CHAPTER I

The Historical Development of Hypnotherapy

It is the purpose of this opening chapter to trace briefly the historic roots of hypnotherapy, in order to show first the persistence of therapeutic applications of hypnosis, and secondly, the manifold attempts to rationalize these applications in some systematic way which would link the therapy with the presumed etiology of the illness. The frames of reference into which the phenomenon of hypnosis has been placed range from the strictly religious systems of the Egyptians, the Persians, and the Hindus, to the most sophisticated theories of present-day psychology.

The theoretical constructs developed to explain the phenomena and to guide the therapeutic applications of hypnosis have evolved along a fairly consistent line; they have moved from a belief in the exclusive importance of physical or physiological processes to a recognition of the significance of psychological factors, and recently include some tentative efforts to achieve, at least in theory, a synthesis of the two. Except for those clinicians who have used hypnosis as a tool without reference to any psychopathology, the specific therapeutic applications have been clear reflections of the theoretical system held to by the therapist.

To date, no satisfactory formulation has been reached. It is our belief that the curious disparity which exists between the rich empirical observations of hypnotherapy, and the primitive state of our understanding of them, is intelligibile only as a reflection inherent in the difficulties in the exploration of hypnosis, and of the youthfulness of the science of psychology. We feel, therefore, that the theoretical systematizations that have been attempted thus far are perforce inadequate, but that at present we are in a somewhat better position to evaluate these attempts in the light of the investigations of Freud and his followers.

It is well known that the first effort to bring hynotherapy within the realm of science was made by Anton Mesmer during the 18th Century. In line with the dominant scientific interest of his day, he attempted to erect a psychopathology based on disturbances of the "universal fluids" in which man and all the planets are immersed, his cures being mediated through the power of "magnets." Apparently he believed that the iron rods to which his patients held firmly during the seances were the immediate source of the therapeutic power, although he did regard "magnetism" as a human emanation. The next important historical step occurred when the "mesmerists" split among themselves, one group seeking a scientific or rational basis for mesmeric phenomena, the other devoting themselves to developing "mesmerism" as an aspect of clairvoyance. After Mesmer's death, only a few scattered individuals, mainly in Germany and in England, continued these investigations.

The major turning point in the history of hypnotherapy occurred during the fourth decade of the 19th Century, when James Braid (2), an English doctor and himself at first an arch-skeptic, devoted himself to a re-examination of the so-called "mesmeric phenomena." At first, Braid attempted to consider these as strictly neurophysiological occurrences, and accordingly his therapeutic efforts were regarded by him as attempts to "excite" or "depress" the "nervous energy" of the patient. He believed at first that the secret of "mesmerism" was to be discovered by researches in physiological processes. Later he abandoned this position, and stated that the important point was the subjective or psychological character of these phenomena.(*)

(*) It has frequently been claimed by historians (3) (21) (37) that investigators like Bertrand, the Abbe Faria, and others had anticipated Braid, but inasmuch as it was Braid who elaborated this psychological view and re-christened the technique "hypnosis," he is usually given the credit.

In his discussion of the evolution of psychotherapy, Janet (20) points out the efforts of all psychotherapists to integrate their findings within some larger conceptual system. Speaking of the eternal efforts of man to effect intelligible influences on both his inner and outer worlds, he says: "The forces that he summons to help him were first the gods, then by a natural evolution they became natural forces, but very mysterious forces, acting according to unknown laws analoguos, in short, to divine caprice." Thus, the importance of Braid's investigations seems to be his effort to bring the phenomena of hypnotherapy within the frame first of neurophysiology and later of an ill-defined psychology, even as Mesmer had leaned on astronomy in his attempt to go beyond the mere observation of phenomena.

It appears, however, that Braid's work was only a first and tentative step in the direction of wresting the facts of hypnosis from both a vague astronomy and a prescientific and speculative neurophysiology. The bitter and extended struggle between the "physicalists" of Paris, led by Charcot (5), and the "suggestionists" of Nancy, under Liebeault (23) and Bernheim (1), had yet to take place before the issue could become clear-cut. Although the work of Charcot was more experimental than therapeutic, and his observations were limited to 12 hysterics at the Salpetriere Clinic (3), his prestige as a neurologist and his emphasis on the tangible made him a formidable opponent to those who championed the elusive "psychological factor" in hypnosis. Bramwell (3) and Janet (20) have shown that the Nancy-Paris controversy was essentially a sophisticated revival of the historic struggle between Braid and the early mesmerists. Logically this period of debate was unnecessary, but historically it was inevitable. Bramwell says: "All the old errors, the result of ignoring mental influences, are once more revived. Medicines are again alleged to exercise an influence from within sealed tubes. The physical and mental conditions of one subject are stated to be transferable to another, or even to an inanimate object. It is useless to enter into any arguments to refute these statements; for this would be needlessly repeating the work of Braid. Indeed, in many instances, their absurdity renders argument unnecessary : for example when a sealed tube containing laurel-flower water was brought near a Jewish prostitute, she adored the Virgin Mary! From this it might be inferred that different religious beliefs were represented by different nerve centers, and that these could be called into action by appropriate physical stimuli." (Page 300)

In the context of this dispute during the classical period of hypnosis in the '90's, Bernheim's concept of suggestion was a more meaningful and less pallid notion than its current use implies. He used the term "suggestion" to stress that the essential mechanisms at work in hypnosis are psychological rather than physical. This was of crucial importance while the battle raged; but since the victory of the "suggestionists," the concept of suggestion has lost its impact as a differentiating idea and has become a shallow cover-all behind which our ignorance of the specific psychological mechanisms hides. Even the layman no longer supposes that hypnosis is a function of medicines in sealed tubes; he "knows" it is "merely a matter of suggestion." This was the temporary blind alley into which the triumph of the psychological approach led. It had been proved that the stubborn facts of hypnosis could not be fitted into a physiological frame of reference, but there was as yet not even a semblance of an organized set of psychological concepts into which to integrate these facts. Accordingly, the wild enthusiasm accorded hypnosis during the last two decades of the 19th Century waned. Janet (21) says in this connection: "What was it that the school of Nancy put in place of this fine dream? A few vague assertions on suggestibility and credulity that could not be discussed or understood without going into the new studies of psychology. But psychology, considered a confused mixture of literature and ethics, had no standing in the school of medicine, and indeed it is a question whether psychology as it was at that period deserved to be more studied by physicians. It may be added that the enthusiastic exaggerations of the hypnotists had brought about the random application of hypnotism in all sorts of disease, without any indication of its fitness, and that the usual results were meaningless or absurd."

The subsequent history of hypnotherapy is largely a record of the attempts of various individuals to use hypnosis in psychotherapy and to formulate a systematic psychopathology within which to operate. Although it might be said that from the beginning the attempt to fit hypnosis into a larger framework inevitably involved some assumptions regarding the etiology of mental illness, the more advanced applications of hypnosis in psychotherapy became much more tightly bound to implicit or stated systems of psychopathology. Most practitioners, however, con tinued to follow Bernheim in commanding symptom-disappearance "in a clear loud voice (1)." Others drew back in fear from the "irrationalities" of hypnosis, preferring to deal with more readily understandable phenomena and to appeal to the "common sense" of the patient; for the most part, these men rejected hypnosis in their psychotherapeutic practice, and opposed it in their theories. This movement, brought to its most articulate expression by Du Bois (8) and, according to Hart (17), somewhat less puritanically by Dejerine (6), was perhaps the last stand of those psychotherapists who preferred to retain the illusion of "man as a rational animal." Hart has pointed out, however, that even these active opponents of hypnosis and "suggestion" were forced to utilize the patient's emotions as levers in their therapy, whether or not they admitted or even recognized this fact.

Some of the efforts to establish a new rationale for hypnotherapy overlapped in time with the work of Bernheim and Charcot; but inasmuch as the general direction of these attempts was significantly different from the older views, we shall discuss them separately. These were all efforts to meet the gap left by the abdication of the "physicalists," by developing a set of psychological concepts to explain both the origins of mental illnesses and the role of hypnosis in their treatment. We shall reserve extended discussion of current theories for a later chapter, and mention them only briefly here in order to complete the chronological development.

It is of considerable interest that all these transitional psycho-pathologies took as their point of departure the fact first elaborated in the work on hypnosis, that mental activity may take place in human beings without their being directly aware of it. The development and elucidation of this fundamental discovery leads to the next important series of struggles in the history of psychotherapy in general and hypnotherapy in particular.

Pierre Janet was one of the first who tried to establish links between etiology and therapy (21). Proceeding from his clinical observation and the results of experimental hypnosis, he developed his well-known theory of "dissociation." At first he drew simply on the facts of hypnotic hypermnesia, and on his observations of clinical syndromes in which there appeared to be a "split" or a "disaggregation of consciousness." Later (20) he accounted for hypnotic phenomena and for pathological states (fugues, amnesias, hysterical signs) by ascribing both to a weakening of the "mental synthesis" of the individual. He believed that mental illness was always such a lack of synthesis, and that this represented a more or less reversible state of emotional "bankruptcy." According to him, this weakness made possible the splitting off of certain mental contents fromthe mainstream of personal consciousness. He tried to give this theory a greater specifity by suggesting that once the weakness existed, those mental contents charged with strong emotion" would be the more likely to dissociate themselves (20). Janet's complete psycho pathology was an elaborate analogy between the human psyche and a great budgetary system. Thus, the aim of all psychotherapy was to restore solvency where bankruptcy had led to dissociation or to excessively costly psychic expenditure. If the difficulty lay in the fact that the patient's "debits" were greater than his "credits," it followed that attempts should be made either to institute economies or to provide new forms of "psychic income." Hypnosis could be applied in either way. The recovery of a dissociated traumatic memory was "an economy through liquidation," whereas direct suggestion was an attempt to strengthen the resources of psychically-impoverished patients; they were particularly receptive to such "contributions" while in hypnosis, itself a state of weakened synthesis or "dissociation." Janet was an acute observer and an earnest thinker, but his psychopathology still lacked the nuclear elements of a dynamic psychology; his application of hypnotherapy was accordingly limited. Zilboorg (37) says of him: "Janet actually used the word 'unconscious,' seemingly ascribing to it the value of a truly dynamic psychological factor, but he stood before his own excellent description and failed to draw the consequences." (Page 376)

The "consequences" for a dynamic psychopathology were drawn by Sigmund Freud as a direct result of his applications of hypnotherapy in collaboration with Joseph Breuer (4). The latter had discovered the fact that in hypnosis a significant memory might be re-lived, and that this "discharge" of emotion had a therapeutic value. His theoretical systematization of these observations was very close to Janet's, although he used a different vocabulary. Freud had watched Charcot, Liebeault, and Bernheim at work and had been impressed. He tried to interest Charcot in Breuer's method of permitting the patient to talk freely and to express deep feeling, but Charcot was indifferent. Janet, independent of Breuer, had made the same innovation with his hypnotized patients (19) but had stopped short of the final implications of his own work.

The critical last step was taken by Freud alone (15). Unlike Janet, he was not content with the belief that ideas are "split off" sheerly as a result of an inherent weakness of the person, or a quantitative deficit of emotional energy. He felt such a split must take place in a less arbitrary, more lawful way. Such a dissociation was for him not a mere lack of cohesion or a mechanical psychic crumbling, but a systematic necessity for the person: the dissociated set of impulses must be qualitatively different from the mainstream of personal consciousness, and must have been purposively "pushed" from awareness in the patient's effort to protect himself from their onslaught. Freud devoted himsell to the elaboration and development of this revolutionary finding, and abandoned the exploration of hypnotherapy within this framework. He gradually built the therapeutic techniques of psychoanalysis and, from his observations, the first dynamic psychopathology.

Now, for the first time, there existed the possibility of viewing hypnosis and hypnotherapy as rational phenomena within the conceptual framework of a scientific psychology; but the accidents of history precluded this. The founder of the new set of concepts had stated that "psychoanalysis . . . only began with my rejection of the hypnotic technique (11)." Thus, for a long time after the publication of Studies in Hysteria (4) Freud and his followers avoided the therapeutic application of hypnosis, and only a few isolated attempts were made to suggest a psychoanalytic theory of hypnosis. Freud made one such attempt in his effort to integrate the phenomena of hypnosis with his conception of the role of the group-leader and with the fact of "falling in love (14)." Ferenczi (9), Schilder (32) and others formulated provocative but speculative theories based on the idea that hypnosis is essentially "a resuscitation of infantile erotic masochistic adjustments." Both Ferenczi and Schilder tried to accumulate clinical data to substantiate their theories; although they present some interesting evidence it seems clear that a good deal more will be necessary before a well-founded theory is possible.

Anna Freud (10), following the leads suggested at the outset by her father (4), has tried to show that hypnosis in therapy seeks to eliminate the ego with all of its defense mechanisms, thus concealing the resistance of the patient. Although this view has not been substantiated by clinical observation, it is at least a hypothesis conceived in the theoretical framework of a scientific psychology and amenable to empirical check.

It has been unfortunate for the development of hypnotherapy that it was a historical necessity for Freud to reject hypnosis. This left both its practice and theory to those who were desperately fighting the insights of psychoanalysis. The psychological theories of hypnosis advanced in the first decades of this century were, with but a few notable exceptions (26), either variations on Janet's concept of "dissociation" or hybrid compromises between this view and the Freudian theories. There were also offered elaborate but highly speculative neurophysiological theories (26) (29) which led to no new advance. The practice of hypnotherapy therefore simply followed one of two old paths: the removal of symptoms by direct suggestion, or the attempt to remove symptoms by hypnotically inducing a re-living of one or more specific traumatic episodes.

Typical for this period are the researches of Morton Prince (29) (30), William Mc Dougall (24) ( 26), and Boris Sidis (33) (350 (36). Prince, by far the most conservative of the three, devoted more ofhis energy to hypnotic experiment and exploration than to therapy.

He believed like the others in the existence of menial processes inaccessible to direct awareness, but he insisted on their "logical, orderly" character (31). He said: "Now a word as to my conception of the unconscious. I conceive the unconscious not as a wild, unbridled, conscienceless subconscious mind, as do some Freudians, ready to take advantage of an unguarded moment to strike down, to drown, to kill, after the manner of an evil genii, but as a great mental mechanism which takes part in an orderly, logical way in all the processes of daily life but which under certain conditions involving particularly the emotion-instincts, becomes disordered or perverted. We think that in everyday life we consciously do the whole of our thinking; but I am inclined to think that our unconscious self does most of our thinking, and that we simply select from the ideas furnished by the unconscious those which we believe are best adapted to the situation; that our problems are much more solved by the unconscious than by the conscious. I regard the normal unconscious as a logical, orderly mind, playing an important part in everyday life. Therefore, as I see it, this conception of unconscious ideas is fundamental, and not the libido, although the instincts play a tremendous role in carrying, by the force of their conative impulses, ideas to fruition and setting up conflicts between opposing ideas with resulting disharmony."

This notion of a dissociated consciousness, in essence similar to that of consciousness as we ordinarily think of it, actually goes back to the early discoveries of (so-called) unconscious processes by workers in hypnosis (16) who felt they had proved their existence by showing that an arithmetical problem could be solved without the subject having any awareness of this process. The belief in the essentially rational nature of the unconscious necessarily leads to an over-rationalistic application of hypnosis in therapy, and completely neglects the role of instinctual strivings, as well as the nature of symptom-development and defense mechanisms. Prince's theoretical position was very close to that of Janet; McDougall, on the other hand, while rejecting violently what he termed the "pan-sexuality" of the Freudians, represented an important advance in that his concept of the unconscious included a recognition of the existence of purposive strivings. He developed an independent psychology, firmly rooted in a belief in the importance of instinctual drives; his therapeutic applications of hypnosis were thus less academic than those of Prince. Sidis, too, although holding to a belief in "disaggregations of consciousness," was closer to a dynamic position. None the less, he launched bitter and scathing denunciations of psychoanalysis, and built his own psychology and psychopathology largely on the "instinct of fear(36)." His most important contribution perhaps lies in his distinction between therapies employing "direct" and "indirect" suggestion (34). He regarded as "indirect suggestion" the use of trickery and deception in therapy (the use of placebos, faradic brushes, etc.). In contrast to this he described the "direct suggestion" of hypnosis, which may be successful in the absence of faith or of credulity. Thus he attacks the nebulous concept of "suggestion," and explores the possibility of giving it some specificity. The implications of this view for the practical applications of hypnotherapy are self-evident.

Since the work of these men during the first decades of this century, little systematic effort has been made to understand hypnosis as a rational phenomenon or to develop it as a tool of psychotherapy within the frame of our modern psychology. Many investigators have tried to do both when dealing with circumscribed experimental or clinical problems; but aside from the work of Schilder and Kauders (32), summarized by them in 1927, there has been no comprehensive statement of the role of hypnosis in modern psychotherapy.

We have seen that hypnotherapy has undergone a historical evolution which has reflected the history of the science of psychology and the development of psychopathology, and that the therapeutic applications have been a direct expression of these. The attempt to understand hypnosis in terms of physical forces or neurophysiological processes failed; this position gave way to an approach which has emphasized psychological factors which we are only now beginning to understand. A synthesis of these positions has seemed impossible. However, the current researches on mechanical adjuvants to hypnotherapy, and on the relationship between drugs and hypnotic states, suggests that an integration may finally be achieved.

We have omitted in this chapter many of the great names in the history of hypnotherapy, because our aim has been not to record the clinical achievements of hypnotherapy, but the significant theoretical developments which altered clinical practice.