hypnosis, family ther-
apy, and brief therapy. He is currently a psychotherapist in private practice in
Phoenix and conducts professional training seminars throughout the world.
Kevin Miller is completing his graduate training in psychology at The Massa-

chusetts School of Professional Psychology. Kevin is also a commissioned offi-
cer in the U.S. Navy.
Dr. Jessica Wexler is a graduate of the Massachusetts School of Professional

Psychology. After several years as a licensed clinician in Israel working within
the immigrant community, Dr. Wexler has returned to the US as a psycholo-
gist in private practice. She has a general practice of clinical psychology with
a specialty in the treatment of anxiety disorders.
Michael D. Yapko, PhD, is a clinical psychologist in Fallbrook, California. He

is internationally recognized for his work in advancing clinical hypnosis and
outcome-focused psychotherapy, routinely teaching to professional audiences
all over the world. Dr. Yapko has had a special interest for more than three
decades in the intricacies of brief therapy and the clinical applications of hyp-
nosis and directive methods. He is the author of ten books and editor of three
others, as well as numerous book chapters and articles. These include his
widely used classic text, Trancework: An Introduction to the Practice of Clinical
Hypnosis (3rd ed.), the award-winning Treating Depression with Hypnosis: Inte-
grating Cognitive-Behavioral and Strategic Approaches (2001), Hypnosis and Treat-
ing Depression: Applications in Clinical Practice (2006), as well as Essentials of
Hypnosis and Hypnosis and the Treatment of Depressions. He has produced many
CD and DVD programs. His works have been translated into nine languages.
More information about Dr. Yapko’s publications can be found on his Web
site: www.yapko.com. Dr. Yapko is a member of the American Psychological
Association, a clinical member of the American Association for Marriage and

Family Therapy, a member of the International Society of Hypnosis, and a fel-
low of the American Society of Clinical Hypnosis. He is a recipient of the
Milton H. Erickson Award of Scientific Excellence for Writing in Hypnosis,
and the 2003 Pierre Janet Award for Clinical Excellence from the Interna-
tional Society of Hypnosis, a lifetime achievement award honoring his many
contributions to the field of hypnosis. He also received the Milton H. Erickson
Foundation Lifetime Achievement Award for Outstanding Contributions to the
Field of Psychotherapy.
Index
abreactive effect of hypnotic dreams, Barber Suggestibility Scale scores, 105

99 Bateson, Gregory, 3, 13
adverse effects, 159 Beck, Aaron, 130
affect and emotion protocol, 29 behavior, 19, 23
age progression, 129 behavioral medicine strategies, 177
age regression, 129 behavioral psychotherapy, 126
aikido, 5 behavioral rehearsal, 20, 186
alcohol, treatment of: hypnosis in, behavior change protocol, 30
169–170 believed-in imagination, 131–132
Alcoholics Anonymous, 166 biochemical markers, 171
Alice-in-Wonderland, psychedelic borderline personality disorder (BPD),
distortion scale, 113 57
ambiguous function assignments, 10 Bowers Doctrine, 172
analgesia, 129, 150 building realistic expectancy, hypnosis
analysis paralysis, 135 and, 133–134
anecdote, 10 bulimia, hypnosis in treatment for,
anesthesia, 129, 147, 148 182–184
anticipatory nausea and vomiting
(ANV), 184 central self-image (CSI) construction,
anxiety, 148, 149 30
anxiety resistance, 5 child’s self, 53–54
archetypes personalities, 50–51 chloroform, 146
arousal, 136 Clinical and Experimental Hypnosis,
asthma, hypnosis in treatment for, 103
180–182 cognitive-behavioral and relaxation
attentive listening, 152 strategies, 177
attitude change protocol, 29 cognitive behavioral therapy (CBT),
authoritarianism, 18 128, 130, 132, 171, 179, 182, 183,
authoritative approach, 17 185, 187
autonomic nervous system (ANS) cognitive processes, 177
arousal, 178 cognitive psychotherapy, 126
awareness, 52 cognitive restructuring, 186
204 Index
complementary matching, 19, 20 116–118, to influence the content

complex goal-directed metaphors, 29 or recall of nocturnal dreams,
complex personalities, 50–51 118–119. See also daydreams;
conscious, 59 hypnotic dreams, nocturnal dreams
conscious/unconscious therapeutic drive/libido theory, 53–54
binds, 37
conscious-unconscious dissociation, 25 ego-dystonic nature, 30
conscious waking daydream, 103–104 ego-energized and object-energized
context of the problem, 14 elements, 51
coping skills, 137 ego energy, 56–59. See also energy(ies);
covert ego state, 64, 67 psychoses and
ego psychology techniques: boundaries
daydreams, 107, 112; deep trance of, 66–67, characteristics of, 67,
subjects, means of variable ratings efficacy research, 68–69; ego energy,
for, 112, dream reports, 114–117, 56–59; ego state theory, 56; ego
from the same subjects, content of, state therapy, 67–68; ego state
107–116, means of variable ratings therapy, ego states, 63–66, ego state
for, 113, medium trance subjects, therapy treatment, 70–71; evolution
total subjects, means of variable of, 50–52; and hidden observers,
ratings for, 111. See also dreaming 69–70; hypnosis and energies, 59–
decision-making strategies, 137 60; in hypnotherapy, 49–72; object
delusions, 60 energy, 56–59; personality
depression, 123–140; believed-in development, 63; psychoses and,
imagination, 131–132, hypnosis for 60–61; reality A, 61–63; reality B,
treating, 127–128, hypnotic 61–63; self, 52–55; subject-object,
phenomena, 128–129; in 52
combination with hypnosis, 129– ego states, 56, 63–66; boundaries of,
131 major, 124–125; psychotherapy 66–67; characteristics of, 67; and
for treating, 125–127 hidden observers, 69–70
Diagnostic and Statistical Manual of ego state therapy, 67–68; evolution of,
Mental Disorders-IV, 67 50–52; treatment, 70–71
diagnostic tools, 129 ego-syntonic nature, 30
differentiation, 63 embellished reminiscence, 105
differentiation-dissociation continuum, emotional experience, 17
66–67 empathic techniques, 159
direct communication, 7 endoscopies, 147
Directed Daydreaming, 104 energy(ies); defined, 56; ego, 56–59,
direct suggestion, 10, 20 psychoses and, 60–61; hypnosis and,
dissociation, 50, 63, 129 59–60; object, 56–59
dissociative identity disorder (DID), Ericksonian:
50, 51, 65, 67 ambiguous aspect of: formal
double dissociative conscious/ induction sequence outline, 24–26,
unconscious therapeutic binds, goal-directed metaphor protocols,
37–38 29–30, hypnosis, 20–21, hypnosis
dreaming: hypnosis with, continuing with families, 21–22, induction of
or interpretation of a nocturnal hypnosis, 22–24, interventions of,
dream in the hypnotic state, 18–32, metaphor, 30–32, metaphor,
Index 205
use of, 26, metaphoric stories, use event-driven perspective, 126

of, 26–27, simple isomorphic evidence-based approach, 166, 169, 172
metaphors, 28–29, 28, speaking the existence, 53, 57, 65
client’s language and matching, expectancy, 133
18–20 approaches to hypnosis, 1, experience amplification, 130
13, 133 changes in treatment
approach, 15–16 fabricated case histories, 26
changes in treatment duration, face-to-face communication, 10
Erickson’s conceptualization of Federn, Paul, 51, 55; ego psychology,
symptoms, 16–17, cure 55
accomplished by reassociation of First World Congress on Ego State
experience, 17, use of hypnotic Therapy, 68
suggestion, 17–18 flexibility, 8, 20
focusing inward, 22
history and background, 1–4
formal induction, 22–24
indirect suggestion language: formal induction sequence outline,
apposition of opposites, 36, binds of 24–26
comparable alternatives, 36–37, Freud, Sigmund, 52, 53, 55, 101
conscious/unconscious therapeutic functional bowel disorder (FBD), 185
binds, 37, double dissociative functional gastrointestinal disorders
conscious/unconscious therapeutic (FGID); hypnosis in treatment for,
binds, 37–38, forms, 33–34, 185–187
illustration of, 32–38, implication
and presupposition, 34–35, open-
goal-directed fantasy, 11
ended suggestions, 34, pseudo non-
goal-directed metaphor protocols, 29
sequitur binds, 38, questions or
goal-oriented, skill-building
statements, 35, truism, 35
approaches, 126
induction using indirect suggestions,
38–40, 39
Haley, Jay, 15–16, 19
rationale and philosophy: hallucination, 52, 60, 61
assessment and treatment planning, here-and-now behavior, 5
4–5, client behavior, utilization of, hidden observers, ego states and,
5–6, context for change, creating, 69–70
12, depathologizing, 12, flexibility Hippocratic Corpus, 159
and direct communication, 7–8, Hull, Clark, 3
getting clients active and moving, Human Genome Project, 125
13, hypnotic language, 10–11, hyperemesis, hypnosis in treatment
indirection and ambiguity, 8–10, for, 184–185
present and future orientation, 13– hyperemesis gravidarum (HG), 184
15, resistance, reduction of, 6–7, “hypnobehavioral” treatment (HBT),
speak the client’s own experiential 183
language, 6 hypnosis: asthma, 180–182; and
research, 40–42 building realistic expectancy, 133–
Esdaile, James, 146 134; bulimia, 182–184; and
establish associations and energies, 59–60; enhancing sleep,
dissociations, 130 135–136, 137, transcript, 138–140;
Ether Dome, 146 Ericksonian approaches to (see
206 Index
Ericksonian approaches to implication and presupposition,

hypnosis); functional 34–35; open-ended suggestions,
gastrointestinal disorders, 185–187; 34; pseudo non-sequitur binds,
hyperemesis, 184–185; insomnia, 38; questions or statements,
178–180; in interventional 35; truism, 35
radiology and outpatient procedure individual’s personal reality, 132
settings, 145–160; and positive injudicious behavior, 178
psychology, 132–133; role in insomnia, 99; hypnosis for treating, in
smoking cessation, 187–189; combination with psychotherapy,
targeting rumination, 135–136, 137; 134–135; hypnosis in treatment for,
treating depression, 127–128, 178–180
believed-in imagination, 131–132, insula, and smoking cessation, 173
hypnotic phenomena, 128–129, in integration, 63
combination with psychotherapy, Interpersonal Check List, 10
129–131; treating insomnia, in interpersonal posture, 20
combination with psychotherapy, interpersonal psychotherapy, 126
134–135; treatment of smoking, interpersonal relationships, 14
166–168. See also individual entries interpersonal therapy (IPT),
hypnotherapy, 26; ego psychology 130
techniques in, 49–72 interventional radiology and
hypnotic analgesia, 69 outpatient procedure settings,
hypnotic approaches, 137–138 hypnosis in, 145–160; challenges,
hypnotic deafness, 69 158–159; patients responsiveness
hypnotic dreams, 97, 98–100; and acceptance, 157–158;
comparison with nocturnal dreams, precautions and safety
100–107, 104; from the same considerations, 159–160; procedural
subjects, content of, 107–116, deep environment, 148–149; procedural
trance subjects, means of variable pain management, 149–150;
ratings for, 112, dream reports, 114– scientific evidence, 155–157;
117, medium trance subjects, means script, 152–155; surgical and
of variable ratings for, 113, total anesthetic approaches, evolution
subjects, means of variable ratings of, 146–148; techniques,
for, 111. See also dreaming; 150–152
hypnotic language, 10–11, 32 introjection, 58, 59, 62
hypnotic phenomena, 129 irritable bowel syndrome (IBS), 185
hypnotic suggestion, 17–18
Janet, Pierre, 50
identification, 58, 59, 63 Jung, Carl, 50
identofact, 63
in-between ego states, 66 karate, 5
indirect suggestion, 7–8, 10, 32–38;
apposition of opposites, 36; binds of laboratory-verified lucid dreams,
comparable alternatives, 36–37; 118–119
conscious/unconscious therapeutic left brain thinking, 97
binds, 37; double dissociative libido. See single energy (libido)
conscious/unconscious therapeutic theory
binds, 37–38; forms, 33–34; lucidity, 119
Index 207
major depression, 124–145. See also personalities, 49

depression personality development, 63
maladaptive behaviors, 64 positive expectancy, 133, 134
maladaptive state, 65 positive psychology, 133, 140;
matching the behavior of the client, hypnosis and, 132–133
18 pre-scripted hypnosis protocols,
matching the client’s behavior, 19 171–172
mental disease, 16 primary ego energy, 56
Mesmer, Franz, 146 primary narcissism, 52
metaphor, 10, 26–27; ambiguous primary process, 97
aspect of, 30–32; isomorphic, 28–29, problem-solving skills, 126
28; protocols, goal-directed, 29–30 process-driven perspective, 126
mind-body techniques, 157 pseudo non-sequitur binds, 38
multiple personalities (DID), 51, 65 pseudoperception, 60
psychophysiological education, 186
Narcotics Anonymous, 166 psychoses and ego energies, 60–61
National Cancer Institute, 168
National Institute of Health, 179 quasi-allegory, 105
naturalistic induction method, 22–23 quasi-dream, 105
negative expectancy, 134
nightmares, 99, 118 randomized controlled trial, 172–173
nocturnal dreams: comparison with Rapid Eye Movements (REMs), 100;
hypnotic dreams, 100–107, 104; during hypnotic dreams, 116
from the same subjects, content of, rapid therapy, 98
107–116, deep trance subjects, reality A, 61–63
means of variable ratings for, 112, reality B, 61–63
dream reports, 114–117, medium rehearsal technique, 98
trance subjects, means of variable relationship and family approach, 4
ratings for, 113, total subjects, relaxation, 32, 36, 137, 186
means of variable ratings for, 111. repressed memory, 59
See also dreaming resistance, reduction, 12
non-pathological hallucinations, 97 right brain thought, 97
rumination, 134–135; hypnosis
object, 53 targeting, 135–136, 137, 138
object energy, 56–59. See also
energy(ies) Sacerdote, P., 98, 99, 113
object-relations theories, 53, 62 schizophrenic, 60, 61
object representation, 59 secondary process, 97
one-energy (libido) system. See single- sedatives, 150, 179
energy (libido) theory selbst, 52
outpatient procedure settings, hypnosis self, the, 52–55, 70
in, 157–158 self-effacing patient, 54
outpatient psychotherapy, 9 self-esteem, 169, 170
self-hypnosis, 168, 172
paradoxical directives, 20 self-hypnotic dream, 102
past events and traumas, exploration, 17 self-hypnotic relaxation, 151
perceptions, 52 self-image scenarios process, 30
208 Index
self-image thinking protocol, 30 therapeutic conversations, 20

self representation, 59 therapeutic language, 32
shock technique, 16 therapeutic receptivity, 21
single energy (libido) theory, 56, 57, 62 time hypnosis, 134
skill acquisition, 130 traditional ritualistic induction, 23,
skill-building strategies, 126 24
sleep: hypnosis for enhancing, trance, 20, 21, 22, 42, 97; depth versus
135–136, 137, transcript, 138–140 relevance, 40
smoking cessation, 166–168, 187–189 transtheoretical model, 188–189
social supports, 177 treatment plan, 136
Stanford Hypnotic Susceptibility true multiple personality (DID), 50, 64
Scale, 106 truism, 35
static pictorial image, 105 two-energy theory, 56, 57, 60, 62
strategic assignments, therapeutic
ordeals, or family therapy, 20 Uncommon Therapy (Haley), 19
stronger suggestion, 11 unconscious conflicts, 98
structured attentive behaviors, 152 undifferentiated energy, 56
structured interactions, 20 United States Agency for Health Care
subject-object, 52 Policy and Research (AHCPR)
substance abuse, treatment of: [now the Agency for Healthcare
hypnosis in, 169–170 Quality and Research (AHQR)],
Substance and Mental Health Services 126
Administration, 165 USDHHS Clinical Practice Guideline,
suggesting eye closure, 33 167
symmetrical matching, 19
symptoms, 16, 17; management of, verbal and nonverbal communication,
130 43
tai chi, 5 Watkins, John G., 51, 55

Thematic Apperception Test (TAT), Weiss, Eduardo, 55, 59
107 World Mental Health Survey,
therapeutic binds, 10 180

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Library of Congress Cataloging-in-Publication Data

Chapter 1 The Hypnotic Deactivation of Self-Conscious Source

Chapter 2 Dissociaters, Fantasizers, and Their Relation

Chapter 3 Hypnosis, Mindfulness Meditation, and Brain Imaging

Chapter 4 Forensic Hypnosis: A Practical Approach

Chapter 5 Hypnosis in Popular Media

Chapter 6 Hypnotic-Like Procedures in Indigenous Shamanism

Chapter 7 Lay Hypnotherapy and the Credentialing of Zoe

Chapter 8 Pedagogical Perspectives on Teaching Hypnosis

About the Editor and Contributors 161

The Society for Clinical and Experimental Hypnosis

American Society of Clinical Hypnosis

Society of Psychological Hypnosis

European Society for Hypnosis

International Society for Hypnosis

during hypnosis from usual waking modes. He characterizes the core

how hypnosis is associated with changes in the executive attention func-

persuasion. People come to hypnotherapy with similar complaints and hopes

how the classic conceptualization of hypnosis as “believed-in imagination” is

The Hypnotic Deactivation of

In clinical cases throughout the nineteenth century, hypnosis was associated

SLEEP, HYPNOSIS, AND THE DEACTIVATION OF

Similarly, in the case of hypnosis, Prince (1925) made the following

Now, given an hysteric of a certain type with absolute anesthesia of

The introspective testimony of my dissociated subjects, who in that

The theoretical issue of interest here is what purpose self-consciousness

subjective quality of a neural process monitoring the central innervation of

SPONTANEOUS AND SUGGESTED HALLUCINATING

discriminative response was measured to the nearest hundredth of a second. In

Figure 1.1 An idealized 28-trial scattergram for a hypothetical subject prior to

This seemingly paradoxical result—that percepts during normal wakeful-

DISSOCIATED PERCEIVING WITH OR WITHOUT

response to hypnotic suggestions. By this account, because hypnotized

After subjects in Kunzendorf’s second study were tested for suggested

Next, the 76 amnesic subjects in this study—the 23 amnesic subjects

events are immediately experienced only as “familiar” events, not as “per-

HYPNOTIC HYPERMNESIA FOR SUBCONSCIOUS PERCEPTS

chance during hypnotic testing. Apparently, then, subliminal stimuli that

HYPNOTIC RECOVERY OF DISSOCIATED MEMORIES AND

(1986) Dissociative Experiences Scale. In related research, Heaps and

Janet, P. (1910). The subconscious–Part 4. In H. M€unsterberg, T. Ribot, P. Janet,

Kunzendorf, R. G., & McGlinchey-Berroth, R. (1997–1998). The return of ‘the

Dissociaters, Fantasizers, and Their

The most common misconception about hypnosis is that trance, hallucina-

Hypnotic susceptibility also correlates with Tellegan and Atkinson’s

Several dreamlike qualities have been suggested to be more characteristic

TABLE 2.1 Waking Imagery and Hypnotic Characteristics of Fantasizers

Vivid Imagery and Fantasies

imagination, it would look just like . . . (that $200-whatever-Susie-just-

Alps; feeling hot, dry, and impulsively getting something to drink in

Early Memories and Parental Discipline

Fantasizers’ Experience of Hypnosis

This group showed a moderate degree of muscular relaxation during hypno-

Fantasies, Early Memory, and Parental Discipline

equal vividness in self-directed fantasy seemed to stem partly from an

Dissociaters’ Experience of Hypnosis

produced by themselves. They were resistant to hearing that it was something

FOLLOW-UP: COMPARISON WITH HIDDEN OBSERVER

interviewed with detailed queries about childhood trauma, dream content,

TABLE 2.2 Hidden Observers, Nightmares, and Trauma of Fantasizers

content than those of the fantasizers including things such as suffocating,