David Spiegel, MD

Mr. M, a world-class athlete, collapsed suddenly in an alley. He was rushed to a hospital emergency room, where he nearly died of internal bleeding from a grapefruit-sized abdominal lymphoma. He was hospitalized and placed on chemotherapy.

Increasing doses of opiates hardly reduced his pain, and he became extremely anxious. Staff described him as “climbing the walls.” He lay in bed writhing, and his parents feared he was becoming a “drug addict.”

Anxiety about his life-threatening illness was clearly compounding his pain, so his attending physician ordered a psychiatric evaluation. When I interviewed the patient, I felt that hypnosis could help.

Hypnosis—as a state of highly focused attention—can help us treat patients’ anxiety, phobias, pain, posttraumatic stress disorder (PTSD), and dissociative disorders. With training, an experienced psychiatrist can quickly start using hypnosis as an adjunct to other therapies.

This article describes how hypnosis helped Mr. M and a young woman traumatized by a criminal assault. Based on my experience and the literature, I discuss what hypnosis is, what training is required, how to measure hypnotizability, and the value of hypnosis in helping patients control their anxiety, posttraumatic, and dissociative states.

Case continued: ‘Surfing’ in Hawaii

When I met Mr. M in the hospital, I acknowledged his distress and the reasons for it, saying “You don’t really want to be here, do you?”

“How many years of medical training did it take you to figure that out?” he replied.

“Well then,” I said, “let’s go somewhere else. Where would you like to be right now?”

He responded, “I’ve never surfed.”

“Good,” I replied, “let’s go to Hawaii.” In hypnosis, I had him picture himself surfing. He continued to groan, but the pattern changed. “What happened?” I asked. “I fell off the surfboard,” he replied. “OK, get back on, and do it right,” I told him.

He learned to practice self-hypnosis, which markedly reduced his anxiety and pain. Two days later he was off pain medications and joking with the nurses in the hall. The attending physician noted in the patient’s record: “Patient off pain meds. Tumor must be regressing.”

What is hypnosis?

Mr. M’s response, though unusually strong, underscores the fact that hypnosis can rapidly produce analgesia and anxiolysis in the medical setting. Hypnosis—often called “believed-in imagination”—is characterized by an ability to sustain a state of attentive, receptive, intense focal concentration with diminished peripheral awareness. The hypnotized person is awake and alert, not asleep. Hypnosis’ three main components are absorption, dissociation, and suggestibility.

Biological basis. The hypnotic state has no brain “signature” per se, but brain imaging portrays hypnosis as a state of alertness with altered anterior cingulate gyrus activation, which helps to focus attention.^1-3 Hypnotized persons can demonstrably alter blood flow in brain regions involved in perceptual processing in response to suggestions of altered perception, whether somatosensory, visual, or olfactory.^4,5 Thus, patients report not only reduced pain but changes in how they experience pain with hypnotic analgesia.

The brain’s dopamine neurotransmitter system—especially in the frontal lobes—also may be involved in hypnosis, as highly hypnotizable persons have elevated levels of dopamine metabolites in their cerebrospinal fluid.⁶

Hypnotic trance. The trance experience is often best explained to patients as similar to being absorbed in a good novel. One loses awareness of one’s surroundings and enters the imagined world. When the novel is finished, the reader requires a moment of reorientation to the surrounding world.

A trance is a state of sustained, attentive-receptive concentration in response to a signal from within or from someone else. The signal activates this shift of awareness and permits more-intensive concentration in a designated direction.

All hypnosis is self-hypnosis. Much of its clinical value is that it can be self-induced throughout the day and whenever symptoms emerge. During the first weeks, patients can be encouraged to practice every 1 or 2 hours.

Applying hypnosis to practice. A well-trained clinician can learn to use hypnosis in classes offered by the two professional hypnosis societies or the American Psychiatric Association (Box 1) Because hypnosis is not something “done to” a patient but rather a capacity to be measured, tapped, and utilized, psychiatrists can integrate hypnosis into clinical practice after some initial training, with ongoing learning and supervision.

Who can be hypnotized?

Not everyone is equally hypnotizable, and hypnotizability is a stable and measurable trait. Approximately one-quarter of adults cannot respond to hypnotic instructions, whereas 10% are extremely hypnotizable.⁷

Brief, clinically useful tests of hypnotic responsiveness have been developed, such as the Hypnotic Induction Profile (HIP).⁸ The clinician usually can induce the trance experience and systematically measure the patient’s response within 5 minutes. A HIP score of 5 indicates usable hypnotizability.

The HIP test includes instructions to produce a sense of lightness in the left arm and hand, with tests of response to this instruction. Response is characterized by dissociation, hand elevation after it is lowered, involuntariness, response to the cutoff signal, and altered sensation.

Turning hypnotic induction into a test of hypnotic capacity transforms the initial encounter by:

• removing pressure on the clinician to successfully hypnotize the subject
• reducing patients’ experiences of complying with the clinician’s wishes, rather than exploring and discovering their own hypnotic capacity.

Placing the hypnotic experience in the context of a test also makes it consonant with other medical examinations and procedures.⁸

Once a patient’s hypnotizability is determined, structured measurement is no longer necessary. The test-retest correlation for hypnotizability scores is 0.7 over 25 years, which is more consistent than IQ testing.⁷ Subsequent inductions usually can be generated by the patient or signaled by the clinician, and only seconds are required for the shift into trance.

Box 1

Reducing anxiety

Anxiety can be understood as a vaguely defined but immobilizing sense of distress. Lack of clarity about the discomfort’s source enhances the patient’s sense of helplessness and avoidance. One therapeutic challenge is to convert anxiety into fear—to give it a focus so that something can be done about it.

Box 2

Anxiety sets up a negative feedback cycle between psychological preoccupation and somatic discomfort, a “snowball effect” in which subjective anxiety and somatic tension reinforce each other. Hypnosis can help reduce anxiety and induce relaxation,⁹ and its dissociative component can help separate anxiety’s psychological and somatic components.

Hypnosis is as effective at reducing anxiety as 1 mg of alprazolam, at least in a study of college students.¹⁰ Student volunteers with high and low hypnotizability were given alprazolam, 1 mg, and a hypnotic suggestion based on their reactions to the drug. Four days later, when students received hypnosis only and hypnosis plus alprazolam:

• combination therapy reduced anxiety more effectively than did hypnosis or alprazolam alone, as measured by the Profile of Mood States tension-anxiety scale
• improvement was comparable with hypnosis or alprazolam alone
• highly hypnotizable students showed significantly greater relaxation than did those with low hypnotizability in all three treatment groups
• EEG data showed similar frontal and occipital changes in the alprazolam and hypnotic suggestion groups.

In randomized trials, simple self-hypnosis training has reduced pain and anxiety during medical procedures, reducing procedure time by an average 17 minutes and resulting in fewer complications.¹¹

A typical hypnotic instruction for managing anxiety is provided in Box 2. This approach teaches patients how to deal with stressors that complicate their anxiety and to control their somatic response. Hypnosis expands patients’ repertoire of responses and enables them to feel less helpless.

Confronting phobias

Phobic symptoms of fear and avoidance or exposure with distress respond especially well to brief hypnosis interventions. Although behavior modification and antidepressants also can treat phobias successfully, one or two hypnosis sessions often can reduce or cure phobic symptoms.

For example, one can help patients with airplane phobia prepare for flight by going into a hypnotic state and learning three concepts:

• Think of the airplane as an extension of the body, such as a bicycle.
• Float with the plane.
• Think about the difference between probability and possibility.

The hypnotic state—with its focused attention and physical relaxation—can amplify this cognitive restructuring technique. Phobic patients can feel more in control of their somatic reactions and, by extrapolation, the flying experience itself. In one study, 52% of patients taught this self-hypnosis exercise remained improved or cured at least 7 years later.¹²

Treating traumatic reactions

Evidence is growing that trauma elicits dissociation. Thus, hypnosis could help us understand and treat traumatic reactions, including patients with acute and posttraumatic stress disorder (PTSD) and dissociative disorders.

The hypnotic state’s controlled dissociation can be used to model the uncontrolled dissociation represented by posttraumatic phenomena such as flashbacks, numbing, and amnesia.¹³ This view is supported by evidence that PTSD is associated with high hypnotizability.^14,15

Acute stress disorder—as introduced in DSM-IV¹⁶—is characterized by prominent dissociative symptoms, with intrusion, avoidance, and hyperarousal. These diagnostic criteria recognize that acute dissociation is a common and predictable reaction to trauma.

Hypnosis involving grief work, exploration of trauma-related transference issues, and emotional expression are effective psychotherapies for persons exposed to trauma. Becoming familiar with hypnotic states can teach patients to recognize, understand, and control their dissociative states.

Evidence suggests that hypnosis’ intense concentration may reverse the dissociative mind fragmentation caused by trauma.¹⁷ Traumatic memories may seem less overwhelming and intrusive once patients discover they can:

• exert greater control over memory access and retrieval
• work through and assimilate disturbing thoughts.

The controlled experience of hypnotic abreaction (reliving traumatic and other memories with strong emotion) provides boundaries for psychotherapeutic grief work.^18,19 Instead of telling patients not to ruminate over a traumatic event, the clinician instructs the patient how to think about the experience.

The inferred message is that the patient can work on other things—such as relationships and daily living problems—after this therapeutic work is done.

Patients are slowly separated from the victim role. The goal is to help them restructure their memories, both cognitively and emotionally. They bear the memories’ impact, yet come to see the information differently.⁷ Traumatic input becomes more bearable when linked to a cognitively restructured recognition of an adaptive response.^,20 For example, patients may acknowledge what they did during a traumatic event that was self-protective or helped others.

PTSD. Hypnosis shares common elements with other cognitive and behavioral treatments for PTSD, including exposure to traumatic memories for cognitive and emotional processing. Few studies have examined using hypnosis to treat PTSD, but evidence suggests it is at least as effective as other cognitive-behavioral treatments.^20,21

Patients can be taught to view PTSD’s intrusive memories and bodily symptoms as re-experiencing painful memories. The memories often intrude less frequently after patients find a controlled method—such as self-hypnosis—to access and work them through.²²

Box 3

Self-blame. Many trauma victims would rather feel guilty than helpless. They blame themselves inappropriately for events over which they had no control, rather than accept their helplessness. They misuse hindsight about the trauma to assume the events were predictable and therefore avoidable. They imagine they can replay the events and change the outcome.

Such an approach to trauma can be profoundly demoralizing, leaving victims burdened by needless guilt and shame. Helping them face and bear the feelings associated with traumatic events can free them from efforts to “undo” or take responsibility for the trauma and accept what happened.

Split-screen technique. Using hypnosis with a “split-screen” technique can help patients restructure the memory of trauma. The left screen symbolizes the trauma in condensed form. The right screen helps patients focus on how they tried to master the situation. This grief work allows patients to acknowledge, bear, and put into perspective the humiliation of the experience and their loss of invulnerability, health, or loved ones (Box 3).¹⁸

Dissociation. Dissociating during a threatening situation may enable a person to put aside some awareness of the danger and take self-protective action. Persistent dissociation, however, may make it too easy to avoid working through the traumatic experiences later on.^22-24

Dissociation makes subsequent exposure to reminders of the trauma more similar to a reexperiencing rather than a controlled remembering of it. This can trigger physiologic stress reactions and lead to or worsen PTSD.^25-27

Dissociative disorders can be understood as chronic and severe PTSDs.²⁸ Many individuals with dissociative disorders have histories of sexual and physical abuse.^29-31 Clearly, traumatic experiences sensitize survivors to subsequent trauma through conditioned activation of fear circuitry involving the amygdala, hippocampus, and frontal lobes.³²

Hypnosis can be especially helpful—both for diagnosis and therapy.³³ It can assist the controlled recovery of memories, while allowing some images to remain dissociated from cognition until the patient is ready to deal with them. The patient can turn memories on and off by entering and exiting the hypnotic state and thereby recover and reprocess memories at a tolerable pace.

Related resources

• Society for Clinical and Experimental Hypnosis. http://ijceh.educ.wsu.edu
• American Society of Clinical Hypnosis. www.asch.net
• American Psychological Association, Division 30. Society of Psychological Hypnosis. http://www.apa.org/about/division/div30.html

Mr. M, a world-class athlete, collapsed suddenly in an alley. He was rushed to a hospital emergency room, where he nearly died of internal bleeding from a grapefruit-sized abdominal lymphoma. He was hospitalized and placed on chemotherapy.

Increasing doses of opiates hardly reduced his pain, and he became extremely anxious. Staff described him as “climbing the walls.” He lay in bed writhing, and his parents feared he was becoming a “drug addict.”

Anxiety about his life-threatening illness was clearly compounding his pain, so his attending physician ordered a psychiatric evaluation. When I interviewed the patient, I felt that hypnosis could help.

Hypnosis—as a state of highly focused attention—can help us treat patients’ anxiety, phobias, pain, posttraumatic stress disorder (PTSD), and dissociative disorders. With training, an experienced psychiatrist can quickly start using hypnosis as an adjunct to other therapies.

This article describes how hypnosis helped Mr. M and a young woman traumatized by a criminal assault. Based on my experience and the literature, I discuss what hypnosis is, what training is required, how to measure hypnotizability, and the value of hypnosis in helping patients control their anxiety, posttraumatic, and dissociative states.

Case continued: ‘Surfing’ in Hawaii

When I met Mr. M in the hospital, I acknowledged his distress and the reasons for it, saying “You don’t really want to be here, do you?”

“How many years of medical training did it take you to figure that out?” he replied.

“Well then,” I said, “let’s go somewhere else. Where would you like to be right now?”

He responded, “I’ve never surfed.”

“Good,” I replied, “let’s go to Hawaii.” In hypnosis, I had him picture himself surfing. He continued to groan, but the pattern changed. “What happened?” I asked. “I fell off the surfboard,” he replied. “OK, get back on, and do it right,” I told him.

He learned to practice self-hypnosis, which markedly reduced his anxiety and pain. Two days later he was off pain medications and joking with the nurses in the hall. The attending physician noted in the patient’s record: “Patient off pain meds. Tumor must be regressing.”

What is hypnosis?

Mr. M’s response, though unusually strong, underscores the fact that hypnosis can rapidly produce analgesia and anxiolysis in the medical setting. Hypnosis—often called “believed-in imagination”—is characterized by an ability to sustain a state of attentive, receptive, intense focal concentration with diminished peripheral awareness. The hypnotized person is awake and alert, not asleep. Hypnosis’ three main components are absorption, dissociation, and suggestibility.

Biological basis. The hypnotic state has no brain “signature” per se, but brain imaging portrays hypnosis as a state of alertness with altered anterior cingulate gyrus activation, which helps to focus attention.^1-3 Hypnotized persons can demonstrably alter blood flow in brain regions involved in perceptual processing in response to suggestions of altered perception, whether somatosensory, visual, or olfactory.^4,5 Thus, patients report not only reduced pain but changes in how they experience pain with hypnotic analgesia.

The brain’s dopamine neurotransmitter system—especially in the frontal lobes—also may be involved in hypnosis, as highly hypnotizable persons have elevated levels of dopamine metabolites in their cerebrospinal fluid.⁶

Hypnotic trance. The trance experience is often best explained to patients as similar to being absorbed in a good novel. One loses awareness of one’s surroundings and enters the imagined world. When the novel is finished, the reader requires a moment of reorientation to the surrounding world.

A trance is a state of sustained, attentive-receptive concentration in response to a signal from within or from someone else. The signal activates this shift of awareness and permits more-intensive concentration in a designated direction.

All hypnosis is self-hypnosis. Much of its clinical value is that it can be self-induced throughout the day and whenever symptoms emerge. During the first weeks, patients can be encouraged to practice every 1 or 2 hours.

Applying hypnosis to practice. A well-trained clinician can learn to use hypnosis in classes offered by the two professional hypnosis societies or the American Psychiatric Association (Box 1) Because hypnosis is not something “done to” a patient but rather a capacity to be measured, tapped, and utilized, psychiatrists can integrate hypnosis into clinical practice after some initial training, with ongoing learning and supervision.

Who can be hypnotized?

Not everyone is equally hypnotizable, and hypnotizability is a stable and measurable trait. Approximately one-quarter of adults cannot respond to hypnotic instructions, whereas 10% are extremely hypnotizable.⁷

Brief, clinically useful tests of hypnotic responsiveness have been developed, such as the Hypnotic Induction Profile (HIP).⁸ The clinician usually can induce the trance experience and systematically measure the patient’s response within 5 minutes. A HIP score of 5 indicates usable hypnotizability.

The HIP test includes instructions to produce a sense of lightness in the left arm and hand, with tests of response to this instruction. Response is characterized by dissociation, hand elevation after it is lowered, involuntariness, response to the cutoff signal, and altered sensation.

Turning hypnotic induction into a test of hypnotic capacity transforms the initial encounter by:

• removing pressure on the clinician to successfully hypnotize the subject
• reducing patients’ experiences of complying with the clinician’s wishes, rather than exploring and discovering their own hypnotic capacity.

Placing the hypnotic experience in the context of a test also makes it consonant with other medical examinations and procedures.⁸

Once a patient’s hypnotizability is determined, structured measurement is no longer necessary. The test-retest correlation for hypnotizability scores is 0.7 over 25 years, which is more consistent than IQ testing.⁷ Subsequent inductions usually can be generated by the patient or signaled by the clinician, and only seconds are required for the shift into trance.

Box 1

Reducing anxiety

Anxiety can be understood as a vaguely defined but immobilizing sense of distress. Lack of clarity about the discomfort’s source enhances the patient’s sense of helplessness and avoidance. One therapeutic challenge is to convert anxiety into fear—to give it a focus so that something can be done about it.

Box 2

Anxiety sets up a negative feedback cycle between psychological preoccupation and somatic discomfort, a “snowball effect” in which subjective anxiety and somatic tension reinforce each other. Hypnosis can help reduce anxiety and induce relaxation,⁹ and its dissociative component can help separate anxiety’s psychological and somatic components.

Hypnosis is as effective at reducing anxiety as 1 mg of alprazolam, at least in a study of college students.¹⁰ Student volunteers with high and low hypnotizability were given alprazolam, 1 mg, and a hypnotic suggestion based on their reactions to the drug. Four days later, when students received hypnosis only and hypnosis plus alprazolam:

• combination therapy reduced anxiety more effectively than did hypnosis or alprazolam alone, as measured by the Profile of Mood States tension-anxiety scale
• improvement was comparable with hypnosis or alprazolam alone
• highly hypnotizable students showed significantly greater relaxation than did those with low hypnotizability in all three treatment groups
• EEG data showed similar frontal and occipital changes in the alprazolam and hypnotic suggestion groups.

In randomized trials, simple self-hypnosis training has reduced pain and anxiety during medical procedures, reducing procedure time by an average 17 minutes and resulting in fewer complications.¹¹

A typical hypnotic instruction for managing anxiety is provided in Box 2. This approach teaches patients how to deal with stressors that complicate their anxiety and to control their somatic response. Hypnosis expands patients’ repertoire of responses and enables them to feel less helpless.

Confronting phobias

Phobic symptoms of fear and avoidance or exposure with distress respond especially well to brief hypnosis interventions. Although behavior modification and antidepressants also can treat phobias successfully, one or two hypnosis sessions often can reduce or cure phobic symptoms.

For example, one can help patients with airplane phobia prepare for flight by going into a hypnotic state and learning three concepts:

• Think of the airplane as an extension of the body, such as a bicycle.
• Float with the plane.
• Think about the difference between probability and possibility.

The hypnotic state—with its focused attention and physical relaxation—can amplify this cognitive restructuring technique. Phobic patients can feel more in control of their somatic reactions and, by extrapolation, the flying experience itself. In one study, 52% of patients taught this self-hypnosis exercise remained improved or cured at least 7 years later.¹²

Treating traumatic reactions

Evidence is growing that trauma elicits dissociation. Thus, hypnosis could help us understand and treat traumatic reactions, including patients with acute and posttraumatic stress disorder (PTSD) and dissociative disorders.

The hypnotic state’s controlled dissociation can be used to model the uncontrolled dissociation represented by posttraumatic phenomena such as flashbacks, numbing, and amnesia.¹³ This view is supported by evidence that PTSD is associated with high hypnotizability.^14,15

Acute stress disorder—as introduced in DSM-IV¹⁶—is characterized by prominent dissociative symptoms, with intrusion, avoidance, and hyperarousal. These diagnostic criteria recognize that acute dissociation is a common and predictable reaction to trauma.

Hypnosis involving grief work, exploration of trauma-related transference issues, and emotional expression are effective psychotherapies for persons exposed to trauma. Becoming familiar with hypnotic states can teach patients to recognize, understand, and control their dissociative states.

Evidence suggests that hypnosis’ intense concentration may reverse the dissociative mind fragmentation caused by trauma.¹⁷ Traumatic memories may seem less overwhelming and intrusive once patients discover they can:

• exert greater control over memory access and retrieval
• work through and assimilate disturbing thoughts.

The controlled experience of hypnotic abreaction (reliving traumatic and other memories with strong emotion) provides boundaries for psychotherapeutic grief work.^18,19 Instead of telling patients not to ruminate over a traumatic event, the clinician instructs the patient how to think about the experience.

The inferred message is that the patient can work on other things—such as relationships and daily living problems—after this therapeutic work is done.

Patients are slowly separated from the victim role. The goal is to help them restructure their memories, both cognitively and emotionally. They bear the memories’ impact, yet come to see the information differently.⁷ Traumatic input becomes more bearable when linked to a cognitively restructured recognition of an adaptive response.^,20 For example, patients may acknowledge what they did during a traumatic event that was self-protective or helped others.

PTSD. Hypnosis shares common elements with other cognitive and behavioral treatments for PTSD, including exposure to traumatic memories for cognitive and emotional processing. Few studies have examined using hypnosis to treat PTSD, but evidence suggests it is at least as effective as other cognitive-behavioral treatments.^20,21

Patients can be taught to view PTSD’s intrusive memories and bodily symptoms as re-experiencing painful memories. The memories often intrude less frequently after patients find a controlled method—such as self-hypnosis—to access and work them through.²²

Box 3

Self-blame. Many trauma victims would rather feel guilty than helpless. They blame themselves inappropriately for events over which they had no control, rather than accept their helplessness. They misuse hindsight about the trauma to assume the events were predictable and therefore avoidable. They imagine they can replay the events and change the outcome.

Such an approach to trauma can be profoundly demoralizing, leaving victims burdened by needless guilt and shame. Helping them face and bear the feelings associated with traumatic events can free them from efforts to “undo” or take responsibility for the trauma and accept what happened.

Split-screen technique. Using hypnosis with a “split-screen” technique can help patients restructure the memory of trauma. The left screen symbolizes the trauma in condensed form. The right screen helps patients focus on how they tried to master the situation. This grief work allows patients to acknowledge, bear, and put into perspective the humiliation of the experience and their loss of invulnerability, health, or loved ones (Box 3).¹⁸

Dissociation. Dissociating during a threatening situation may enable a person to put aside some awareness of the danger and take self-protective action. Persistent dissociation, however, may make it too easy to avoid working through the traumatic experiences later on.^22-24

Dissociation makes subsequent exposure to reminders of the trauma more similar to a reexperiencing rather than a controlled remembering of it. This can trigger physiologic stress reactions and lead to or worsen PTSD.^25-27

Dissociative disorders can be understood as chronic and severe PTSDs.²⁸ Many individuals with dissociative disorders have histories of sexual and physical abuse.^29-31 Clearly, traumatic experiences sensitize survivors to subsequent trauma through conditioned activation of fear circuitry involving the amygdala, hippocampus, and frontal lobes.³²

Hypnosis can be especially helpful—both for diagnosis and therapy.³³ It can assist the controlled recovery of memories, while allowing some images to remain dissociated from cognition until the patient is ready to deal with them. The patient can turn memories on and off by entering and exiting the hypnotic state and thereby recover and reprocess memories at a tolerable pace.

Related resources

• Society for Clinical and Experimental Hypnosis. http://ijceh.educ.wsu.edu
• American Society of Clinical Hypnosis. www.asch.net
• American Psychological Association, Division 30. Society of Psychological Hypnosis. http://www.apa.org/about/division/div30.html

Mr. M, a world-class athlete, collapsed suddenly in an alley. He was rushed to a hospital emergency room, where he nearly died of internal bleeding from a grapefruit-sized abdominal lymphoma. He was hospitalized and placed on chemotherapy.

Increasing doses of opiates hardly reduced his pain, and he became extremely anxious. Staff described him as “climbing the walls.” He lay in bed writhing, and his parents feared he was becoming a “drug addict.”

Anxiety about his life-threatening illness was clearly compounding his pain, so his attending physician ordered a psychiatric evaluation. When I interviewed the patient, I felt that hypnosis could help.

Hypnosis—as a state of highly focused attention—can help us treat patients’ anxiety, phobias, pain, posttraumatic stress disorder (PTSD), and dissociative disorders. With training, an experienced psychiatrist can quickly start using hypnosis as an adjunct to other therapies.

This article describes how hypnosis helped Mr. M and a young woman traumatized by a criminal assault. Based on my experience and the literature, I discuss what hypnosis is, what training is required, how to measure hypnotizability, and the value of hypnosis in helping patients control their anxiety, posttraumatic, and dissociative states.

Case continued: ‘Surfing’ in Hawaii

When I met Mr. M in the hospital, I acknowledged his distress and the reasons for it, saying “You don’t really want to be here, do you?”

“How many years of medical training did it take you to figure that out?” he replied.

“Well then,” I said, “let’s go somewhere else. Where would you like to be right now?”

He responded, “I’ve never surfed.”

“Good,” I replied, “let’s go to Hawaii.” In hypnosis, I had him picture himself surfing. He continued to groan, but the pattern changed. “What happened?” I asked. “I fell off the surfboard,” he replied. “OK, get back on, and do it right,” I told him.

He learned to practice self-hypnosis, which markedly reduced his anxiety and pain. Two days later he was off pain medications and joking with the nurses in the hall. The attending physician noted in the patient’s record: “Patient off pain meds. Tumor must be regressing.”

What is hypnosis?

Mr. M’s response, though unusually strong, underscores the fact that hypnosis can rapidly produce analgesia and anxiolysis in the medical setting. Hypnosis—often called “believed-in imagination”—is characterized by an ability to sustain a state of attentive, receptive, intense focal concentration with diminished peripheral awareness. The hypnotized person is awake and alert, not asleep. Hypnosis’ three main components are absorption, dissociation, and suggestibility.

Biological basis. The hypnotic state has no brain “signature” per se, but brain imaging portrays hypnosis as a state of alertness with altered anterior cingulate gyrus activation, which helps to focus attention.^1-3 Hypnotized persons can demonstrably alter blood flow in brain regions involved in perceptual processing in response to suggestions of altered perception, whether somatosensory, visual, or olfactory.^4,5 Thus, patients report not only reduced pain but changes in how they experience pain with hypnotic analgesia.

The brain’s dopamine neurotransmitter system—especially in the frontal lobes—also may be involved in hypnosis, as highly hypnotizable persons have elevated levels of dopamine metabolites in their cerebrospinal fluid.⁶

Hypnotic trance. The trance experience is often best explained to patients as similar to being absorbed in a good novel. One loses awareness of one’s surroundings and enters the imagined world. When the novel is finished, the reader requires a moment of reorientation to the surrounding world.

A trance is a state of sustained, attentive-receptive concentration in response to a signal from within or from someone else. The signal activates this shift of awareness and permits more-intensive concentration in a designated direction.

All hypnosis is self-hypnosis. Much of its clinical value is that it can be self-induced throughout the day and whenever symptoms emerge. During the first weeks, patients can be encouraged to practice every 1 or 2 hours.

Applying hypnosis to practice. A well-trained clinician can learn to use hypnosis in classes offered by the two professional hypnosis societies or the American Psychiatric Association (Box 1) Because hypnosis is not something “done to” a patient but rather a capacity to be measured, tapped, and utilized, psychiatrists can integrate hypnosis into clinical practice after some initial training, with ongoing learning and supervision.

Who can be hypnotized?

Not everyone is equally hypnotizable, and hypnotizability is a stable and measurable trait. Approximately one-quarter of adults cannot respond to hypnotic instructions, whereas 10% are extremely hypnotizable.⁷

Brief, clinically useful tests of hypnotic responsiveness have been developed, such as the Hypnotic Induction Profile (HIP).⁸ The clinician usually can induce the trance experience and systematically measure the patient’s response within 5 minutes. A HIP score of 5 indicates usable hypnotizability.

The HIP test includes instructions to produce a sense of lightness in the left arm and hand, with tests of response to this instruction. Response is characterized by dissociation, hand elevation after it is lowered, involuntariness, response to the cutoff signal, and altered sensation.

Turning hypnotic induction into a test of hypnotic capacity transforms the initial encounter by:

• removing pressure on the clinician to successfully hypnotize the subject
• reducing patients’ experiences of complying with the clinician’s wishes, rather than exploring and discovering their own hypnotic capacity.

Placing the hypnotic experience in the context of a test also makes it consonant with other medical examinations and procedures.⁸

Once a patient’s hypnotizability is determined, structured measurement is no longer necessary. The test-retest correlation for hypnotizability scores is 0.7 over 25 years, which is more consistent than IQ testing.⁷ Subsequent inductions usually can be generated by the patient or signaled by the clinician, and only seconds are required for the shift into trance.

Box 1

Reducing anxiety

Anxiety can be understood as a vaguely defined but immobilizing sense of distress. Lack of clarity about the discomfort’s source enhances the patient’s sense of helplessness and avoidance. One therapeutic challenge is to convert anxiety into fear—to give it a focus so that something can be done about it.

Box 2

Anxiety sets up a negative feedback cycle between psychological preoccupation and somatic discomfort, a “snowball effect” in which subjective anxiety and somatic tension reinforce each other. Hypnosis can help reduce anxiety and induce relaxation,⁹ and its dissociative component can help separate anxiety’s psychological and somatic components.

Hypnosis is as effective at reducing anxiety as 1 mg of alprazolam, at least in a study of college students.¹⁰ Student volunteers with high and low hypnotizability were given alprazolam, 1 mg, and a hypnotic suggestion based on their reactions to the drug. Four days later, when students received hypnosis only and hypnosis plus alprazolam:

• combination therapy reduced anxiety more effectively than did hypnosis or alprazolam alone, as measured by the Profile of Mood States tension-anxiety scale
• improvement was comparable with hypnosis or alprazolam alone
• highly hypnotizable students showed significantly greater relaxation than did those with low hypnotizability in all three treatment groups
• EEG data showed similar frontal and occipital changes in the alprazolam and hypnotic suggestion groups.

In randomized trials, simple self-hypnosis training has reduced pain and anxiety during medical procedures, reducing procedure time by an average 17 minutes and resulting in fewer complications.¹¹

A typical hypnotic instruction for managing anxiety is provided in Box 2. This approach teaches patients how to deal with stressors that complicate their anxiety and to control their somatic response. Hypnosis expands patients’ repertoire of responses and enables them to feel less helpless.

Confronting phobias

Phobic symptoms of fear and avoidance or exposure with distress respond especially well to brief hypnosis interventions. Although behavior modification and antidepressants also can treat phobias successfully, one or two hypnosis sessions often can reduce or cure phobic symptoms.

For example, one can help patients with airplane phobia prepare for flight by going into a hypnotic state and learning three concepts:

• Think of the airplane as an extension of the body, such as a bicycle.
• Float with the plane.
• Think about the difference between probability and possibility.

The hypnotic state—with its focused attention and physical relaxation—can amplify this cognitive restructuring technique. Phobic patients can feel more in control of their somatic reactions and, by extrapolation, the flying experience itself. In one study, 52% of patients taught this self-hypnosis exercise remained improved or cured at least 7 years later.¹²

Treating traumatic reactions

Evidence is growing that trauma elicits dissociation. Thus, hypnosis could help us understand and treat traumatic reactions, including patients with acute and posttraumatic stress disorder (PTSD) and dissociative disorders.

The hypnotic state’s controlled dissociation can be used to model the uncontrolled dissociation represented by posttraumatic phenomena such as flashbacks, numbing, and amnesia.¹³ This view is supported by evidence that PTSD is associated with high hypnotizability.^14,15

Acute stress disorder—as introduced in DSM-IV¹⁶—is characterized by prominent dissociative symptoms, with intrusion, avoidance, and hyperarousal. These diagnostic criteria recognize that acute dissociation is a common and predictable reaction to trauma.

Hypnosis involving grief work, exploration of trauma-related transference issues, and emotional expression are effective psychotherapies for persons exposed to trauma. Becoming familiar with hypnotic states can teach patients to recognize, understand, and control their dissociative states.

Evidence suggests that hypnosis’ intense concentration may reverse the dissociative mind fragmentation caused by trauma.¹⁷ Traumatic memories may seem less overwhelming and intrusive once patients discover they can:

• exert greater control over memory access and retrieval
• work through and assimilate disturbing thoughts.

The controlled experience of hypnotic abreaction (reliving traumatic and other memories with strong emotion) provides boundaries for psychotherapeutic grief work.^18,19 Instead of telling patients not to ruminate over a traumatic event, the clinician instructs the patient how to think about the experience.

The inferred message is that the patient can work on other things—such as relationships and daily living problems—after this therapeutic work is done.

Patients are slowly separated from the victim role. The goal is to help them restructure their memories, both cognitively and emotionally. They bear the memories’ impact, yet come to see the information differently.⁷ Traumatic input becomes more bearable when linked to a cognitively restructured recognition of an adaptive response.^,20 For example, patients may acknowledge what they did during a traumatic event that was self-protective or helped others.

PTSD. Hypnosis shares common elements with other cognitive and behavioral treatments for PTSD, including exposure to traumatic memories for cognitive and emotional processing. Few studies have examined using hypnosis to treat PTSD, but evidence suggests it is at least as effective as other cognitive-behavioral treatments.^20,21

Patients can be taught to view PTSD’s intrusive memories and bodily symptoms as re-experiencing painful memories. The memories often intrude less frequently after patients find a controlled method—such as self-hypnosis—to access and work them through.²²

Box 3

Self-blame. Many trauma victims would rather feel guilty than helpless. They blame themselves inappropriately for events over which they had no control, rather than accept their helplessness. They misuse hindsight about the trauma to assume the events were predictable and therefore avoidable. They imagine they can replay the events and change the outcome.

Such an approach to trauma can be profoundly demoralizing, leaving victims burdened by needless guilt and shame. Helping them face and bear the feelings associated with traumatic events can free them from efforts to “undo” or take responsibility for the trauma and accept what happened.

Split-screen technique. Using hypnosis with a “split-screen” technique can help patients restructure the memory of trauma. The left screen symbolizes the trauma in condensed form. The right screen helps patients focus on how they tried to master the situation. This grief work allows patients to acknowledge, bear, and put into perspective the humiliation of the experience and their loss of invulnerability, health, or loved ones (Box 3).¹⁸

Dissociation. Dissociating during a threatening situation may enable a person to put aside some awareness of the danger and take self-protective action. Persistent dissociation, however, may make it too easy to avoid working through the traumatic experiences later on.^22-24

Dissociation makes subsequent exposure to reminders of the trauma more similar to a reexperiencing rather than a controlled remembering of it. This can trigger physiologic stress reactions and lead to or worsen PTSD.^25-27

Dissociative disorders can be understood as chronic and severe PTSDs.²⁸ Many individuals with dissociative disorders have histories of sexual and physical abuse.^29-31 Clearly, traumatic experiences sensitize survivors to subsequent trauma through conditioned activation of fear circuitry involving the amygdala, hippocampus, and frontal lobes.³²

Hypnosis can be especially helpful—both for diagnosis and therapy.³³ It can assist the controlled recovery of memories, while allowing some images to remain dissociated from cognition until the patient is ready to deal with them. The patient can turn memories on and off by entering and exiting the hypnotic state and thereby recover and reprocess memories at a tolerable pace.

Related resources

• Society for Clinical and Experimental Hypnosis. http://ijceh.educ.wsu.edu
• American Society of Clinical Hypnosis. www.asch.net
• American Psychological Association, Division 30. Society of Psychological Hypnosis. http://www.apa.org/about/division/div30.html