Hypnosis and Hypnotherapy

This chapter briefly reviews the neodissociation theory of hypnosis, and the limitations and strengths of clinical hypnosis. Although many contemporary theories of hypnosis exist, the focus here is on the neodissociation theory of hypnosis as it forms part of the cognitive-dissociative model of depression (CDMD) described in Chapter 4.

Theories of Hypnosis

Hypnosis, in one form or another, has been used in different parts of the world to treat various medical and psychological disorders since ancient times. In the 18th century, Franz Anton Mesmer, a physician from Vienna, conceptualized hypnotherapy as a formal form of psychotherapy for a variety of psychological disorders (Spiegel & Maldonado, 1999). As yet no universal definition or explanation of hypnosis has been postulated. Many theories, loosely classified under state and nonstate theories, have been advanced to explain hypnosis, but none of the theories has satisfactorily explained all the phenomena associated with. State theorists conceptualize hypnosis as a trance or altered state of consciousness (Barber, 1969,1979), influenced by subjective traits and the states of the hypnotized person. The nonstate theorists purport a social, psychological explanation and maintain that there is nothing unique about hypnosis hypnosis; they argue that most hypnotic phenomena can occur without a hypnotic induction (Barber, 1969). These theorists focus on the social or relational aspects of the hypnotic interaction, and they emphasize the role of a variety of interactional forces, such as expectations and situational demands, in the production of hypnotic phenomena (Kirsch, 2000). These different formulations of hypnosis have broadened our understanding of the subject, but it is beyond the scope of this book to discuss the merits and controversies surrounding each theory (see Kallio & Revonsuo, 2003, for review, and rejoinder in the whole issue of Contemporary Hypnosis, 2005, 22 [1], pp. 1-55). From his review of the well-known theories of hypnosis 20 years ago, Rowley (1986, p. 23) concluded:

None of them seem to be able to deal adequately with all the phenomena which come under the general heading of hypnosis. This is perhaps not surprising given the tremendous variety of phenomena. Accordingly the theories have different ways of dealing with this variety. Some redefine hypnosis, e.g., Edmonston (1981). Others reinterpret subjective experience, e.g., Spanos (1982). … Despite these inadequacies, each of the theories has something to offer, a new conceptualization of the issues, a methodological approach, a new synthesis of the evidence. Of course, in one sense it is impossible to produce
a theory which is satisfactory to all researchers, for they are likely to have different criteria for evaluating theories.

Almost a decade later, Yapko (2003, p. 61) expressed similar opinions when addressing the complexity of the hypnotic concept:

With a subject as complex as hypnosis, the inadequacy of a single theory’s ability to explain the broad range of responses on so many different dimensions of experience becomes glaringly apparent. The complexities of the subject of hypnosis, and even greater complexities of the human being capable of hypnosis, are so great that it seems highly improbable that a single theory can evolve to explain its origin and character.

Kallio and Revonsuo (2003) proposed a multilevel framework to explain the hypnotic phenomena, which is strongly endorsed by Spiegel (2005, p. 32), who commented that:

Multilevel explanations are an absolute necessity in understanding human mind/brain/body phenomena because we are both neurally based and social creatures who experience the world in mental phenomenal terms. To choose one of these domains as the complete explanatory context is to be by definition wrong.

Academics and experimentalists have generally endorsed nonstate, interpersonal, or multifactorial views of hypnosis, whereas clinicians have tended to adopt state, intrapersonal, or single views of hypnosis, particularly the neodissociation theory of hypnosis, described here. Proponents of both camps, however, agree that hypnotic suggestions can produce altered states, and that some subject variables can influence the hypnotic performance. The important subject variables include cooperation (Spanos & Barber, 1974), expectations (Barber, 1984, 1999), motivation (Araoz, 1981,1985), and level of involvement in suggestion-related thoughts and images (Erickson & Rossi, 1979; Spanos & Barber, 1974). Kirsch (2005), a well-known nonstate or sociocognitive theorist, emphasizes that both state and nonstate theorists agree that hypnotic suggestions can produce altered states such as amnesia, analgesia, involuntariness, and others, although there is disagreement about whether these altered experiences depend on the prior induction of a trance state. To clinicians, who are mainly concerned with reducing a patient’s distress, the debate whether trance exists or does not exists, or whether trance-induction is necessary or not necessary, although interesting, is not considered paramount. What is important in the clinical context is the skilful negotiation of variables to maximize therapeutic gains. To a clinician, hypnosis denotes:

An interaction between two people characterized by a number of inter- and intra-personal processes of which the “essence of hypnosis” only forms a part, if indeed it is present at all. These processes, which are not independent of one another (and which may apply to the behavior [sic] and experience of both the subject and the hypnotist) include the following: selective attention, imagination, expectancy, social conformity, compliancy, role-playing, attribution, usually though not necessarily, relaxation, rapport, suggestion, and hypnotic or trance experience. (Heap, 1988, p.3)

Clinicians emphasize the subjectivity of hypnosis and recognize that hypnotic techniques must be individualized for each patient. This can involve drawing on techniques from more than one theoretical model. The treatment approach described in this book adopts different therapeutic techniques, derived from diverse theoretical conceptualizations. Golden, Dowd, and Friedberg (1987) describe this approach as technical eclecticism. Using this approach, the clinician, in order to maximize therapeutic effects, borrows techniques freely from diverse therapeutic approaches without necessarily accepting the theories from which the techniques were derived.

The neodissociation theory of hypnosis continues to be a dominant contemporary theory of hypnosis. It has inspired extensive research, and it provides a rationale for clinical work (Kihlstrom, 2003; Lynn & Kirsch, 2006). It also forms part of the integrated conceptualization of depression proposed in Chapter 4. The focus on the neodissociation theory here is not meant to discredit the contributions made by other competing or completing theories of hypnosis. In fact, the clinical approaches to the treatment of depression described in this book actively utilize techniques proposed by many other theories of hypnosis to maximize therapeutic gains.

Neodissociation Theory of Hypnosis

Although controversial, Hilgard’s (1973, 1974, 1977) neodissociation conceptualization of hypnosis is one of the most influential theories of hypnosis, both from an experimental and clinical standpoint. Hilgard describes hypnosis and other related phenomena such as fugues, possession states, multiple personality, and the like in terms of dissociation or divided consciousness. West (1967) defines dissociation as a psychological process in which information (incoming, stored, or outgoing) is actively deflected from integration with its usual or expected associations. This produces alterations in thoughts, feelings, or actions so that, for a period, certain information is not associated or integrated with other information in the usual or logical way. West regards such an experience to be either normal or pathological. Janet’s early research (1907) established a close relationship between hypnosis and dissociation. Janet (1889) put forward the view that systems of ideas can become split off from the main personality and exist as an unconscious subordinated personality, capable of becoming conscious through hypnosis. The theory was applied to hypnosis and various other normal and pathological states such as automatism, amnesia, fugues, and multiple personality. Hilgard, by deriving ideas and concepts from information processing, selective attention, brain functioning, and the cognitive model of consciousness, reformulated the theory in contemporary terms and called it neodissociation theory. In Hilgard’s reformulation, dissociation is seen as an extension of normal cognitive functioning. He posited that, during ordinary consciousness, information is processed on a number of levels by a hierarchy of cognitive operations and controls. Ordinarily, these operations are integrated, but during hypnosis or dissociation, the integration decreases, and certain aspects of experiences may not be available
to consciousness. Dissociation or hypnotic involvement is seen as a cognitive process on a continuum ranging from minor or limited to profound and widespread. Hilgard also considered the role of the concept of self and will in his neodissociation theory. He maintained that hypnosis and other dissociative experiences all involve some degree of loss of voluntary control or division of control.

Hilgard’s theory proposed that an individual possesses a number of cognitive systems, hierarchically arranged, with a central control structure (executive ego) and multiple superordinate and subordinate structures, each with its own input and output connections with the world. Although the executive ego is normally in control, the other structures can take over as a result of hypnotic-type suggestions or other similar procedures or situations. In other words, hypnosis or other similar procedures has the effect of dissociating these systems from one another, and some of these systems can be taken out of awareness or consciousness. A hypnotized individual may thus report feeling no pain, but the hidden observer–the name Hilgard gives to the cognitive system that is aware of what is going on–may report feelings of pain.

Hilgard (1977) has utilized experiments involving hypnotic analgesia and automatic writing to demonstrate this hidden observer effect. This effect can also be demonstrated by suggesting to the hypnotized subject that, when a prearranged signal such as the placing of the hypnotist’s hand on the subject’s shoulder is given, the hypnotist will be able to contact a “hidden part” of the psyche, unknown to the subject’s present conscious “part.” Hilgard claims that when this suggestion is given to responsive subjects, the hypnotist may then contact another system of control, which can speak, unaware of the normal “waking” or “hypnotized” part. These parts are not normally aware of each other, because they are separated by amnesic barriers. These amnesic barriers can sometimes break down partially or completely, causing incongruities. The automatic or involuntary nature of hypnotic responding can be easily explained by this process. For example, in automatic writing, the active part that is writing is dissociated or split from the conscious part, which is unaware that such activity is taking place. The hidden observer (or a covert cognitive system) is aware of the automatic writing. The hidden observer can also be accessed after the termination of hypnosis by providing posthypnotic instructions during hypnosis. Thus, the neodissociation theory proposes that, when a subject is hypnotized, only some of the cognitive systems are involved, while others remain unaffected. “Thus a person who experiences only a vague feeling of relaxation has only a very few low level cognitive systems affected. A person who experiences arm levitation and analgesia has many more cognitive systems affected” (Rowley, 1986, p. 16). Dissociation can be externally induced, self-induced, or it can occur spontaneously.

Hilgard’s attempts to link hypnosis with consciousness seem intuitive and logical. With the recent upturn of interest in consciousness as an area of scientific study in affective and cognitive neuroscience (e.g., Gazzaniga, 2000;Mesulam, 2000; Zeman, 2001), the relationship between consciousness and hypnosis
is likely to be further clarified. Some striking parallels have already been observed in the mental processes involved in dreaming and hypnosis. For example, Llinas and Pare (1991) observed dissociations between the specific and nonspecific thalamocortical systems underpinning dreaming, implying that a state of hyperattentiveness to intrinsic activity can occur without registering sensory input. Similarly, Furster (1995), in dreaming, observed a dissociation between context and sensory input and the cognitive features of dreaming including altered sense of time, absence of temporality, lack of guiding reality and critical judgment, anchoring in personal experience, and affective coloring. These findings led Gruzelier (1998, p. 18) to draw parallels between hypnosis and altered state of consciousness:

The fragmented networks activated in the dream seem to lack the associative links to a time frame, anchored as they are in the present, without time tags and references. This could equally be a description of the hypnotic state as high susceptibles experience it.

Hilgard’s neodissociation theory of hypnosis is, however, incomplete. Although he proposed cognitive structures, he gave little information about what happens inside them. It is also unclear how many cognitive systems a person possesses, and how many of these are engaged in hypnosis. Moreover, the neodissociation theory has been criticized for ignoring the role of social compliance factors. However, some followers of Hilgard have addressed the role of social compliance in hypnosis. For example, Nadon, Laurence, and Perry (1991) have proposed an interactionist approach in which both cognitive and social factors play a part.

The scientific validity of the hidden observer phenomenon also has been challenged. Although Hilgard (1977) and Watkins and Watkins (1979) have provided experimental evidence for the presence of the hidden observer (see Hilgard, 1977), the studies and interpretation of the hidden observer have been questioned by sociocognitive theorists. Spanos (1986, 1991; Spanos & Coe, 1992) has been the most vocal critic of the hidden observer phenomenon. In several studies, Spanos and his colleagues demonstrated that the reports of the hidden observer varied as a function of the explicitness of instructions that the subjects received about the nature of the hidden observer. For example, Spanos and Hewitt (1980) obtained reports of more or less hidden pain as a function of whether the subjects were told that their hidden parts would be either more aware or less aware of the actual amount of pain. Such findings led Spanos and Coe (1992) to conclude that the hidden observer phenomenon is not an intrinsic characteristic of hypnosis, but a social artifact shaped by a subject’s expectancies and situational demand characteristics. One study (Spanos, Radtke, & Bertrand, 1984) thus manipulated the instructions to produce two hidden observers, one sorting memories of abstract words and the other storing memories of concrete words. This led Lynn and Kirsch (2006) to argue that the hidden observer is implicitly or explicitly suggested by the hypnotist; hence they dubbed the hidden observer phenomenon the flexible observer.

The fact that the hidden observer reports vary with instructions does not disprove the neodissociation theory of hypnosis. Khilstrom and Barnier (2005) declare that it is the very nature of

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