Clinical Applications of Hypnosis to General Medicine
In one of his lectures William James remarked that every scientific theory goes through a classical career of stages. First it is attacked as absurd. Then it is admitted to be true, but obvious and insignificant. Finally it is deemed to be so important that its adversaries claim they were the ones who discovered it. Hypnosis is at present in the second of these stages, with indications that the third stage has begun in certain areas. Some of our colleagues believe that its use should be limited to the psychiatric field. Others still feel that hypnosis is of no consequence. A few think it is absurd. Actually, none of these opinions is valid. Hypnosis has a practical application in almost all fields of medicine and its allied professions. It can and should be used by general practitioners and anesthesiologists, pediatricians, dentists, clinical psychologists and, obviously, psychiatrists.
Hypnosis adds speed and directness to psychotherapy, but it is not a panacea. Where the therapeutic goal has a time element involved, where an exhaustive rehabilitation of the individual is not essential, a short-term therapeutic maneuver utilizing hypnosis may restore the individual’s capacity to meet the rigors of his inter- and intrapersonal relationships. This utilization of hypnosis may also help in the development of a motivation to continue further treatment in the psychiatric realm with the total reintegration of the personality as the goal.
Wolberg emphasizes that the history of hypnosis demonstrates conclusively that it is no miracle method but that, shorn of extravagant claims made for it by some of its adherents, it is an important and useful therapeutic tool. The late Robert Lindner contended that hypnoanalysis can be the equivalent of surgical removal of barriers and hazards in that it pierces the psychic substrata and raises the repressed to the level of awareness. Brenman and Gill state that in the induction of hypnosis, the various illusions or even hallucinations a patient may go through are due to a change in the ego, which leads to a minimization of the importance of external reality and to alteration in bodily sensation and body image.
In April 1955, after eighteen months of intensive study, a subcommittee of the psychological medicine group of the British Medical Association reported the following:
2. It is valuable for revealing unrecognized motives and conflicts.
3. As a method of treatment, it has proved its ability to remove symptoms and to alter morbid habits of thought and behavior.
4. Doctors do a disservice to themselves and medicine by making communications to lay audiences and the lay press in a manner inconsistent with medical ethics.
5. Description, therapeutic possibilities, and limitations of hypnosis should be taught to medical undergraduates.
6. The clinical use of hypnosis should be taught to medical graduates, particularly psychiatrists, obstetricians, gynecologists, and anesthesiologists, as well as to others who practice in any of the fields of psychological medicine, which actually includes all people in the therapeutic field.
7. University departments and research foundations should institute more research along clinical and experimental lines.
The utilization of hypnosis in modern medicine began, as we well know, with Mesmer. Probably all the proponents of hypnosis utilized direct suggestion to produce anesthesia and a direct removal of symptoms to effect their medical “cures.” Esdaile, Elliotson, Charcot, and others described the necessity of making suggestions forceful, strong, dogmatic, and repetitious. Some of them used flowing robes, austere surroundings, and a dramatic showmanship in an attempt to elicit the sensations of awe and fear and to heighten their prestige with patients. Apparently, if one can accept their reports as valid, these procedures did work on a large number of patients. It is difficult, however to determine whether the use of hypnosis resulted in a “cure,” or whether prestige suggestion might have had the same results without the production of the trance state.
Five main techniques are utilized in hypnotic treatment. First, and most rarely used, is the prolonged, deep hypnotic trance, where the patient is placed in a deep hypnotic state and kept there for a period of hours or days. This treatment has been utilized for some fifty years, particularly in some of the neuroses, e.g., the vomiting of the gastric neuroses. It has also proved some value with some of the emotionally based tics.
The second method, also utilized for some time, is indirect suggestion. Here the technique employed is that of indirect, permissive suggestion, or indirect permissive removal of symptoms. The suggestions must be very detailed. For example, in treating an insomniac and teaching him how to go to sleep by means of posthypnotic suggestion, one must bear in mind that he must also be told that if he should awaken during the night for any reason, this teaching will also include the ability to return to sleep.
Direct hypnotic suggestion constitutes a third method. This particular technique can be effectively employed in a small percentage of cases, but it requires especially careful handling of the patient to avoid arousing resistance.
The fourth method of treating patients hypnotically is the use of a cathartic hypnotic state wherein, as Breuer stated, the hypnosis diminishes the inhibitions and repressions and releases the emotional block. This is a psychiatrically oriented type of therapy.
Hypnoanalysis, the fifth type of therapy, constitutes an approach in which analytic techniques are utilized on a psychiatric level, the hypnosis constituting an adjunct to shorten the therapeutic course.
DIRECT HYPNOTIC SUGGESTION
Kline’s expression “directive hypnotherapy” as a term to replace “direct suggestion” is very well taken. The terms may be considered synonymous; however, they have different connotations. Despite the fact that it is called “directive hypnotherapy,” the best type of therapy would actually be one that is utilized as an indirect suggestion in therapy—not a means of directly attacking the problem or symptoms or directly suppressing them with orders, but rather a technique bringing about a condition within the patient that can lead him to evaluate more productively the effectiveness of the activity, and resulting in a behavioral response more adequate for him as a total personality.
Two elements are requisite to the elicitation of productive activity in the hypnotic subject when direct suggestion is used. One is the depth of the hypnosis required; a somnambulistic state is probably necessary for most psychophysiologic conditions. The second requisite is adequate understanding by the patient of the purposes to be served and their relationship to his personality needs.
Direct suggestion will probably never be as efficacious as indirect suggestion, which can eliminate some of the natural resistances of the patient. As one might expect, resistances increase in proportion to the neurotic needs of the patient and the resulting altered state of psychologic and neurophysiologic functioning. In a patient with fewer neuroses and less neurotic behavior, there is more willingness to comply with direct suggestion.
INDIRECT PERMISSIVE SUGGESTION
An adaptation of the second hypnotic technique, indirect permissive suggestion, is probably most important to the general practitioner and the one with which we shall concern ourselves primarily in this discussion. The internist or the general practitioner is not usually qualified to give extensive psychiatric therapy to the patient, but he can utilize many of the techniques of indirect permissive suggestion to render the most satisfactory treatment to his patient. Most physicians have been treating symptoms by giving aspirin for headaches, codeine for coughs, and in many of these cases merely treating the symptom without getting to the underlying cause. With the utilization of hypnosis, one has a valuable therapeutic adjunct. This type of therapy frequently presents the best opportunity for application and is usually the most effective in the ordinary complaints presented to the physicians.
Such suggestion can be employed (1) to obtain the deepest possible state of hypnosis within the time allotted to the patient, directing the symptoms and the suggestions with all eventualities considered; (2) to repeat these things frequently to the patient, thus reinforcing them.
Of course it is also important, before determining the type of suggestion to offer a patient, to get a well-oriented history without necessarily going into a detailed psychiatric history. It is important, as well, to utilize the patient’s questions, both in the induction stages and in his treatment.
The depth of trance is probably not too important in the treatment of the minor neuroses that the average practitioner handles providing the doctor can clear up the mental state of the patient. Frequently, definitive results can be obtained. Schilder and Kauders claimed that they could obtain results in from one to four sessions. Of course, this may not suffice for a permanent cure. Many persons learn by slipping or erring and some patients need to experience this. Treatment should be continued subsequent to this “slip.”
Severe neuroses generally require more extensive hypnotherapy and many more sessions are usually indicated. The therapist may find that it is important to the patient to learn the purpose of his symptoms, when they do serve a purpose for him. It is not necessary for this awareness to be on a conscious level, however; the actual purpose may never become consciously recognized, but the patient’s realization of the possibility that his symptoms may be important may lend itself to a revaluation of his symptoms. Consequently, substitutions may be evoked on the part of the patient through permissive suggestions, allowing for an improvement of the total personality. Schilder and Kauders also state that medical hypnosis helps the patient to rebuild his personality on the basis of an increased ability to adjust himself and to accept reality. This reconstruction takes place under the direction of the physician.
It is important also to note that reassurance, persuasion, re-education, and the like, which are certainly of value in the nonhypnotized patient, will have increased value in the hypnotized individual. These measures can be used effectively with even a light trance.
In the production of the trance state, the utilization of indirection allows for a better acceptance on the part of the patient; it removes the possibility of defenses that are a normal response to a direct ordering away of either a physical sign or a symptom.
DIRECT AND INDIRECT APPROACHES CONTRASTED
In contrasting the two methods, one might employ the following direct approach to the production of hypnotic deafness: “When I count to ten, you will find yourself getting more and more deaf, until finally, at the count of ten, you will be unable to hear anything at all.”
On the other hand, the indirect approach might proceed in this fashion: “I wonder how it feels to a person who is about to lose his hearing? I wonder if he notices the fact that sounds seem to grow very, very slightly less distinct at first, if he finds that they seem to be fading off into the distance? And I wonder if the person then sits in his chair, leaning forward toward the sound? Docs he cup one ear or both ears, or does he test his hearing by putting a finger in his ear to see if there is an obstruction there? Does he find himself straining more and more and holding his head to the side, all in an attempt to try to get an accumulation of more of the sounds? Does he find that, despite this, the sounds continue to fade farther and farther into distance? Do things finally sound as though they are only being whispered? Then does he notice despite the fact that he can see the speaker’s lips moving, that he is unable to hear anything except an occasional noise coming through? I wonder if this is distinguished by a slight buzzing noise, or if there is no buzzing noise? Then how does he feel; how does he look at one? Does he gaze intently, staring at people in an attempt to read their lips?”
All the while, of course, as this is drawn out very carefully and in detail, the speaker can be reducing the volume of his own voice, to help in the realization of the situation. In a careful, indirect procedure of this sort, one can produce hypnotic deafness. It will stand all the tests of physiologic deafness, because the subject was allowed unconsciously to utilize his own feelings, his own sensations, and his own knowledge of things, in order to limit and delimit his ability to hear sounds and the spoken word. He did not experience the normal resistances evoked by ordering him directly not to be able to hear. This type of procedure should also be used in the production of the hypnotic trance state. It should be employed in the treatment of any of the ailments where hypnosis is utilized.
General therapeutic approaches
Several general types of therapy can be used by the general practitioner in medicine. First are symptom-removal techniques. These utilize a direct hypnotic approach, similar to that described earlier. There is probably little place in the modern concept of dynamics for this particular type of technique for despite careful planning on the part of the hypnotist, the procedure can again result in evoking the resistances of the patient.
The second type of treatment is the alleviation or amelioration technique. By inducing changes in perceptions, changes in reception of stimulation, and changes in sensations, a large portion of the treatment procedures can be accomplished. Relaxing mechanisms of the physical as well as the emotional state can be utilized in this type of technique and anxiety symptoms can frequently be lessened.
The third technique is a replacement or change in the symptoms. Actually, this amounts to a substitution of the symptoms. While it is frequently stated, particularly by psychotherapists, that direct removal of one symptom will result in another symptom, many workers have found that if the suggestions offered are indirect and permissive, frequently a symptom will not be substituted. One needs also to bear in mind that the therapist can manipulate symptoms, causing a patient to accept a substitute that is less disturbing.
CASE OF MR. THOMAS A.
One such case was reported by Erickson. He described a patient, Mr. Thomas A, with a functional paralysis of one arm. The paralysis was gradually maneuvered by the therapist to the point where the patient agreed to have it placed in the right little finger.
The patient still satisfied his neurotic needs by having a hysterical paralysis; however, it is located in such fashion that it does not prevent his carrying out his normal activities. This is a very specialized therapeutic maneuver, but one that can readily be accomplished by many therapists familiar with hypnotic techniques.
Another technique is that of yielding the symptom to the therapist. Initially the therapist may be permitted only to increase the symptom, but this carries with it a tacit permission on the part of the patient for it to be further manipulated. Thus the symptom can be gradually reduced, or finally eliminated.
In treating a patient with migraine headache, for example, one might tell the patient that there is a possibility that his headaches could become worse, that temporarily, in a limited situation, they might not only become more severe but more frequent. When the patient allows the therapist to make his headaches worse, he is surrendering a measure of control. The implication is that if the therapist can make the headache worse, he can also make it better.
Symptom manipulation can be effected with the use of hallucinations and other sense-modality changes, such as age regression and time distortion. These processes, it must be remembered, do not cause a change in the self-understanding or insight processes of the patient directly, but they may be employed directly to affect and ameliorate the patient’s distress. It would seem, however, that there must of necessity be some re-evaluation of symptoms, at least on an unconscious basis, for these results to be permanent in character.
Brief reference has been made to the fact that some persons learn by slipping or erring and that some patients need this experience before a permanent cure is effected. Patients ought to be made aware of such a possibility and should be instructed to report back to the office following such an experience.
Patients are usually told that everybody who learns something learns it in a different manner. Sometimes the example of the typist is given. She may learn to type by making errors, going over and over those errors, correcting them, then making still others, until she finally learns exactly where her fingers should be in relation to the keys. They are also told that people are frequently able to remove symptoms in themselves, but then they may need subconsciously to know how it was before they removed the symptoms. Thus they can sometimes reproduce the symptoms subconsciously, merely to test them and decide whether they want to continue with them, or whether they want to remain free of them. In that manner, patients are prepared for the fact that they may have a recurrence, but the information is given without positively suggesting the recurrence. Consequently, when they do find the symptom recurring, they do not simply give up, feeling that everything is hopeless.
Nancy B, a girl of fifteen who had severe dysmenorrhea and excessive bleeding, was put in a deep trance and discussed with the doctor her first menstrual period. This had occurred at the age of eleven or twelve. There was excessive bleeding, although she experienced little pain. A great furore was raised about it, however, and she was hospitalized and given hormones by mouth. This was a very exciting experience for Nancy. Since that time, all her periods had been accompanied by very severe pain and an unusual amount of bleeding.
The fact was discussed that often young girls of eleven, twelve, and thirteen do not have a standard body reaction: thus, some months they need to have excessive bleeding; other months they need to have little bleeding; some months they need to have more contractions, and others, fewer contractions. Following the discussion, the patient was told “Now you’re a grown girl and, of course, your body should have learned by now. It can learn within the next thirty days exactly which mechanism is necessary.”
Nancy’s next period was painless and she bled about 60 per cent of the amount she had previously, probably the normal amount for her. She came back to see the doctor after that period and the possibility of the body learning things first one way and then another was discussed. The second month she again had a relatively painful period, although not as painful as originally; furthermore, she lost almost as much blood as she had been doing. It was pointed out to her that this actually could be an excellent thing, since she was experiencing various ways of learning.
Her third period was entirely normal and free from pain. Nancy was told that she might “slip up” again. She was also told that, since she was going to be menstruating for many, many years, it was almost inevitable that she would miss some periods because of illness, accidents, or pregnancy, after which she would start to menstruate again. These things were explained in detail to allow for the possibility of their occurring without disturbing her emotionally to the point where she would revert to the old painful and excessive bleeding pattern.
Areas of usefulness
The use of hypnosis in general medicine can be put together and classified under the systems. Under the respiratory system we might treat colds, asthma, hay fever, and the like.
The gastrointestinal system will include ulcers, hyperacidity, constipation, plain old-fashioned bellyaches, heartburn, perhaps gall bladder diseases, and ailments of that nature. Under the genitourinary system, such problems as enuresis, impotency, and premature ejaculation would be included, along with others discussed under obstetrics and gynecology.
In regard to the nervous system, apart from matters handled by the psychiatrists, one could use hypnosis for such disturbances as anxiety, insomnia, and migraine. Also, questions of excessive smoking, nail biting, stammering, obesity, and the like can often be resolved by the nonpsychiatrist.
Many persons have a fear of the unknown or a fear of something known, without understanding that there is probably some reason for it; sometimes such fears persist, even when the person understands that these feelings may be based on traumatic events of early childhood. One such type of patient is the high school or college student, more often the graduate college student, who comes in with a fear of failing an examination, for which he admits he has read adequately. Or he may be one who was too restless to study very much for the examination and is now exhibiting marked concern.
One needs to teach such persons in the hypnotic state the necessity of respecting the unconscious. One needs to teach them that all memories are stored in compartments within the subconscious or the unconscious mind, and that when students read for an examination, they need not read with the idea of memorizing but only for the purpose of understanding the material. It can be impressed upon this particular type of patient that if he reads with understanding, his knowledge will be retained within his unconscious. Of course, it takes longer to discuss it with the patient than it does to review here the few general broad statements that are made.
One needs to teach these patients that if respect for the unconscious has been properly developed by the doctor and by the patient, they need merely sit down when they go into the examination with a feeling of well-being, with a feeling of satisfaction, with a knowledge of the material being there within the unconscious and of its being forthcoming at the proper time.
Two different mechanisms are involved here. One concerns itself with posthypnotic trance states, since the subjects tend to go into light trances while they are writing the examinations. The other mechanism has to do with the fact that by putting the pen on the paper, the patient is allowing the unconscious to rule. The unconscious, having a knowledge of the material, can allow it to pour forth and the patient will frequently write an excellent paper. One patient, a law student, after taking the bar examination recently, reported that he sometimes didn’t even know how the information got on the paper, that he didn’t know how he knew the law involved, yet he wrote a passing examination.