Clinical Hypnosis Introductory Workshop

1. Clinical HypnosisIntroductory Workshop Susan Kelly Becker, Ph.D. Joseph F Zastrow MD FAAFP.

2. Outline • Definitions, History, Theories • Myths and Misperceptions; Memory • Assessment, Presenting Hypnosis, The Hypnotic Relationship, Informed Consent • Hypnotic Phenomena and their applications • Principles and Process of Induction and Realerting; Principles in Formulating Hypnotic Suggestions • The Hypnotic Relationship • Assessment,

3. Outline • Demonstrations of inductions 7. Demonstrations or Video of eliciting Hypnotic Phenomena • Supervised small group practice • Concepts of Susceptibility; Stages of Hypnosis; Methods of Deepening • Self-hypnosis

4. Outline • 11. Treatment planning, Strategy and technique selection • 12. Strategies for Managing Resistance to Hypnosis • 13. Introduction to Susceptibility Scales • 14. Ethical Principles, Professional Conduct; Certification • 15. Integrating Hypnosis into the clinical practice

5. LearningObjectives: A. Learn a definition of hypnosis related to relevant scientific research. B. Understand major historical events in hypnosis and mesmerism. C. Understand and utilize major theories of hypnosis including neo-dissociative, social psychological, psychodynamic, social learning or expectancy, the Ericksonian atheoretical approach, and multifactor or multidimensional formulations.

6. DEFINITION OF HYPNOSIS: A state of inner absorption, concentration or focused attention which assists a client in altering some aspects of thought, emotion, behavior or perception.

7. User-friendly Definition Hypnosis is … • Using your mind to help yourself • Learning how to control your mind / body • Daydreaming with a purpose • Learning what you didn’t know you knew • Controlling what you didn’t know you could

8. Process Definition “Hypnosis is a procedure during which a health professional or researcher suggests that a client, patient, or subject experience changes in sensations, perceptions, thoughts, feelings or behavior. The hypnotic context is generally established by an induction procedure…most include suggestions for relaxation, calmness and well-being.” APA, Div.30 (Kirsch, 1994)

9. Different responses to hypnosis altered state of consciousness. normal state of focused attention calm, relaxed, pleasant experience Varied responsiveness to hypnosis inhibited by fears, concerns, common misconceptions (depictions of hypnosis in books, movies, television) Executive Committee of the American Psychological Association Division of Psychological Hypnosis, 1993, Fall. Psychological Hypnosis: A Bulletin of Division 30, 2, p. 7.

10. People who have been hypnotized do not lose control over their behavior typically remain aware of who / where they are usually remember what transpired during hypnosis (unless amnesia has been specifically suggested) Hypnosis makes it easier for people to experience suggestions, but it does not force them to have these experiences.

11. Content Definition • Altered state of consciousness / awareness different from normal waking / stages of sleep • Resembles meditative states narrowly focused attention (absorption) primary process thinking ego receptivity alterations in cognition dissociations from usual perceptions / memories trance logic • Sometimes indistinguishable from simple physical and mental relaxation

12. All hypnosis is self hypnosis that can be used for one’s own benefit.Milton Erickson

13. Hypnosis is a state of highly focused attention, with a constriction in peripheral awareness and a heightened responsiveness to social cues. David Speigel MD jnci.oxfordjournals.org JNCI | Editorials 1281

14. Components of Hypnosis • Focused attention, absorption • Dissociation, distortion • Suggestibility and generalization

15. Contraindications • Do not use hypnosis with any presenting problem you are unprepared to treat without hypnosis. • Hypnotic uncovering work : caution with fragile ego-strength, extreme emotional lability, tenuous control, thought disorder, some medically impaired patients (e.g., organic brain syndromes). • Indiscriminate removal of organic pain (can cloud symptoms, cause further harm) • Indiscriminate removal of neurotic symptom • Assess potential for abuse of hypnotic skill by client.

16. History of Trance • Early Trance Uses Prehistoric / Indigenous Peoples: Shamans, Medicine Men, Mystics Egyptians: Sleep Temples Greeks: Delphic Oracle, Aesculapian rituals • Pre-Mesmer Religious Healers Father Kircher Father Hell Abbé Faria

17. Asclepius Temple of Epidaurus Asclepius' most famous sanctuary was in Epidaurus. Another famous "asclepieion" was on the island of Kos, where Hippocrates, the legendary doctor, may have begun his career. A seeker of healing would make pilgrimage to a temple such as the Temple of Epidaurus. A priest would welcome and bless them and promote dreams in the seeker which promoted healing and the solutions to problems aided by the oracles.

18. Asclepius Greek god of healing and patron deity of physicians. Son of Apollo and the nymph Coronis. Husband of Epione. Father of Hygieia (health) and Panacea (all-healing). Homer refers to him only as a skillful physician, and it was Apollo who was regarded as the god of healing until that role was taken over by his son beginning in the fifth century BC. As a deified mortal. His cult originated in Thessaly (the location of the oldest known temple honouring him), where he was said to have been raised by the centaur Cheiron, who taught him the art of healing. Zeus, fearing that Asklepios might make men immortal, killed him with a thunderbolt. His attribute is a staff with a snake coiled around it, the caduceus of Hermes serves as a symbol of the medical profession.

19. The more recent history of hypnosis begins with Franz Anton Mesmer (1734-1815)who theorized that disease was caused by imbalances of a physical force, called animal magnetism. Mesmer also believed that cures could be achieved by redistributing this magnetic fluid -- a procedure that typically resulted in pseudoepileptic seizures known as "crises".

20. Search For A Scientific Basis Franz Anton Mesmer(1734-1815) Universal Fluid Magnetic energy from doctor to patient “AnimalMagnetism” Importance of rapport Royal Commission (Chair: Benjamin Franklin) discredited Mesmer’s theories concluded cures were due to imagination, imitation, touch

21. Marquis de Puységur (1751-1825) Observed spontaneous amnesia (as seen in sleep walking) “Artificial Somnambulism” Clairvoyance in some of his patients

22. Abbé Faria (1746 - 1819), Abbé Faria, (1746 - 1819), an Indo-Portuguese priest, introduced oriental hypnosis to Paris in the early 19th century. Faria came from India and gave exhibitions in 1814 and 1815 without manipulations or the use of Mesmer's baquet. Unlike Mesmer, Faria claimed that it “generated from within the mind” by the power of expectancy and cooperation of the patient. Faria's theoretical position, and the subsequent experiences of those in the Nancy School made significant contributions to the later autosuggestion techniques of Émile Coué and the autogenic training techniques of Johannes Heinrich Schultz.

23. John Elliotson(1791-1868) London surgeon Published first mesmeric journal, ZOIST, (1842 to 1856,13 vols.) Gave the Harveian-Lecture on Mesmerism. Resignedfrom London University Hospital when mesmerism was banned there.

24. James Esdaile(1808-1859) British surgeon in India Hypnoanesthesia Mesmeric passes by hypno-technicians Over 3000 major, many minor surgeries Infection rate reduced from 50% to 5% Before sterile technique

25. James Braid (1795-1860) Scottish surgeon Coined “Hypnosis” (“nervous sleep”, Neuro- Hypnosis) - not “mesmerism” Book NEURYPNOLOGY First to use eye fixation Hypnotic phenomena due tomonoideism,suggestion.

26. Auguste Ambroise Liébeault (1823-1904) French family physician, founded School of Nancy Father of modern hypnotism Opposed theories of Charcot Described deepening by fractionation Adhered to Braid’s theory

27. Hippolyte Bernheim (1837-1919) Hippolyte Bernheim (1837-1919), a professor of medicine at the University of Nancy regarded hypnosis as a special form of sleeping where the subject's attention is focused upon the suggestions made by the hypnotist. He emphasized the psychological nature of the process of hypnosis.

28. Emile Coué (1857-1926) Pharmacist, student of Liébeault Demonstrated efficacy of Self-Hypnosis Laws of Dominant Effect Reversed Effect Concentrated Attention

29. Jean-Martin Charcot (1825-1893) Jean-Martin Charcot (1825-1893), a leading neurologist of his day. He concluded that hypnosis induced seizures when his hysteric patients showed epileptic-like symptoms when they were in a trance. He endorsed hypnotism for the treatment of hysteria. Opposed School of Nancy La méthode numérique ("The numerical method") led to a number of systematic experimental examinations of hypnosis in France, Germany, and Switzerland. The process of post-hypnotic suggestion was first described in this period. Extraordinary improvements in sensory acuity and memory were reported under hypnosis.

30. Pierre Janet (1859-1947) French Psychiatrist First to use hypnotic regression to uncover the traumatic origin of symptoms Produced cathartic cures antedating Freud’s Psychoanalysis Studied neurotic “idées fixes” at Salpêtrière

31. Josef Breuer (1842-1925) Collaborated with and stimulated Freud in seeking the cause of neurosis Co- author of “Studies in Hysteria” with Freud (Case of Anna 0.)

32. Sigmund Freud (1856-1939) Viennese Psychiatrist. Started with-hypnosis and abandoned it because he could not get good trances in many of his patients, and because his interest was in getting to the cause (he only used hypnosis for direct suggestion). His move to free association set back the acceptance of hypnosis by the psychiatric community.

33. Jerome Schneck (1920- ) In 1949 became founding president of the SOCIETY for CLINICAL and EXPERIMENTAL HYPNOSIS (SCEH). In January, 1953 the first issue of the JOURNAL of CLINICAL and EXPERIMENTAL HYPNOSIS was published under the editorship of Milton Kline.

34. After World War II, interest in hypnosis rose rapidly. Ernest and Josephine Hilgard and Andre Weitzenhoffer founded a laboratory for hypnosis research at Stanford University.

35. British Medical Society (1955) Officially endorsed hypnosis.

36. Milton Erickson (1902-1980) In 1957 was founding President of the AMERICAN SOCIETY of CLINICAL HYPNOSIS (ASCH) In 1958 the first Editor of the AMERICAN JOURNAL of CLINICAL HYPNOSIS (AJCH)

37. International Society Of Clinical and Experimental Hypnosis Founded in 1959 with Bernard Raginsky as first President and John G. Watkins as Executive Secretary. In 1973 this became International Society of Hypnosis (ISH) with Ernest R. Hilgard as President.

38. American Medical Association (1958) Recommended that hypnosis be taught in Medical and Dental Schools.

39. Special Process Theories • Modified sleep: sleep and hypnosis not the same, EEG studies confirm that, but similarities between the two phenomena, particularly in Stage I sleep. • Altered State (Orne): An out of the ordinary, trance like state. • Dissociation / neo-Dissociation (Janet, Hilgard) • Adaptive regression (Meares): atavistic aspects, regression to primitive mode of mental functioning. • Psychodynamic (E. Fromm): A different style of dealing with transference. • Trait (Spiegel and Spiegel): an attitudinal capacity, stable throughout life.

40. Special Process Theories: • Pathology (Charcot): abnormal nervous system, looked at similarity in hysterical (dissociative) phenomena and hypnosis. • Biological (Pavlov): selective inhibition of certain brain centers Conditioned response- conditioned stimulus are the words of trance induction. Preconceived ideas of what to expect, led to certain response set. • Animal magnetism (Mesmer): essentially an organic theory. • Neurochemical- current MRI and Brain/neurological system measures suggest chemical changes in parts of brain. Similarity of hypnosis to shock response.

41. Neodissociation Theory Focuses on the dissociative experience, rather than the behavior. Systems of ideas can become split off from the main personality and exist as a subordinate personality, unconscious, but capable of becoming conscious through hypnosis. (i.e. A state theory). E.R. Hilgard

42. Social-Learning Theories: • Suggestion (Hull): Responsiveness of a person to interpersonal communication • Expectation (Kirsch): anticipation of favorable outcome, “belief” in being capable of hypnotic experience • Social Role (Sarbin, Barber): ability to “enact” a role; role involvement as opposed to role-playing (Shore)

43. Integrated / Multimodal Theories: • “Domain” of Hypnosis (Brown and Fromm) • “Three-factor” theory (T.X. Barber) • “Non-Theory” (Erickson) • Psycho-structural Levels (Crasilneck and Hall) atavistic aspects, regression to primitive mode of mental functioning

44. Cognitive-Behavioral Theory • Depends on the willingness of the subjects to think along with and imagine the experiences which are suggested, and to put other thoughts and ideas out of their minds. (i.e. 1784 royal commission report conclusion that the effects were due to the imagination, imitation, and touch.) S.C. Wilson & T.X. Barber

45. Social Psychological Theory • Subject is seen as strategically manipulating his own behavior and subjective reports to bring them into line with the demands and expectations present in the hypnotic situation. (i.e. Hypnosis is not a "special process".) N. P. Spanos G. F. Wagstaff

46. Non-State • Many "hypnotic" phenomena can be readily produced in subjects who had not previously received a hypnotic induction procedure. (i.e. There is no real justification to refer to hypnosis as an altered state of consciousness.) T.X. Barber

47. Structural Theory Hypnotic influence is exerted through the executive control system to co-ordinate how information to the level of awareness is handled. It is an evolutionary, hierarchical description of a more sophisticated level of information processing in humans than in mammals than in reptilian brains with an advancing subjective experience into a more meaningful perspective.

48. fMRI Neurostructure theory Rainville and his associates showed that strategically worded suggestions can dissociate the two components of pain, selectively altering one but not the other. (Rainville, Duncan, Price, Carrier, & Bushnell, 1997). The two components of pain have different biological substrates: sensory pain in the primary somatosensory cortex, and suffering in the anterior cingulate cortex.

49. fMRI Neurostructure theory ….In contrast with imagined pain, functional magnetic resonance imaging (fMRI) revealed significant changes during this hypnotically induced (HI) pain experience within the thalamus and anterior cingulate (ACC), insula, prefrontal, and parietal cortices. These findings compare well with the activation patterns during pain from nociceptive sources and provide the first direct experimental evidence in humans linking specific neural activity with the immediate generation of a pain experience. Cerebral activation during hypnotically induced and imagined pain. Derbyshire, Stuart W G. Whalley, Matthew G. Stenger, V Andrew. Oakley, David A. Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA. derbyshiresw@anes.upmc.eduNeuroimage. 23(1):392-401, Sept. 2004.

50. fMRI Neurostructure theory We can speculate on the basis of our findings of increased BOLD signals in the left hemispheric ACC and the basal ganglia and less activation of the classic pain network under hypnosis that the left ACC and basal ganglia might play a role in increasing inhibitory signals, which in turn may lead to a loss of signal from painful thermal stimuli in the more proximal sensory cortex. Clinical Hypnosis Modulates Functional Magnetic Resonance Imaging Signal Intensities and Pain Perception in a Thermal Stimulation Paradigm Schulz-Stubner S, Krings T, Meister IG, Rex S, Thron A, Rossaint R. Regional Anesthesia and Pain Medicine, Vol 29, No 6 (November-December, 2004: pp 549-556