CHAPTER IV

THERAPEUTIC APPLICATIONS

The need for a review of the specific applications of hypnosis in psychotherapy is immediately evident to anyone who makes the most cursory survey of discussions of hypnotherapy in current textbooks of psychiatry. For the most part, with the notable exception of Kraines (178) the authors present this form of treatment as if its history had stopped sixty-five years ago with the early editions of Bernheim's "Suggestive Therapeutics (119)." Only the most primitive form of hypnotherapy (namely, the removal of symptoms by direct suggestion) is mentioned and even this is usually presented in a way which hopelessly confuses even this form of treatment with the deceptions and sadistic trickeries of faradic brushes and the like.

Actually there has taken place a considerable development since the "classical period" of hypnosis and it is our purpose in this chapter to present a review of the varieties of hypnotherapy that are being used currently. We shall summarize the methods, their advantages and limitations, and the kinds of cases treated by each.

There are at least six different ways described in the literature in which hypnosis may be applied therapeutically: 1. Prolonged hypnosis without direct suggestion or exploration. 2. Direct suggestion of symptom-disappearance. 3. Direct suggestion of disappearance of attitudes underlying symptoms. 4. Abreaction of traumatic experience. 5. The use of specialized hypnotic techniques. 6. Hypnoanalysis.

1. Prolonged hypnosis.

This method has been used most extensively by Wetterstrand (242). The patient is hypnotized as deeply as possible and is allowed to remain in hypnosis for an extended period, much as in prolonged narcosis or "Dauerschlaf." Depending on its initial depth, the hypnotic state may or may not have to be supported by small drug dosages. Wetterstrand, who frequently kept his patients in a deep hypnosis for periods of several days, likened the therapeutic effect of this to the healing power of deep sleep. During this period, no direct therapeutic suggestions are given and no explorations made. Schilder and Kauders (219) who have used a modification of this technique say: "We believe that, in addition to the physical effect of the sleep, the psychic elaboration which the person devotes during sleep, to his experience, also has value." (Page 97) They report especially good results in the treatment of stubborn tics and in acute conversion symptoms (e. g., psychogenic vomiting). Rothenberg (215) has had similar success with such symptoms.

This technique is not widely used because of the practical difficulties involved. It may be applied succewfully in a hospital situation where adequate nursing care is available.

2. Direct suggestion of symptom-disappearance.

This is the oldest and still most widely used of the techniques of hypnotherapy. Hypnosis is induced by one of the methods described in Chapter II and direct suggestions are made to the patient to the effect that his symptoms will disappear. The prototype for this primitive, though often effective, technique is Bernheim's description of his own approach:

"For example, a child is brought to me with a pain like muscular rheumatism in its arm dating back four or five days; the arm is painful to pressure; the child cannot lift it to its head. I say to him, 'Shut your eyes, my child, and go to sleep.' I hold his eyelids closed and go on talking to him. 'You are asleep and you will keep on sleeping until I tell you to wake up. You are sleeping very well, as if you were in your bed; you are perfectly well and comfortable; your arms and legs and your whole body are asleep and you cannot move.' I take my fingers off his eyelids and they remain closed; I put his arms up, and they remain so. Then, touching the painful arm, I say, 'The pain has gone away. You have no more pain anywhere; you can move your arm without any pain; and when you wake up you will not feel any more pain. It will not come back any more.' In order to increase the force of the suggestion by embodying it, so to speak, in a material sensation, following M. Liebeault's example, I suggest a feeling of warmth loco dolenti. The heat takes the place of the pain. I say to the child, 'You feel that your arm is warm; the warmth increases, and you have no more pain.' " (Pages 207-8)

This is the simplest therapeutic application of hypnosis and the one which most closely resembles the magical or the miraculous. The literature published between 1880 and 1900 is replete with case reports both of temporary relief and of some follow-up studies where this relief has been maintained. Although there have been reports of frequent relapses or formation of substitute-symptoms after a "successful" removal of symptoms, there exist many instances of permanent cure as well.

Janet (172) reported a fair number of permanent cures particularly when the disturbance was treated shortly after its inception. Hollander (167) has pointed out also that in his experience, relapses may be averted by avoiding mechanical suggestions that are not adapted to the patient. He says that relapses are not more frequent in hypnotherapy than they are in any form of treatment and that no other psychotherapy can claim so many rapid and lasting cures.

More recently Wells (242) has added to the record a striking and detailed account of pernament cure by direct suggestion. this was the case of a young college student who had suffered a constant disabling headache for five years after suffering a trauma to one of his eyes. He had consulted several internists, and had been placed on a strict regime of diet and bowel control by a neurologist. These measures had been completely without result. During this period, he had showed also almost all of the major symptoms of hysteria (hysterical contractures, fugues, nocturnal somnambulism, amnesia). Here, as is so often the case in the method of direct suggestion, the technique was almost absurdly simple. Wells (242) describes it as follows: " 'When I count up to 10 your headache will entirely disappear.' I counted up to 10 and Mr. Jones reported that his headache had stopped. I then said, 'When I count from 10 to 20 the headache will be gone permanently.' Then I counted from 10 to 20. I explained to Mr. Jones, while he was still in deep hypnosis, that the evidence was clear that the headache had been purely hallucinatory and that no ill effects could follow its complete eradication by hypnotic methods. I stated that when he came out of hypnosis he would find himself permanently freed from the pain, and that he would have complete amnesia for all that had occurred during the entire hypnotic period." For the first time in four years, the patient was able to sleep normally and the "strained facial expression of pain" had disappeared. The fugue states were now explored by breaking through the amnesia in deep hypnosis and have not since recurred.

There is scarcely any functional disturbance which has not been successfully treated by the technique of direct suggestion in hypnosis. To attempt a compilation of "types of cases treated by this method" becomes an almost impossible and even pointless task. Individual therapists offer in their summaries long lists of the ailments they have treated with this approach; the scientific value of these lists is limited by the fact that there is little or no agreement between them (222). Thus, for example, Forel (153) has enthusiastically maintained his particularly good therapeutic results with cases of all kinds of addiction: alcoholism, morphinism, etc. Wetterstrand (243) has reported good success with these cases with only three recidivists out of 40 cases of morphine addiction. Heyer (164) has supported these data. Tuckey (241), on the other hand, believes from his experience that the majority of addicts treated by direct suggestion soon suffer a relapse. Schilder and Kauders (219) also report negative results on the hypnotherapy of addicts.

Almost every syndrome which we might now label "psychosomatic" has been reported successfully treated by direct suggestion. Warts have been removed (121), all varieties of menstrual disturbance have been treated (153) (179), and skin diseases like psoriasis (245) are included in the list, as are asthma (155) (233), muscular rheumatism (246), migraine (239), constipation (153) epilepsy (166), sea-sickness (165) and insomnia (241). We present this sampling only to suggest the unlimited scope given this method, particularly during what Janet (172) has facetiously labelled the "palmy days of hypnosis." The Zeit schrift fur Hypnotismus includes scores of reports of this sort (138). A typical article of this kind is Bauer's paper (116) on a group of patients treated during a single summer at Forel's polyclinic. Even symptoms of known organic origin have been alleviated by direct suggestion. Reinhold's results with postencephalitic Parkinsonism lead Schilder and Kauders (219) to the statement that: "At any rate, these observations at least suggest that even organic symptoms may be influenced in hypnosis, and that the accessibility to influence in hypnosis may not always be made use of in setting up a differential diagnosis between a functional and an organic disturbance." (Page 112)

In addition, all known psychological aberrations are to be found in a compilation of cases treated by direct suggestion. Although most authors agree that obsessions and compulsions are particularly unresponsive to this technique (173), there are reports of the successful treatment even of these (244) (137), especially if they are mild or of recent origin (164) (219). There seems to be a fairly good agreement that if a hysterical patient is hypnotizable in the first place, he is "one of the most grateful objects of hypnotherapy (219)." Janet (172) says that in his breakdown of cases, the paraplegias, mutisms, amauroses, contractures, sleep-walking, etc., are those which show the greatest reliability and permanence of cure when treated by this method. This does not mean, however, that hysterics are regularly amenable to this form of treatment because there is much evidence, as we shall see, that hysterics are frequently refractory to all attempts to hypnotize them. Heyer (164), on the other hand, warns against the use of hypnosis in "grave" hysteria, saying that severe hysterical attacks may occur and one may lose rapport with the subject. The possibility of an "attack" may actually be utilized, however, as a therapeutic lever as will be shown in the later discussions.

Phobias are generally not regarded as suitable for treatment by direct suggestion (248) although here again there are reports of their successful hypnotherapeutic treatment (219).

Speech disturbances have frequently been cured by direct suggestion (166) (181), although recent trends in treatment have been away from a simple statement that the difficulty would disappear and more toward a manipulation of underlying attitudes.

We have by no means exhausted the list of types of disorders treated by direct suggestion nor have we attempted to include even a fraction of the papers presenting these results. Tuckey (241), whose book on direct suggestion is perhapsthe best of its kind, has said :"...when ever we find a chronic disease resitting the usual methods of treatment, suggestion may be thought of as auseful ally."In the recent literature, the only two kinds of cases where this method is generally regarded as of no value are the psychoses and "true melancholia." In the latter it is usually contraindicated (219). Heyer (164) has felt it is not advisable in schizophrenia because it may become pathologically elaborated.

Direct suggestion was used far more extensively with psychiatric casualties in World War I than it is in the present war. The Lancet and the Journal of the Royal Army Medical Corps contained, particularly in the early days of the war, numerous articles describing the use of this technique in the war neuroses. Hurst (168), who was at first one of the best known advocates of this method, later felt it important to enlist the active participation of the soldier in his treatment and to combine "persuasion and education" with hypnosis, with the emphasis distinctly on the former. Tombleson (238) in 1917 registered a plea for the use of direct suggestion in his description of "twenty cases treated by hypnotic suggestion." He describes the rapid cure of many cases of "neurasthenia" and "psychasthenia" (which, from his description, sound more like cases of conversion hysteria) and even of hyperthyroidism in soldiers.

Trotter (240) writing in 1918, following the early work of Hurst, described a treatment for what he called the "motor psychoneuroses" among war casualties. Although he does not label it as hypnotherapy, his description makes it quite clear that essentially the same principles are involved. He, too, felt the necessity for supplementing direct suggestion with "persuasion" and "explanation."

The reaction against methods which sought merely rapid symptom-relief became increasingly evident during this period. Thus, men like Ross (213) writing in The Lancet in 1918 comment ironically, on the use of "electricity, hypnotism and manipulation." Here, as is so frequently the case, he confuses the use of sadistic deception and terror typified in Yealland's (247) treatment of conversion hysteria by faradism with direct suggestion in hypnosis.

There was fairly unanimous agreement, however, that in the recovery of amnesic periods, hypnosis was of great value in the war situation (196), although here, too, the fact of its being an auxiliary technique and not the core of the psychotherapy of amnesias was emphasized by McDougall (187) and others.

In the present war, hypnotherapy of any sort has thus far not been widely employed. There are few reports of the use of direct suggestion of the classical type. Modified techniques applied in a context of substantial psychotherapeutic "tact" have been used by a few physicians.

Fisher (152) has reported on his findings with several hypnotherapeutic techniques, direct suggestion having been one among them. He achieved one of his most striking successes by using this method to cure hyperhydrosis and painful callouses in a Coast Guardsman. Although he regards this as simply a "symptomatic cure," he emphasizes the importance of such cures if they are instituted early. Miller (191) and Kardiner (174) recommended the use of hypnotherapy in the war neuroses also.

Before proceeding to a description of the modified methods of direct suggestion in hypnosis, we shall summarize the values and limitations of the method of simply suggesting symptom-disappearance. If the patient responds at all to this kind of treatment, this response is usually fairly prompt and the improvement rapid. Very little specialized training or experience in the specific techniques of psychotherapy is necessary in order to achieve good therapeutic results with this approach, inasmuch as no attempt is made to "uncover" the root of the difficulty. Training and experience in the technique of hypnosis are the only prerequisites. The therapeutic leverage consists largely of whatever deep unconscious needs are stirred in the patient in his relationship to the therapist during the hypnosis. We do not understand the nature of this relationship, but this does not alter the fact that by dint of its existence, the patient may obtain relief from his symptoms, sometimes temporarily and often permanently.

On the other hand, in the advantages of this method lie also its limitations. Because it is, in effect, an attempt to suppress the patient's symptoms, it is not possible for the patient to gain any insight into the emotional roots of his' difficulty. Accordingly, (and this is especially true in disturbances which have remained untreated for any length of time), the possibility of relapse or of the formation of a substitute symptom is always present, although not inevitable. Another limitation of this method is that it usually requires a fairly deep hypnosis for rapid results, although there have been reports of successful symptom-removal even in light states of hypnosis (153) (223) or in what Sidis called "hypnoid states."

3. Direct suggestion of disappearance of attitudes underlying symptoms.

Although the work of Bernheim has been cited as typical of the approach which commands symptom-disappearance, a close study of his writings shows that he himself went beyond this in his clinical work. Although most of his followers directed their attention largely to the direct suppression of symptoms, Bernheim shows himself to be a more imaginative therapist by the following:

"The mode of suggestion should also be varied and adapted to the special suggestibility of the subject. A simple word does not always suffice in impressing the idea. upon the mind. It is sometimes necessary to reason, to prove, to convince; in some cases, to affirm decidedly; in others, to insinuate gently; for in the condition of sleep just as in the waking condition the moral individuality of each subject persists according to his character, his inclinations, his special impressionability, etc. Hypnosis does not run all its subjects into a uniform mould, and make pure and simple automatons out of them, moved solely by the will of the magnetizer." (Page 210)

The flexibility of method was taken up with enthusiasm and developed by those workers who were embarrassed by the complete absence of rational psychotherapeutics in classical hypnotherapy. We have discussed the dissatisfaction of several investigators with the comparatively shallow technique of direct suggestion and mentioned their introduction of "persuasion and re-education." It is as if this variant of hypnotherapy represents an historical compromise between the "irrational" appeal of hypnosis with the "rational" appeal of a naive common-sense psychotherapy. Its adherents represent a mediating position between the classical hypnotists and the almost moralistic approach of a man like Du Bois, who denounced hypnosis as bringing "a blush" to his cheek.

This trend first found articulate expression in the early decades of this century in the work of Prince, Coriat, Sidis, and others. A typical example is an article written in 1907 by Prince and Coriat entitled, "Cases Illustrating the Educational Treatment of the Psychoneuroses (210)." Although there are, even in this article, case records of cure by direct symptom suppression, and by indirect suggestion (fictitious "magnets"), emphasis is laid on re-education. In one typical account, the authors describe their treatment of "psycho-epileptic attacks simulating Jacksonian epilepsy." In hypnosis, the patient recalled that an earlier fright had produced in her what she called a "delirium" and that people around had then remarked that apparently, like her mother, she had epilepsy. The treatment then consisted of telling her while she was in deep hypnosis that she did not have epilepsy, but that she did have an unfounded fear. Thus, the fear would disappear and along with it, the epileptic attacks. The patient was told that now she "realized and believed." The attacks ceased immediately.

Although one is struck by the naivete of this psychotherapy, one cannot but be impressed at the same time with the records of clinical results. Here, as in the use of direct suggestion, it would appear that on the basis of the relationship with the therapist (and whatever else being in hypnosis consists of), the patient is able to give up symptoms with only a meagre and rudimentary insight into their origin. We have seen both from the results of "direct suggestion" and from "faithcures" that symptoms are relinquishedeven in the complete absence insight. The importance, therefore, of the introduction of even so primitive a variety of insight lies in its attempt to bolster the patient against future attacks.

Similar lines were followed by Sidis (224) and Donley (139) for some cases. For instance, an obsessional neurosis in a 21-year old student was "cured" within less than three weeks. The young man had the insistent thought after reading a newspaper article that a comet might strike the earth and destroy it. At first he had attempted to deal with this idea by making elaborate mathematical calculations to prove to himself the statistical remoteness of this possibility. This was futile. When he applied for help to Donley, he was put into the hypnoidal state and asked to recall when he had first had this idea. It is uncertain just what Donley did at this point. He says: "Having completed his narrative he was then given an explanation of the origin, the nature and the significance of his ideas. In view of his superior intelligence he was able to comprehend what was said to him with apparently little difficulty. He declared himself after half an hour's treatment to feel much relieved mentally and less disturbed physically, in the sense that he felt less of the nervous bodily trembling of which he complained." He was given another treatment a week later and ten days after this he announced himself as being practically over his fear and since had had no recurrence of this idea.

One could continue indefinitely to add illustrations of this general approach. The extreme to which the "rational" approach was pushed is shown in Brown's (127) "golden rule of psychotherapy:" the therapist must never become angry and he must never permit the patient to become angry. The cool and reasonable character of the psychotherapy would be interfered with if such emotional expression were admitted. In this connection an earlier paper by Van Renterghen (211) is of interest. In treating a case of torticollis by hypnosis, he emphasized at the same time that the patient control his anger during the course of treatment which lasted several months. The patient was cured and told Van Renterghen, "You treated me not only for my spasms but for my rages."

The historical significance of the "rational" approach in hypnotherapy lies in the fact that this trend reflected the growing awareness of the importance of giving the patient some understanding of his difficulty. That it took so intellectualized a form is ascribable to the fact that during the first decades of this century the laws governing unconscious processes were as yet little accepted.

During the period between 1900 and 1920, men like Hollander (166) (167), Miller (192), and Gerrish (155) supported this point of view. More recently Kraines (178) summarizes this method as follows:

"In the therapeutic suggestions it is not only important to suggest the symptoms clear up, but to suggest that the basic emotional difficulties be dealt with in a more hygienic manner. Indeed, far more emphasis should be placed on the underlying factors than on the symptom. This line of suggestion presupposes that the patient was examined and studied before the hypnotic treatment was begun and that an analysis was made of the etiologic factors. Hypnosis thus becomes a valuable aid in enabling the patient to carry out the retraining of the personality, as well as 'suggesting away the symptom'." Illustrating this technique he gives a fragment of the hypnotherapy of a case of torticollis:

"Now relax your neck; relax it still more. Your head feels so very d, and all the tension is gone. It relaxes still more and still more. Now the head begins to straighten itself out. It turns to the midline —and your head tips to the opposite side. Good. Now your chin is down and your head is in normal position. It will continue to be normal. It feels so good now. Your head will remain normal. (After these specific suggestions, the emotional bases behind the symptom should be dealt with.) Your aversion to your employer will disappear, and you'll regard him as an old and disagreeable person; but you will not be affected by his manners. You will not be disturbed by your husband's irritability but will just let his anger fall off you — like water off a duck's back. You will learn not to let anything bother you. That's why you will face everything straightforwardly. Your head is straight now and will stay that way. Next time you come here you will go to sleep more easily and quickly, and until then your head will remain in midline. Now gradually wake up, and you feel very well. Wake up completely."

It is quite obvious from this account that Kraines had concluded from his preliminary examination that the torticollis symptom was a symbolic representation of the patient's reluctance to "face things straightforwardly" and thus directed his suggestions both at the symptom itself and at its underlying "meaning."

Recently, the applications of hypnotherapy to speech disorders have followed this approach (185) (181). Usually, the direct suggestions of confidence, ease, relaxation, etc., are given rather than suggestions that the stuttering or stammering would disappear.

The choice of which "underlying attitudes" to attack depends largely on the preconceptions of the individual therapist regarding the essential nature of emotional illness. Thus, the conclusions regarding the etiology may be formulated at many different "psychic levels." Morgan (195) in 1924 elicited from a previously inaccessible suicidal girl the fact that she feared she was pregnant, and that she had been taught that "sex is wrong;" he met this therapeutically by telling the patient that sex is not wrong and that it is the task of a normal woman to recognize her womanhood and to finally marry the man of her choice. Although he calls this "a direct psychoanalytic statement," it will be at once apparent to anyone familiar with psychoanalytic theory or technique that this is an extremely crude derivative. The patient responded very well, however, and after three hypnotic sessions began to recover from what had "looked like a case of hebephrenic dementia praecox."

The recent work of Muniz (199) (200) (201) (202) has been along similar lines. Although he too speaks of the combined use of "psychoanalysis and hypnotism," he makes psychodynamic deductions of a shallow variety and then uses these in formulating direct suggestions to the patient. In one case of "anxiety neurosis" he attempted at first to treat the patient by a reorganization of her routine and by giving her medication. When, after several months, no real progress had taken place, he hypnotized her and utilized his insight into the fact that she had first developed symptoms when her servant had fallen ill and she had been torn between a desire to help her servant and a desire to flee the entire situation. The superficiality of this "analysis" is at once evident. Despite this limitation, the patient began to improve rapidly under the newly instituted treatment and has remained well.

This is an instructive "natural experiment" because it suggests that the normal, everyday relationshsip of this patient with Muniz, who was her family physician, did not provide sufficient therapeutic leverage nor did the indirect suggestion of regimen-change or medication. Apparently, the hypnotic relationship did introduce a significantly new and important element to make the difference. Here, as in all clinical reports, one cannot be certain of the precise factors which are directly responsible for the cure. One can rely only on the faithfulness of the therapist's report. Schilder (218) brought this technique of hypnotherapy more definitely within the frame of psychoanalytic theory. He compared it with the simpler technique of direct suggestion of symptom-disappearance as follows:

"We have described the method of hypnosis used as direct suggestion. The suggestion can be directed against the symptom as such. In some cases it cannot be avoided; for instance, in tics and in organ neuroses, where the genesis of the symptom is not ascertained. Direct suggestion can also be used in clearly formulating the problems to the patient and suggesting to him that on the basis of the insight, symptoms will disappear. This method is preferable; and it is, of course, necessary in order to formulate the suggestion properly that one know something about the genesis of the symptoms. Preliminary work in this respect will be necessary. One should be careful in suggesting problems and theirsolutions, unless one has a sufficient insight oneself... The full implications of hypnosis can only be understood in connection with general conduct of a psychotherapy. The relation of the patient to the physician has to be fully understood ii one wants, to make the correct use of hypnosis as a therapeutic method. In the limits discussed above, hypnosis can be of help in short psychotherapy."

A list of comparable length and variety to that described in connŠ tion with simple direct suggestion could be compiled for the method described above. Here, too, all of the usual psychiatric syndromes, with the exception of the psychoses (in the modern sense) have been treated with success by some therapists. However, this method of hypnotherapj has been somewhat more limited in its scope of cases (*) and has been used more frequently for the symptoms of conversion hysteria than anything else, although it has by no means been restricted to these.

(*) Janet (172) points out that there was literally no illness, functional or organic, which was not treated by the early mesmerists and that in fact Liebeault had treated all sorts of disorders regarded as strictly organic (as an antidote to poison, for anemia, pulmonary tuberculosis, migraine, etc.) It is probably not an accident that those forms of therapy which seem to rest on a concrete or symbolic relationship with a parent-surrogate also do not restrict themselves in their scope (Christian Science, "miracle-cures," etc.). It is as if a belief in omnipotence is revived and thus "anything is possible." This belief is sometimes rewarded by the cure of a psychosomatic disturbance where irreversible organic changes have not yet taken place.

For example Schilder and Kauders (219) say:

"We recently treated a young man who always failed at examinations owing to a feeling of acute fear and terror. It turned out that whenever he was present at an examination, he experienced a revival of his fear of his over-severe father. The suggestion was therefore aimed not only against his fear of examinations, but also against his attitude of terror toward his father. It is therefore our effort always to get down to the psychic causes and to combat these psychic causes by means of suggestion. But it is evident at once that such a treatment absolutely requires an intimate association with the patient. We are of a view that such intimate association with the patient will be more fruitful if the physician has a knowledge of psychoanalysis and is capable of applying the psychoanalytic technique in the conversations preceding the hypnosis."

We fully agree that a technique which attempts to go beyond the treatment of symptoms requires far more specialized training in psycho therapy than the method of direct suggestion. Thus from the point of view of ready and wide applicability, this is its disadvantage. However, insofar as such a technique provides the patient with some understanding of his problem, it is a more reliable and substantial method of hypnotherapy. It may take somewhat longer than a course of treatment by direct suggestion, particularly it a systematic attempt is made to establish the specific etiological factors underlying the symptom before the suggestion is formulated.

4. Abreaction of traumatic experiences.

Although the concept of "catharsis" was used by Aristotle in connection with the release of pent-up emotion (as in aesthetic experience), its introduction into the history of psychotherapy generally and of hypnotherapy in particular is fairly recent. The third and final edition (1930) of Bramwell's five-hundred page textbook on hypnosis (122) does not include either the term "abreaction" or "catharsis" in its index. It is actually difficult to explain such an oversight inasmuch as Breuer and Freud (125) had used the term "abreaction" in connection with the re-living of repressed affect 35 years earlier.

Schilder (218) gives Janet credit for first having employed in his therapeutic approach the technique of searching for affect-charged traumatic memories. He admits that Breuer had had an accidental earlier experience with "abreaction" when a patient developed a spontaneous hypnosis but says that Janet's publications (170) preceded Breuer's. Janet himself has argued his priority with some bitterness in several places (171) (172).

Janet (172) gives many interesting case reports to illustrate this method. A well-known example is that of "Marie," a girl of 19 who suffered every month from convulsions, delirium, and fits of shivering accompanying her menstruation. She had other hysterical symptoms as well: an anesthesia of the left side of the face and amaurosis of the left eye. In hypnosis, Marie recovered with much emotion her terror at menstruating at the age of 13, and her frantic efforts to check the flow by getting into a tub of cold water, shivering and trembling all the while. She recalled also a "terrible fright" in this connection, when she had seen an old woman fall and cover the stairs with blood. Other memories, related to the anesthesia were recovered also. None of these was accessible to her normal waking consciousness. Following the recovery of these memories, Marie's "hysterical crisis" ceased. We shall defer the theoretical discussion of the mechanism of "abreaction" until we have concluded a full presentation of the method.

Freud in his Autobiography (154) describes Breuer's first experience with the cathartic method as follows:

"When Breuer took over her case it presented a varigated picture of paralyses with contractures, inhibitions and states of mental confusion. A chance observation showed her physician that she could be relieved of these clouded states of consciousness if she was induced to express in words the affective phantasy by which she was at the moment dominated.

From this discovery, Breuer arrived at a new method of treatment. He put her into a deep hypnosis and made her tell him each time what it was that was oppressing her mind. In her waking state the girl could no more describe than other patients how her symptoms had arisen, and she could discover no link between them and any experiences of her life. In hypnosis she immediately revealed the missing connection. It turned out that all her symptoms went back to moving events which she had experienced while nursing her father; that is to say, her symptoms had a meaning and were residues or reminiscences of those emotional situations. It turned out in most instances that there had been some thought or impulse which she had had to suppress while she was by her father's sick-bed, and that, in place of it, as a substitute for it, the symptom had afterwards appeared. But as a rule the symptom was not the precipitate of a single such "traumatic" scene, but the result of a summation of a number of situations. When the patient recalled a situation of this kind in a hallucinatory way under hypnosis and carried through to its conclusion, with a free expression of emotion, the mental act which she had originally suppressed, the symptom was abolished and did not return. By this procedure, Breuer succeeded, after long and painful efforts, in relieving his patient of all her symptoms." (Pages 33-35)

It appears that the recovery of the significant traumatic experiences with the attendant emotion may take place at any point on a scale of emotional intensity. The patient may recall the previously inaccessible memory with the accompanying statement, "I feel now much as I did then," a kind of muted echo of the original feeling with a complete awareness of current reality or he may, at the other extreme, actually appear to be re-living the episode in an uninhibited and overtly tempestuous manner, screaming, wailing, cowering or trembling.

The "abreactive" method was taken up with much enthusiasm by many who had been dissatisfied with the technique of direct suggestion which provided neither the therapist nor the patient with any understanding of the etiology of the illness. This kind of treatment was actively investigated in the first decades of this century by many workers, among them Sidis (223) (224), Donley (139), Goldwyn (157), Taplin (233), Loewenfeld (186), Prince (209), William Brown (130) (131), McDougall (188), and Hadfield (161). For the most part, this work was essentially like that of Janet, Freud, and Breuer, although the attempts to "re-associate" or "synthesize" the recovered memory with the normal ego of the person vary from a dependence on the mere ventilation of the traumatic event to a systematic effort to re-integrate the newly discovered material with the current life of the patient.(*)

(*) Although Hadfield and later Taylor referred to their therapeutic applications of hypnosis as "hypno-analysis" and Brown speaks of "hypnotic analysis," we include these men in this section because their techniques seem closer to the classical use of "abreaction" than to recent methods of hypnotherapy which attempt to combine hypnosis with the specific techniques of psychodynamic psychotherapy and of psychoanalysis. We shall discuss the latter in the section on "hypnoanalysis."

This method has been employed with a more restricted group of disease-entities than either of the two methods previously discussed, Most of the work conducted by Janet, Freud, and Breuer was with hysterical patients. Freud (125) says, however:

"Yet, it sometimes happened that in spite of the diagnosis of hysteria, the therapeutic results were very poor, and even the analysis revealed nothing of importance. At other times I attempted to treat cases by Breuer's method, which no one took for hysteria, and I found that I could influence them, and even cure them. Such, for example, was my experience with obsessions, the real obsessions of Westphal's type, in cases which did not show a single feature of hysteria." (Pages 198-199)

Goldwyn (157) and Donley (139) support Freud in this finding, both having worked successfully with a number of obsessional neuroses. Hadfield (159) (161) reports the best results of this method with "motor symptoms," especially paralyses, and with "sensory disturbances" which remain after an organic illness (with which the pain was originally associated) has been cured. Taylor (234) has also reported success with motor symptoms, and Connellan (135) with depressions. Copeland and Kitching (137) have attempted to use this approach with alcoholics but have thus far been able to report only temporary cures. Phobias have been in a few instances successfully treated by this technique: Smith (228) has recently reported the cure of a 19-year-old youth who suffered from an intense fear of the dark. The most striking aspect of his report is the fact that he was able to recover verifiable memories of the original traumatic episode which took place, apparently, before the boy was yet three years old.

There is general agreement that, if the patient is hypnotizable, the cathartic method is the method of choice in cases of amnesia (213). Schilder (218) has said that he has had success with this approach almost exclusively with amnesias and allied states, and has been disappointed in his attempts to treat other functional disorders.

"Abreaction" has been found particularly suitable to that group of psychological disturbances lately called the "traumatic neuroses of war." Hadfield (159) (161) has reported on his treatment of between six and seven hundred cases in the period from 1915 to 1920, psychiatric casualties of World War I. He describes it as follows: "The patient, hypnotized, istold that when the physician put his hand on his forehead he will feel himself back in the trenches, or under fire; that he will visualize all the circumstances when he was blown up or buried, and live again through all the emotional experiences concerned. He is encouraged to describe them as he experiences them. The patient usually becomes disoriented, shows signs of great emotion, trembles, perspires, engages in violent movements, and may be speechless with horror or cry out with fear." He warns that the immediate effect of recalling the traumatic experience may be an exacerbation of the symptom or the appearance of substitute-symptoms: "The headache disappears but gives place to acute anxiety; or in addition to the pain in the back, the patient begins to vomit." He may have the typical repetitive battle-dream and be more disturbed temporarily than he was before the inception of treatment. He says no harm is done if direct suggestions are given to alleviate the acute attack if this is then followed by further exploration and what Hadfield terms "readjustment." This is constituted by a repeated "working through" of the experience until the patient can actually accept the fact that the original trauma is no longer a threat to him. He says that he has usually obtained satisfactory results within 12 to 15 sessions.

William Brown was one of the most enthusiastic exponents of the cathartic method during World War I. He restricted this form of psychotherapy largely to those soldiers showing major hysterical symptoms and says that in every one of 121 cases of hysterical mutism this method restored the power of speech in a few minutes (128) (129). He describes a typical treatment of a case of "shell-shock" as follows:

"It is the case of a gunner who was admitted to the hospital where I was working, after he had spent two years in military hospitals of different kinds. He was suffering from a tremor of the right hand, dating from the time when he had been blown up at Ypres. He did not remember anything more until he reached his first hospital, and the memory of this interval had never been recalled to him by any of the doctors he had previously seen. I sent him to sleep—that took just about three seconds—and then suggested to him that he should live again through the experience of Ypres. He did so, and began to shout out all sorts of things which showed what had been happening at the time. German shells were falling nearer and nearer the gun pit. He was apparently serving the gun, and someone else was handing him the ammunition, and this person had evidently lost his head, for my patient shouted out: 'What the — do you mean by pulling the — pin out of that — fuse ?' Then I noticed that he was going through the pantomime of moving the handle (to serve the gun) with his right hand; his hand began to shake violently and soon he was shaking all over, but especially in his right hand. Then he suddenly became abaolutely still I suggested to him that he would continue to remember all that he hadjust gone through and then woke him up. He looked at his hand, which was then absolutely still, with amazement and expressed his gratitude, but his mind still appeared somewhat confused, so I told him to go off and sleep it off. An hour later he came back and told me that he had not been to sleep, but that he had been thinking it all over. He knew everything that had happened, and told me that he had not been suffering from shell-shock, but gun-shock. His gun had been blown up, and the emotion which this experience excited in him had been bottled up for two years, with the result that he suffered from this tremor of the hand. The next morning he was able to shave himself with an ordinary razor, for the first time since his illness."

In his report on the treatment of "shell-shock" at an advanced neurological center, he concludes that whereas "mental analysis" (employing the technique of free association) is the ideal method he regards abreactive hypnotherapy as an "aid" and a "short-cut." Similar results are reported by Taylor (234) and Ross (214).

Although the "abreactive method" has been used extensively in World War II, the alteration in consciousness which is necessary for such a "re-living" has usually been brought about by drugs rather than by the verbal methods of hypnosis. There exists some question as to whether or not the drug-induced state is similar to what we think of as an hypnotic state. We have touched upon this problem in the chapter on "Methods of Induction." When a state of being can be defined only in operational terms and when another state appears to be characterized by similar phenomena, it does not seem to us far-fetched to conclude the possible existence of at least a large area of overlapping between them. Actually, a description of the "working through" of a traumatic war experience under the influence of one of the barbiturates is indistinguishable from a description of the abreactive process in hypnosis. The same peculiar revivification of the experience with hypermnesia, hallucinatory experiences, and a complete return of the attendant emotion is seen in both. Thus Grinker and Spiegel (158) describe the release of repressed emotion under the influence of sodium pentothal (with the aid usually of verbal stimulation) as the same kind of dramatic return to the traumatic episode as has been described by Hadfield, Brown and others. The experience with abreaction in what has been called "narcoanalysis" (180) is similar.

We include the abreactive aspect of Grinker and Spiegel's "narcosynthesis" in this section because we feel that that portion of the psychotherapy is closely allied to the cathartic release in hypnosis. It should be added, however, that the total therapy of "narcosynthesis" goes farbeyond a simple abreaction of the experience. The therapist often attempts to allay the patient's anxiety even during the violent re living, sometimes giving consolation, and again reassuring support When this is taken together with the fact that psychotherapeutic interviews are then held in the normal state in order to integrate this material with the waking ego, we see that the total therapy is actually closer, in principle, to the methods of hypnoanalysis than to the technique of abreaction. It is a dynamic psychotherapy broadly oriented by psychoanalytic theories and techniques.

Some of the advantages and disadvantages of drug adjuvants have been mentioned in Chapter II. We feel that the most important objection to stimulating chemically the abreaction of the traumatic experience lies in the fact that one runs the risk of setting off a process which is, in a sense, set apart from the current ego orientation of the patient. Although Grinker and Spiegel have devised excellent techniques for circumventing this difficulty, the fact remains that a radical physiological alteration of consciousness takes place, more radical than that in hypnosis, and less controllable (except again, by other chemical means — e.g., the use of benzedrine to keep the patient awake).

Hadfield (162) has discussed this problem on the basis of his experience with the treatment of the psychiatric casualties of World War II. He believes that the barbiturates may be used as an aid in psychotherapy but that they should not be substituted for the "more delicate psychological methods" of free association and "hypno-analysis." He points out that when the drug succeeds in stimulating the abreactive process that this is an experience often forgotten by the patient and must be again "worked through" in the normal state. Thus, the synthesizing aspect of the psychotherapy is often, of necessity, temporally and psychologically divorced from the re-living of the repressed affect.

Hadfield emphasizes that it is not a matter of determining to use one technique or the other but that each has its specific applicability and that the therapist who is confronted with war casualties should have both at his command.

We conclude this section with an evaluation of the abreactive technique. It has the primary advantage over both types of direct suggestion that it is an "uncovering" rather than a suppressive method. Moreover, it has been our experience and that of others (130) (159) that the relief of acute symptoms may follow directly upon the re-living of the pertinent traumatic episodes. This has seemed particularly true for the war neuroses, although it is by no means restricted to them. Thus, it is a relatively brief method. It is, in addition, a technique which may yield good clinical results even when applied by therapists who have not had intensive training in the methods of modern psychotherapy. This does not imply that the attractive method may be employed by person who have no orientation in the problems of psychodynamics; for if the material brought by the patient is regarded simply as a mechanical release of emotion and is not integrated with his total personality, the re-living experience may be harmful to the patient. However, the kind of sympathetic reassurance which seems of paramount importance here is a psychotherapeutic technique which requires less specialized training than the technique of directly suggesting a change in underlying attitudes or of hypnoanalysis. These methods require a more specific and deeper understanding of the total personality of the individual.

The limitations of the abreactive method lie first in the fact that in general, a deep hypnosis is required before the typical "re-living" can occur. This has been less true for the war neuroses in which it appears that the repressed emotion is closer to the surface. Secondly, this method is largely a "symptom-treatment" if it is restricted to abreaction alone. The therapy starts with the symptom and tries to trace it back, allowing for few detours. The variety of insight which the patient achieves by such an approach is thus relatively shallow and accordingly, one cannot feel that the cure is rooted in personality changes sufficiently deep to provide a reliable equilibrium. Here again, one must emphasize that this is an argument based more on theoretical considerations than on established empirical findings, for many abreactive "cures" are permanent.

5. The use of specialized hypnotic techniques.

Although all methods of hypnotherapy involve the use of one or another of hypnotic techniques and phenomena, we are considering this approach as distinct from the other methods because it has been used beyond the point where hypnosis is merely a catalyst or an adjuvant. The variegated phenomena of hypnosis are used here as the nucleus of the therapeutic leverage in a way which demarcates this methods from the others. Highly differentiated techniques are employed and the fact of the patient's being in hypnosis is therapeutically exploited to its limits; these include not only the standard hypnotic phenomena (hypermnesia, posthypnotic suggestion, etc.) but also more specialized procedures.

For example, it has been established that a patient in hypnosis will automatically write out, if properly instructed, information which is inaccessible to direct awareness. Muhl (198) has used such "automatic writing" to recover childhood memories. A similar approach is the attempt to recover normally inaccessible material by asking a patient in hypnosis to fix his gaze on some neutral, ambiguous field, such as a light-bulb, a glass ball, or a mirror, and to tell him he will experience vivid visual images related to the problems under investigation. This is a kind of "projective technique" in which the patient's projection take on a hallucinatory vividness. It is usually referred to by the ancient expression "crystal gazing," a phenomenon known to occur spontaneously among "mediums." Both Muhl and Prince (207) investigated this device.

Another important specialized technique of hypnosis is the artificial "regression" of the patient to an earlier time in his life. Phenomenally, the patient "returns" in his behavior and in his reported subjective experience to the suggested age-level. Erickson, in his experimental work on hypnotically induced blindness (142) and deafness (144) has described the procedures whereby the subject is first disoriented with regard to current time-place relationships before new orientations arc suggested. In a clinical report (147) he points out the necessity for inducing successive amnesias for the current date, week, month, and year before suggesting that the patient subjectively return to an earlier time. Although there has been much heated controversy regarding the precise nature of such a regression (206) (249) (160), it has been included as one of the tools of hypnotherapy.

Other specialized hypnotic techniques include: the direct suggestion of dreams either in the hypnotic state or posthypnotically as part of the patient's natural sleep; the artificial implantation of a temporary conflict (*); the use of variegated devices to obtain material inaccessible to direct awareness (e.g., telling the patient he will see written on a black board a single word which will provide a clue to the problem at hand, suggesting vivid visual images, etc).

(*)Eisenbud (140) has used this technique in an experimental case study on the "psychology of headache."

Although Janet, Prince, Sidis, Muhl, Wells, and others have explored some of these specialized techniques, the most extensive therapeutic applications of them have been made by Erickson. Combining a unique inventiveness with a shrewd and intuitive grasp of the patient's psychological status, he uses these methods as the essential levers of his therapy.

In a paper written jointly with Kubie (147) the cure of an "acute hysterical depression" in three hypnotic sessions is reported. The patient had become so gravely ill that after her failure to respond to psychoanalytic treatment (*), several consultants had favored her commitment to a state hospital. As a last resort, hypnotherapy was tried. From a fragmentary history obtained from the patient's roommate, Erickson concluded that the depression was the result of deep feelings of guilt and terror connected with a sexual experience which had directly preceded the acute symptoms.

(*) Hypnosis has sometimes been used to render a patient accessible where other techniques have failed. After contact with the patient has been established this may be followed by a course of psychotherapy conducted either in the normal or in the hypnotic state. Brenman and Knight have reported two cases of this kind (123) (124).

In order temporarily to allay her fears, he gave her permission in a deep hypnosis "to forget absolutely and completely many things." The authors point out that this was a radical departure from the technique of psychoanalysis inasmuch as repression was explicitly encouraged by the therapist. Next, she was "regressed" to a period of early adolescence during which her mother had died. Erickson identified himself at first with the prim, moralistic standards of the girl's mother and having established this identity was able to extend, "what the mother might have said had she lived;" this extension included permission and encouragement to lead a normal adult sexual life. The patient responded well and shortly was entirely symptom-free. Although this account does not do justice to the nuances of procedure, it illustrates the unorthodox and skillful use made by Erickson of hypnosis.

In his report on "The Investigation of a Specific Amnesia" (143) he employs almost every possible technical device, including free association, automatic writing, crystal gazing, dream suggestion, underlining significant letters, etc. He succeeded finally in recovering the amnesia by asking the patient to do automatic writing under special circumstances. In a case of a young woman afflicted with an "obsessional phobia" (146), the symptoms disappeared after a few hours of communication with an "unsuspected dual personality" by means of automatic writing and the production of visual images by use of a mirror. Erickson and Kubie (148) report also the use of automatic drawing as an aid in the relief of a state of acute obsessional depression. This is a representative sampling of the case reports.

Although, from the point of view of varieties of hypnotherapy, it suffices to characterize this approach as that which makes the most consistent use of specialized hypnotic techniques, it is of perhaps greater importance to note the way in which these techniques are applied. It is as if they are used as the "heavy artillery" of a specific strategy, planned to outwit the unconscious of each patient. Before the therapist attempts to manipulate the conscious or unconscious forces in the patient, he conceives a general picture of their current distribution and then applies pressure at those points which seem to him crucial. Thus, in the case of hysterical depression, the therapeutic effort was at first oriented around the aim of reinforcing repression rather than resolving it; and only then was a strong attempt made to manipulate the girl's attitudes.

The advantage of this approach lies in the fact that it makes possible, at least in certain kinds of acute, circumscribed problems, a dramatic and rapid cure. However, because its efficacy is largely dependent on the subtle strategies involved, it is as yet an unsystematized method dependent almost entirely on the personal intuition of the therapist. It is thus exceedingly difficult to communicate it as a hypnotherapeutic approach and remains a more or less unique phenomenon, unrelated to a formulated psychology and accordingly, closer to art than science. Whereas all of the foregoing is true, to a degree, of all methods of psychotherapy to be the essential characteristicofthis approach.

Erickson and Kubie have formulated in their discussions (14l the essential problems regarding the "mechanism of cure" in connection with this type of psychotherapy. They say: "It fares us with the question: if recovery can take place with the gain of such rudimentary insight what then is the relationship between unconscious insight, conscious insight, and the process of recovery from a neurosis?" This is a vexed question in any form of psychotherapy. One might well ask for the "mechanism of cure" where there exists not even a "rudimentary insight" as in the therapy of direct suggestion of symptom-disappearance, in the "cures" of Christian Science or of Our Lady of Lourdes. We shall return to this discussion in the concluding chapter.

6. Hypnoanalysis.

Although the hyphenated term "hypno-analysis" was coined by Had field (159) to refer to a combination of cathartic hypnosis and "reeducation," we shall use the word "hypnoanalysis" to describe those hypnotherapeutic approaches which combine in various ways the techniques of hypnosis with those of psychoanalysis. Actually, there exists a fluid transition between the previously described kinds of hypnotherapy and hypnoanalysis; and it is often difficult to decide to which of the six categories a given approach belongs.

For example, Erickson (145) (146) (147) (148) who frequently collaborates with psychoanalysts in his hypnotherapeutic work, often utilizes the insights of psychoanalysis. Yet, the essential nature of the treatment and its duration is usually significantly different from the usual course of a hypnoanalysis. He customarily places but little emphasis on the standard psychoanalytic techniques; and reports the disappearance of symptoms within a comparatively few sessions, whereas hypnoanalytic treatment usually takes from 40 to 100 hours or more.

The investigations of Lifschitz (183) and Hadfield's later work (159) particularly that with civilian neuroses fall into a transitional area also. Both trace a symptom back to earlier traumatic experiences in a more systematic and sustained fashion than that usually employed in cathartic hypnosis. Hadfield's psychopathology, and his "working concepts" are psychoanalytically oreinted, however, whereas Lifschitz, who also calls his technique "hypnoanalysis," is explicitly opposed to psychoanalysis and tries to show that his variety of "hypnoanalysis" disproves many of the basic tenets of psychoanalytic theory.

The term "hypnoanalysis" has been used to refer to somewhat different varieties of hypnotherapy and has been loosely employed to describe a range of therapeutic techniques which includes anything from classical "abreaction" to modified psychoanalytic treatment, carried out with the patient in hypnosis.

Although there were a few sporadic attempts as early as 1917 to combine the techniques of psychoanalysis with those of hypnosis (176), the first consistent application of this combined method was in the work of Simmel who explored this approach to some extent in civilian neuroses (225) and on a broader scale in the war neuroses of World War I (226). Simmel had come to the place where his experience dictated a rejection both of "forcible and restrictive methods" and of the technique of symptom-removal by direct suggestion in hypnosis. He says:

"A medical treatment that is to be effective can only be built up on the pathogenesis of a disease. The psychopathogenesis of the war neurosis, (and no intelligent man any longer doubts its psychic origin), obviously can be elucidated only by means of psychoanalysis. It is intelligible that a hospital regime necessitating the simultaneous treatment of a large number of cases and calling for rapid curative results, would allow a more extensive individual analysis only in a few cases. On account of this I had from the beginning to cut down the length of the treatment. A combination of analytic-cathartic hypnosis with analytical conversations during the waking state, and dream interpretation carried out both in the waking state and in deep hypnosis, has given me a method which on an average of two or three sittings brought about relief of the symptoms (226)." (Page 30)

During the course of this treatment, the soldier frequently "re-lived" the battle trauma as was described under the section on cathartic hypnosis. Often this