Hypnosis and Suggestion in the Treatment of Pain

HYPNOTIC ANALGESIA is one of the most dramatic of all hypnotic phenomena. To observe the tranquil face of a patient undergoing a painful medical procedure, with no anesthetic agent except words, is a remarkable, perhaps even unbelievable, experience. To watch the power of his or her imagination bring a sigh of relief to a patient who has been suffering the pain of a disease is a welcome and satisfying sight. This book explores the ways in which we can use suggestion and hypnotic techniques to treat patients who are suffering from pain. In this chapter I will introduce you to the domain of hypnosis and to its use in the treatment of pain.

“Hypnosis” is a troublesome word. It conjures a variety of images, generated by decades of stage hypnotists, novels and films—each more strange in its portrayal of “hypnosis” than the next. It was not so long ago that a predominant image associated with hypnotic phenomena was that of a mustachioed, dark-eyed man, focusing with a fixed stare upon a vulnerable young woman, conveying by the intensity of his stern visage the plan to coerce and perhaps harm this helpless young person. Although this image of “hypnosis” is well over a hundred years old, it continues to cling strongly to our contemporary associations of hypnosis—even in the context of medical or psychological care.

Another common image is that of a fast-talking, shiny-suited stage hypnotist, compelling audience participants to perform a variety of weird and embarrassing acts—as if they had no choice but to obey his every command. The notion that hypnotic techniques are a means of controlling another person’s will is a deeply rooted one. Even today, hypnotic phenomena can be a source of public entertainment. “Hypnotists” entertain by encouraging members of the audience to act in ways that are, to varying degrees, foolish and, apparently, amusing to those watching. The sight of a stage hypnotist commanding an audience member to crow like a rooster or to hallucinate the audience as undressed is, unfortunately, a common one. A witness to such antics might conclude, reasonably enough, that this can only happen if one person’s will has been overcome by another’s.

Is this really the case? Do hypnotic processes involve the control of a person’s will? You can find interesting and pertinent discussions elsewhere about the nature of hypnosis and about the nature of social coercion (Bowers, 1983; Orne, 1959, 1962; Shor, 1959, 1962). There is ample evidence that human beings can be induced to behave in foolish, even harmful ways—without recourse to hypnotic techniques. While participants do sometimes experience hypnotic phenomena, this is not necessary for the success of the show. It is well demonstrated that the ingredients for “stage hypnosis” include many parts show business and little genuine experience of hypnosis (T. Barber, 1986).

Although some of the foolishness we witness in “stage hypnosis” may, at times, represent genuine hypnotic phenomena, much of “stage hypnosis” depends very little on actual hypnotic effects. It relies, instead, on other social psychological processes. However, no matter what the context, it is still the case that there is something unusually compelling about the true hypnotic experience—something about the involuntary quality commonly experienced by the hypnotic subject. There is also something unusual about the compelling influence of hypnotic suggestions and the feeling of being affected by them.

Although our understanding of and, consequently, our associations to hypnotic phenomena are evolving over time, it has been only very recently that the domain of hypnosis has begun to be systematically explored and demystified.

Since very lucid explorations of the domain of hypnosis already exist (Bowers, 1978; Fromm & Nash, 1992; Hilgard, 1965a, 1965b; Lynn & Rhue, 1991), it is not my purpose here to add to that literature. However, for the reader not yet familiar with this domain, the following discussion is intended to create a useful context for the clinical principles and techniques that will comprise the rest of the book.

It is one of the peculiarities of the study and application of hypnotic phenomena that the definition of hypnosis and an understanding of its basic nature remain in some dispute. In Chapter 4, Don Price explores the fundamental controversy within the domain of hypnosis: whether or not the hypnotic experience includes an alteration of state of consciousness—the state vs. nonstate issue. One’s view of this issue depends, I think, less on one’s interpretation of the data than on one’s fundamental view of human psychology (and, I think, upon whether one has had a hypnotic experience).

The discussion of hypnosis and hypnotic treatment in this book rests on the assumption that hypnotic experience is a complex phenomenon and a function of the dynamic interaction between an alteration in state of consciousness and social psychological forces. You can find a fuller description of this assumption in Barber (1991). For a further exploration of contemporary theories of hypnosis, there are various sources, two of which may be very helpful—Fromm and Nash (1992) and Lynn and Rhue (1991).

Hypnosis is an altered condition or state of consciousness characterized by a markedly increased receptivity to suggestion, the capacity for modification of perception and memory, and the potential for systematic control of a variety of usually involuntary physiological functions (such as glandular activity, vasomotor activity, etc.). Further, the experience of hypnosis creates an unusual relationship between the person offering the suggestions and the person receiving them. Shor (1962) referred to this special relationship as “archaic involvement,” by which he meant that the person being hypnotized experiences a form of transference. This involves feeling and to some extent acting as he or she did with an early caregiver. It may be, in fact, that this transferential quality of the hypnotic experience is a powerful determinant of clinical effectiveness.

All of these features of altered functioning can be useful in the control of pain, but clearly the most important are alterations of perception and physical functioning. With respect to alterations in perception, individuals who are hypnotized can experience both positive and negative hallucinations. Positive hallucination refers to the capacity to perceive something that one would not otherwise perceive. Negative hallucination refers to the capacity to not perceive something that one would otherwise perceive. Such hallucinations can occur in any sensory modality. As will be illustrated in the following text, it is the capacity to alter perception (though not necessarily to hallucinate) that allows the development of hypnotic analgesia or anesthesia. (Anesthesia refers to the absence of sensation; analgesia refers to the absence of pain, but not of sensation.)

A prevalent misunderstanding is that hypnotic methods are effective in treating pain only because they produce relaxation; in fact, some believe that a hypnotic induction is merely an exercise for creating muscular relaxation. Muscular relaxation is not a useful treatment for pain—unless, of course, the pain is specifically caused by muscle tension (McCauley, Thelan, Frank, Willard, & Callan, 1983); even then, such relaxation is likely to have only a temporary effect.

Moreover, hypnosis is not necessarily a relaxed condition (Banyai, 1980). The two phenomena can occur quite independently. Their association is largely the result of the fact that relaxation suggestions are so often a part of hypnotic inductions. Far from being merely relaxation, the hypnotic experience involves a sometimes dramatic shift in consciousness. It is this shift, apparently, that subserves the change in awareness of pain (Orne, 1976; Shor, 1965). Relaxation suggestions can play a very useful role in helping the patient to “relax” the usual level of scrutiny, critical thought, and/or “mind chatter” that may interfere with his or her wish to become absorbed in the experiences that are suggested.

Hilgard’s neodissociation theory proposes that an essential feature of the cognitive process that underlies the hypnotic experience is dissociation (Hilgard, 1973, 1977). The neodissociation theory further proposes that hypnotic analgesia is a function of the disruption—the dissociation—of sensory information on its way to conscious awareness.

Utilization of the capacities made available by the dissociative shift in consciousness distinguishes hypnotic methods from cognitive strategies for pain control. Hypnotic treatment is not cognitive therapy, in the sense that a cognitively oriented clinician teaches a patient how to think differently about a problem. A patient who experiences hypnotic analgesia or anesthesia feels both the change in perception of pain (either the sensory or affective component, or both¹) and, usually, the automaticity of that change.

Sometimes patients who experience hypnotic anesthesia or analgesia do not even believe they have been hypnotized (for reasons that may relate to false expectations about the experience, as well as to the automaticity of the response). Such patients may actually have no awareness of any change in their cognitions or in any other aspect of their experience except for the reduction or absence of pain.

For instance, one patient who endured an ordinarily painful dental procedure (root canal treatment of a vital tooth) with hypnosis as the sole anesthetic believed he was not hypnotized (“because I can’t be hypnotized”) and explained to his surprised dentist that he was not hurting because “you didn’t do anything to me that would hurt.” Another patient, being treated for long-term back pain, came to the first appointment insisting that he needed to be hypnotized and that he could not be. At the termination of treatment (after six appointments, during which he had shown ample evidence of his capacity to experience hypnotic phenomena), he was relieved of his pain. He left, declaring that his only disappointment was that he had never been hypnotized. Though conscious cognitive changes may be part of hypnotic treatment for pain, they are not essential to it and may be entirely unnecessary to pain relief. (The question of why a patient would seek hypnotherapy believing he or she cannot be hypnotized is an interesting psychotherapeutic issue, but is beyond the scope of this chapter.)

It is unfortunate that the distinction between hypnosis and suggestion has been partially lost. Often, upon hearing a suggestion made to a patient in a normal waking state, colleagues remark something like, That’s an example of hypnotic language.” Of course, making a suggestion to a person in a normal waking state is not an example of hypnotic language. It is an invitation to an experience—a suggestion. Such suggestions are ubiquitous in our lives. When we say to a friend on a winter’s evening, “Isn’t it a little cold in this room?” we are communicating our discomfort and perhaps inviting our friend to put another log on the fire. It is not a hypnotic suggestion, and our friend’s subsequent fire-building activity does not represent hypnotic behavior. (If, in a different circumstance, we were to hypnotize this friend and suggest, “After you awaken, you will notice that it’s cold in here, and you will feel compelled to put another log on the fire. And you won’t remember that I’ve told you this,” it would be a hypnotic suggestion. And our friend’s subsequent behavior, if it were experienced as compelling or involuntary, would be an example of a hypnotic behavior.)

If we blur the distinction between suggestion and hypnosis, thereby including all influential communication within the concept of hypnosis, the special meaning of hypnosis is lost. Advertising, for instance, is an example not of mass hypnotic techniques but of a set of suggestions that influence our waking perceptions and desires.

Clinically, suggestions occur all of the time, with all patients, by all practitioners, both witting and unwitting of the influence of a suggestion. This is not an example of clinical hypnotic intervention—except in those cases in which a patient’s vulnerability is so great and suggestibility so high that the circumstance of injury or illness and the anxiety and dread that accompany it evoke an altered state of consciousness. This special circumstance, which is not uncommon in the medical setting, is discussed by Christel Bejenke in Chapter 9 and David Patterson in Chapter 10. It can occur in any setting, of course, even the psychologist’s office. However, if we do not recognize that suggestions can have even greater impact in the context of a hypnotic experience, we lose the particular benefits of such interventions.

Some pain conditions are not amenable to amelioration or cure by either medical or cognitive-behavioral treatment. Certain recurrent pain syndromes, such as migraine headache, trigeminal neuralgia, or osteoarthritis, involve ongoing noxious stimulation. When the best medical care cannot significantly reduce pain, psychological intervention is often undertaken to help the patient function while suffering with an ongoing pain problem. Although cognitive-behavioral treatments may be critical to the rehabilitation of patients, these approaches do not—and are not intended to—eliminate pain itself, but rather to modify its dysfunctional behavioral analogues.

The majority of patients who undergo comprehensive cognitive-behavioral programs at pain clinics are diagnosed with chronic benign pain syndrome (see below). Such patients learn to be more active, to return to work, to take less medication; generally, they are rehabilitated to good function (Fordyce, 1976; Fordyce et al., 1983).

For patients who do not have benign pain syndrome, but who suffer from recurring pain accompanying an injury or disease process, such cognitive-behavioral programs may be of some help, but the problem of suffering from pain persists. Giving such patients mood-altering analgesics (e.g., opioids), even if such medication could continue to ameliorate the pain, which it generally cannot, is clearly undesirable because of the side-effects of such medications (e.g., psychological dependence, physical dependence, tolerance, dysphoria, constipation, pruritis etc.).

1. eliminates or at least significantly reduces pain;

2. does so without untoward psychological side-effects, such as operantly increasing the level of perceived pain or reducing activity levels;

3. enhances the other treatments patients are receiving; and

4. enables patients to learn to use the treatment themselves so that they become more self-reliant and less dependent on the health-care system.

Hypnotic treatment offers such a clinical intervention. No other psychological technique is as efficacious in creating comfort out of discomfort, with none of the adverse side-effects associated with medical treatments of comparable efficacy. Using hypnotic approaches effectively in the management of a recurring pain condition, however, re quires more than a simple application of a hypnotic induction followed by suggestions for analgesia.

Many patients—and some clinicians—turn to a hypnotic method with the expectation that it is a magical treatment for pain, just as many regard it as the primary or even sole treatment for compulsive problems, sexual problems, or anxiety. Such use is misguided and, consequently, fraught with disappointment. To be effective for such complex problems, hypnotic methods must be thoughtfully incorporated into a broader psychotherapeutic model (Barber, J., 1982, 1986, 1991; Edelstien, 1981). When so incorporated, these methods can be a satisfying aspect of treatment.

Acute pain is the pain that results immediately from noxious stimulation (injury or medical procedure or disease process). Examples of acute pain include appendicitis, bone fracture, lumbar puncture, and meningitis.

Recurring pain results from injury or, more likely, disease, which produces repeated noxious stimulation over time. Although I am calling it “recurring pain,” these conditions can sometimes involve almost constant pain. Examples of recurring pain include arthritis, cancer pain, migraine (and other headaches), phantom limb pain, thalamic pain syndrome, irritable bowel syndrome, sickle cell pain, tic doloreux and other facial pains.

Chronic benign pain syndrome is distinguished from the first two by the fact that the patient experiences pain and suffering that endure beyond the noxious stimulation produced by the injury or disease process that resulted in the original pain. Examples of chronic benign pain syndrome include low back pain and most other pain that persists even after healing has occurred.

Psychogenic pain is a variant of somatoform disorder, and is a condition rarely seen in pain clinics.

It is worth considering here the distinction between the sensory-discriminative (or, simply, sensory) and the motivational-affective (or, simply, affective) components of pain. All pain experience involves both of these components simultaneously. This is true even though the sufferer is not likely to recognize each of them separately, unless asked to do so, just as the more complex experience of vision simultaneously includes the components of shape, texture, color, and intensity.

The sensory component of pain provides basic information to the sufferer about the location and the sensory quality of the pain. For example, it tells us if our pain is lancinating or dull, cold or burning, tingling or aching, persistent or intermittent.

The affective component of pain provides quite different information, namely, how much the pain bothers. The two components do not necessarily correspond. For instance, the birth pain of a welcome child may involve very intense sensations for the mother. However, this high intensity pain may not bother her in the same way as a pain of similar intensity, but of different origin, might. She hurts, but she may not suffer. At the other end of the spectrum of human experience, consider the pain of cancer. Even when the cancer pain is not intense, it can be extremely bothersome—ominous and frightening, even—and the patient suffers. This affective component is what determines the overall experience of suffering.

How much we are bothered by pain—how much we suffer—is a function of what the pain means to us—what it tells us about our life and our relationship with the world. If the pain, by virtue of its location or severity or cause, raises the question of our existence, as Bakan (1976) has said, then we are likely to be very bothered and to suffer substantially. If the pain does not signal danger to our good functioning or our life, then even if it is intense it need not cause us to suffer. (For a full discussion of this very important issue, see Price, 1983, 1988; Price & Harkins, 1992a.)

When asking a patient to make the distinction between the sensory and affective components of pain, I often find the following analogy is helpful: Imagine you are listening to music on the radio. How loud is the music? How loud it is—how intense—corresponds to the sensory component of the pain experience. How pleasant or unpleasant is the music? How bothersome the music is corresponds to the affective component of the pain experience.

I then ask the patient to rate the sensory component of pain, using either a visual analogue scale (VAS)² or an imaginary numerical scale, in which “0” corresponds to no intensity at all, and “10” to “as intense a pain as you can imagine” (Price, Long, & Harkins, 1994).

Next I ask the patient to rate the affective component, using the same VAS or imaginary numerical scale, now anchored by “0,” which corresponds to “not bothersome at all,” and “10,” “being bothered as much as you can imagine.”

A clear understanding of the meaning and distinction between these two components is not only important to our apprehension of the theory of pain but also crucial to effective pain treatment and to the evaluation of treatment progress, as we shall see later.

Although the human capacity to experience hypnotic phenomena has probably been used in pain management for as long as there has been clinical treatment of any kind (since most medical treatment prior to the twentieth century was largely dependent upon expectation and suggestion), the modern history of medical hypnosis begins with the work of the Austrian physician Franz Anton Mesmer (1734–1815). Mesmer’s explanation for the phenomenon of cure by his method, “animal magnetism,” was later discarded in favor of an explanation supported by the scientific evidence. This preferred theory then led to the development of the concepts of suggestion and hypnosis (Bloch, 1980).

The use of hypnotic treatment in medicine slowly developed throughout the nineteenth century, most dramatically in the operating room. Because the development of chloroform and ether anesthesia was still in the future, painless surgery was impossible. As early as 1850, James Esdaile (1957), an English surgeon working in India, successfully used hypnoanesthesia for a variety of major surgeries. This development was met with both astonished disbelief and astonished hope, since it meant an alternative to the agony of nonanesthetized surgery. Since then, there have been numerous accounts of surgery performed with hypnotic analgesia—some involving self-hypnosis (Rausch, 1980)—as the sole anesthetic. Almost simultaneous with these initial reports of hypnoanesthesia was the independent development of chemoanesthesia.

Contemporary applications of chemoanesthesia are so successful, of course, that we no longer need to promote the use of hypnotic analgesia as a surgical anesthetic. Though the initial accounts of hypnoanesthesia demonstrated its potential and promised a role in medicine, the lack of a scientific method or model for understanding hypnotic phenomena contributed to its limited application in medicine. Without a credible scientific model, hypnotic methods remained largely in the hands of entertainers and lay healers. Medical practitioners who did use these methods were limited to a few pioneers.

As the science of psychology developed in the nineteenth century, interest in hypnotic phenomena among psychological researchers naturally grew. Severely abbreviating this history, we leap forward to the middle of the twentieth century and the work of Ernest R. Hilgard. After establishing his reputation as a reliable researcher in the field of human learning, Hilgard established the Hypnosis Laboratory at Stanford University in 1957. It is fair to say that the most substantial advances in understanding hypnotic phenomena in general and in understanding hypnotic analgesia in particular resulted from investigations made under Hilgard’s direction at the Stanford Hypnosis Laboratory (Hilgard, 1965a, 1965b, 1967a, 1969; Hilgard & J. R. Hilgard, 1994; Hilgard & Morgan, 1975; Hilgard, Morgan, & MacDonald, 1975; Weitzenhoffer & Hilgard, 1959). By establishing standards for evaluating hypnotic procedures and for measuring hypnotic analgesia, Hilgard and his coworkers demonstrated hypnotic phenomena could be scientifically investigated.

The results of Ernest Hilgard’s research at the Stanford Hypnosis Laboratory stimulated research by other investigators, including his wife, Josephine R. Hilgard, Kenneth Bowers, Perry London, Martin Orne, Andre Weitzenhoffer, Ronald Shor, Frederick Evans, and many others. Consequently, the clinical use of hypnotic methods in medicine, in dentistry, and in psychological treatment has become more commonplace. In recent years, hypnotic methods have been increasingly employed in the treatment of a multitude of pain problems and psychophysiologic disorders, including the acute pain of burns, surgery, and malignant disease, as well as pain syndromes as widely divergent as arthritis, sickle-cell anemia, trigeminal neuralgia, migraine headaches, peripheral neuropathies, and thalamic pain syndrome (Barber, 1990; Barber & Adrian, 1982; Crasilneck & Hall, 1985; Hilgard & Hilgard, 1994).

Many attempts have been made to understand the neurophysiological mechanism by which hypnotic processes operate to produce analgesia. Although such a mechanism has yet to be identified, certain hypotheses have been tested; none has been confirmed. Goldstein and Hilgard (1975), Barber and Mayer (1977), Finer and Terenius (1981), and Spiegel and Albert (1983) each independently found that hypnotic analgesia is apparently not subserved by the endorphin system. Sternbach (1982b) was unable to confirm another possible hypothesis, that acetylcholine underlies hypnotic analgesia. Presumably the mechanism is more complex than can be understood by reference to the action of a single neurotransmitter. More recently, Kiernan, Dane, Phillips, and Price (1995) demonstrated that hypnotic analgesia involves suppression of activity in spinal sensory neurons, emphasizing the complexity of this phenomenon.

Whatever the underlying mechanism, it is clear that the rate and degree to which the hypnotic process enables the modification of pain perception and/or suffering can be quite dramatic. The hypnotic elimination of both experimental and clinical pain, whatever its nature, history, or intensity, has been fully documented (Barber, 1977; Crasilneck & Hall, 1985; Hilgard & Hilgard, 1994, J. Hilgard & LeBaron, 1984; Melzack & Wall, 1973; Olness & Gardner, 1988). Further, the elimination of pain can occur immediately in response to hypnotic suggestion.

Research over the past 30 years has demonstrated that hypnotic subjects (including college students, children, and older adults) are able to reduce or eliminate a variety of experimentally-induced pain, including ischemic, cold-pressor, electric, and thermal (Hilgard & Hilgard, 1994). Careful investigation has established that such hypnotic pain control is superior to that achieved by other psychological means (Hilgard & Hilgard, 1994; Orne, 1980; Turner & Chapman, 1982). However, outside the laboratory setting, there has been no significant investigation of hypnotic analgesia. For example, while there is a substantial case report literature suggesting that hypnotic methods can be effective in the treatment of long-term pain conditions, there is very little rigorous research which speaks to this issue of effectiveness. The research that does exist often involves treatment that on the face of it cannot be expected to be effective (so interpreting the data is difficult). Undertaking controlled investigations that take into account the psychological complexity of these chronic conditions is a difficult but necessary task.

Under what conditions can hypnotic methods be used to achieve elimination of suffering? Recent research has explored the conditions under which such methods are clinically useful. Neither gender nor intelligence is relevant to the development of the hypnotic state (Hilgard & Hilgard, 1994). Nor is age a factor; much work has been done with the hypnotic treatment of children in pain (Olness & Gardner, 1988; J. Hilgard & LeBaron, 1982, 1984; Kellerman, Zeltzer, Ellenberg, & Dash, 1983; Schafer, 1975; Wakeman & Kaplan, 1978; Zeltzer, Dash, & Holland, 1979).

Unfortunately, there is no substantive literature which addresses this issue in the growing population of elders. Perhaps because of this, there exist misconceptions about the inefficacy of hypnotic methods in the elderly. This belief is not supported by my own clinical experience—nor that of Samuel LeBaron and William Fowkes, as they describe in Chapter 12.

Individual differences is a domain that is interesting to explore, but one that can also be frustrating to understand when trying to investigate hypnotic processes. It is well-known that individuals differ in the degree to which they respond to hypnotic suggestion in general and to hypnotic treatment in particular (J. Hilgard, 1975; Hilgard & Hilgard, 1994). In my view, an issue that remains unresolved is the clinical relevance of measured hypnotic responsiveness (Hilgard & Hilgard, 1994). Experimental investigations of this issue have yielded differing results. Whether a particular patient can benefit from hypnotic treatment is, of course, an important clinical issue, so let us explore what we know.

The belief that only some individuals are responsive to hypnotic suggestion is based partly on the old and clearly unsupportable belief that only persons of inferior intellect or “weak personality” could be hypnotized (and on the corollary assumption that the hypnotic experience requires giving control of one’s mind over to the hypnotist). More important than this old misunderstanding, however, are contemporary experimental and clinical investigations that seem to suggest that only a minority of individuals can achieve clinically significant hypnotic analgesia (Hilgard & Hilgard, 1994).

In the typical study, hypnotic responsiveness is measured by reference to an individual’s performance (referred to in this chapter as “responsivity” but elsewhere, variously, as “hypnotizability” or “susceptibility”) on a standardized test, such as the Stanford Hypnotic Susceptibility Scale (Weitzenhoffer & Hilgard, 1959), the Harvard Group Scale of Hypnotic Susceptibility (Shor & E. Orne, 1962), or the Hypnotic Induction Profile (H. Spiegel, 1974). Such tests create a circumstance in which an individual has the opportunity to respond to a hypnotic induction and to several suggestions for hypnotic behaviors. The number of behaviors the individual demonstrates then becomes the numeric measure of hypnotic responsiveness.

Hilgard and Morgan (1975) demonstrated that the correlation between such measures and an individual’s ability hypnotically to reduce experimental pain is significant (r = .50). However, Hilgard and Morgan also reported that 44% of low-susceptible individuals were able to reduce their pain by 10% or more and concluded:

This means that the relation between pain reduction and hypnotic responsiveness is probabilistic, with a greater probability of successful pain reduction for those highly responsive to hypnotic suggestions. The data do not mean that those unresponsive to hypnotic suggestion as measured by the scales, have no possibility of help through suggestion. (Hilgard & Hilgard, 1994, p. 68)

Just as it is clear that there is a wide range of hypnotic responsiveness among individuals, so there is also evidence that another significant variable in determining clinical effectiveness of hypnotic treatment is the clinician’s particular approach to the patient (Alman & Carney, 1981; Barber, 1977, 1980, 1982, 1991; Fricton & Roth, 1985; Gfeller, Lynn, & Pribble, 1987; Price & Barber, 1987). We can infer from these reports that an approach based on suggestions offered in the context of a meaningful relationship is more likely to be successful with individuals performing poorly on tests of responsivity than would be predicted simply on the basis of these tests.

Although such an approach has been characterized in the past as “indirect” as distinct from “direct” (Alman & Carney, 1981; Barber, 1982; Fricton & Roth, 1985), such a characterization is simplistic and misleading. It misses the fundamental difference between suggestions communicated in a standard way, e.g., through a test of responsivity—whether or not the suggestions are formulated in a direct or an indirect manner—and those communicated in a nonstandard but more individualized way (Price & Barber, 1987). Moreover, such a characterization neglects the crucial importance of the relationship that develops between clinician and patient (or even between experimenter and subject).⁴

One explanation for the disparity in research findings, at least with respect to the analgesic capacity of those individuals with low responsivity to hypnotic suggestion, might be that those with high responsivity are better able to reduce the sensory-discriminative component of pain, while those with low responsivity are able to reduce the motivational-affective component (Price & Barber, 1987). If these two components are not independently measured, it is entirely possible that some patients’ measures reflect the sensory component, while others’ reflect the affective component. The disparate findings might be explained by this lack of precision in pain measurement.

Price and Barber (1987) sought to assess this possibility. In their experiment, thermally induced pain was measured independently on both the sensory-discriminative and the affective-motivational dimensions, using a visual analogue scale (from Price, 1983). Highly responsive subjects were better able to reduce the sensory component of pain. However, subjects with low hypnotic responsivity were as able to reduce the affective component of pain as were subjects with high hypnotic responsivity. This finding confirms reports that hypnotic responsiveness predicts the capacity to hypnotically reduce pain perception. However, this finding also suggests that hypnotic responsiveness is not related to the capacity to reduce suffering (i.e., the affective-motivational component of pain).

Another unresolved issue is that of the experimentally verifiable effects of hypnotic suggestion compared with clinical reports of effectiveness. Most of the clinical literature shows hypnotic suggestion to be more effective as an analgesic (and more frequently so) than experimental reports would predict (Crasilneck & Hall, 1985; Haley, 1967; Hilgard & Hilgard, 1994). Part of the explanation for this difference lies in the obvious differences in motivation of the subjects and patients. Experimental subjects are significantly less motivated to experience a hypnotic effect than are clinical patients who are seeking relief from suffering. There are also significant differences in the behavior (and motivation) of experimenters and clinicians. Experimental protocols usually require rigid adherence to a well-operationalized, standardized induction and set of suggestions. Rarely is the purpose of an experiment the search for optimum hypnotic effect. However, that is precisely what is involved in the clinical situation. Effective clinical use of hypnotic suggestion requires an individualized approach. Rarely is a standardized set of procedures followed, and the clinician, normally focused only on doing what is effective, may vary or repeat procedures until success is obtained. While this may lead to successful clinical outcomes, it is usually impossible to assess the causal link between treatment and results.

In this regard, Orne (1980) suggests that effects of the context of the situation, both direct and indirect, must account for at least part of what would otherwise be taken to be the hypnotic effect. For instance, the meaning of the clinician’s attention is very different from that of the experimenter’s. As Diamond (1984) suggests, the relationship between the clinician and patient is a powerful determiner of the hypnotic effect (or any clinical effect). The relationship between an experimenter and a subject is significantly less personal (sometimes the hypnotic induction is even conveyed by a tape recorder) than the well-developed, intimate and more potent relationship of a concerned clinician and a suffering patient. Whatever the explanation for the disparity of reported hypnotic effect between experimental and clinical contexts, it is clear that clinical success with hypnotic suggestion requires innovative, personalized, clinically sophisticated procedures. It is difficult to compare such procedures with experimental procedures.

It is essential that clinical research be done if we are to understand the nature of hypnotic treatment and to be honest in the interventions we offer to patients. The questions we have before us are not particularly difficult ones and they do not require especially sophisticated research designs. If we do not support the thorough scientific exploration of hypnotic treatments, I think we risk eventual dismissal of this domain by reasonable people. The pitfalls I have described above can all be avoided by careful attention to detail and by our interest in placing our clinical interventions on the record. The very least we can do is to simply make careful records of the patients we see, of the interventions we make, and of the results we find. This information would be of substantial advantage to our understanding of hypnotic processes and to our effective utilization of them for the benefit of our patients.

The variation in responsiveness, even in the same individual on different occasions, has led me to a hypothesis that I call the locksmith metaphor.” This hypothesis assumes that most individuals are able to experience hypnotic phenomena, at least to some degree, given the appropriate circumstances, and that psychological defensiveness (both healthy and neurotic) largely accounts for lack of observed responsiveness on some occasions. Moreover, the hypothesis supposes that there may be ways around an individual’s defensiveness in any given circumstance. The key to “unlocking” the individual’s defenses depends on a high degree of sensitivity and flexibility on the part of the clinician.

We know that in clinical circumstances the sincerity of our compassion, as well as our willingness to utilize the patient’s language and style of communication in conveying our compassion, is important in the formation of a trusting alliance that supports the therapeutic work. So it is also in the context of hypnotic treatment. Our capacity for empathy, for intuiting what the patient needs in order to be open to an altered state of consciousness, is primary in discovering the appropriate hypnotic approach.

We may perceive that one patient needs a paternal, even authoritarian approach in order to feel properly supported, or that another patient needs a sense of equality with us. We need to sense what will enable the patient to relinquish “the cares of the day,” as Hilgard once described the phenomenon, and to become profoundly absorbed in responding to our suggestions. If we are sufficiently fortunate to accurately sense what the patient needs, and if we gracefully convey to the patient those qualities that will satisfy those needs, then we may enable the patient to respond to hypnotic suggestions that would otherwise be defended against. A more complete treatment of the locksmith metaphor is found in Barber (1991).

Though the issue of what best predicts hypnotic responsiveness is still far from resolved, I think there are very good reasons not to use responsivity tests to “screen” patients for potential hypnotic treatment. Even if hypnotic responsiveness is a good predictor of hypnotic response to suggestion, it does not predict clinical response to the therapeutic context in which the suggestions are given. Recall that in the Price and Barber experiment, subjects showing low responsivity were quite able to reduce suffering. The evidence suggests that such assessment does not measure actual capacity for response to optimal clinical treatment. Also, because of the potentially discouraging effects of such tests (for both clinician and patient),⁵ I would argue that such screening should be done only under very carefully considered circumstances. Finally, the decidedly unclinical stance required when administering most such tests is a further reason not to use them in the psychotherapeutic context. (The Hypnotic Induction Profile (H. Spiegel, 1974] is a notable exception in this regard.) In order to establish a reliable measure of hypnotic responsiveness, it is necessary to administer the test more than once. Commonly, the first score an individual obtains will be lower than that obtained on a second or third administration. This phenomenon, called “plateau hypnotizability,” may reflect the development of comfort with the hypnotist and with the altered state experience. For the clinician, this necessity for multiple administrations involves a substantial amount of time and effort simply to obtain an idea of the patient’s likely response to hypnotic suggestions.

If the patient obtains a low score, how does this guide the clinician in treatment? Even low responders sometimes benefit from hypnotic treatment, so denying such treatment on the basis of a low score is not justified. The argument that this benefit is from nonspecific aspects of treatment is relevant, but it is also relevant when the patient is highly responsive.⁶

It has been suggested, on the other hand, that a responsiveness score may be clinically useful because it indicates a particular approach to a clinician. For example, a low score may suggest that the clinician emphasize the reduction of suffering, as opposed to the reduction of intensity (Nash, 1995).

An exception to my disinclination toward measures of hypnotic responsivity in my own clinical practice is the use of Tellegen and Atkinson’s (1974) Tellegen Absorption Scale (TAS). The TAS is a brief and clinically unobtrusive means of obtaining an impression of a patient’s openness to the experiences of altered states of consciousness. While the TAS does not permit prediction of hypnotic responsiveness, it does provide a clinician with a sense of how readily a patient may respond to suggestions.

Effectively using hypnotic methods in the treatment of a pain condition requires individualizing the hypnotic treatment and integrating that treatment into the larger psychotherapeutic intervention. (This can be said of any clinical treatment, of course, but perhaps bears mentioning because of common misconceptions about the “standardized” use of hypnotic procedures.) This means that the first step is to assess the patient’s personal style, expectations, and attitudes toward hypnotic treatment, and to choose hypnotic induction procedures and suggestions for pain relief accordingly. In general, a patient’s pain can be reduced by hypnotic means. (Hypnotic suggestion is generally less effective in the treatment of psychogenic pain.) How hypnotic suggestion is used for such treatment, however, is a very complicated issue and requires assessment of the likely consequences of pain reduction for the patient.

In my clinical practice, I would use hypnotic methods to initiate pain reduction if the following criteria were met:

1. The patient will not be harmed by this treatment. Will the patient experience the use of hypnotic treatment as permission for risking harm in some way? Some relatively disturbed patients, for instance, might use the opportunity to ignore pain that signals bodily harm and might thereby injure themselves further. Such patients might also neglect to comply with necessary medication regimen. In extreme cases, such patients might behave in a “trance-like” manner in inappropriate circumstances (e.g., while crossing the street).

In general, if a patient tends to have more than the usual side effects from medication or has a history of developing unexpected complications from medical procedures, it is wise to defer the use of hypnotic treatment.

2. The patient will be able to accommodate the emotional intimacy often associated with hypnotic treatment. If the patient is not likely to feel comfortable with such intimacy, problems of trust may arise. It is important that the clinician will be able to help the patient if this particular difficulty should arise.

3. The patient’s condition will be improved. Aside from doing no harm, will we help? Is the patient likely to experience pain reduction without significant loss (of self-esteem, compensation, other secondary gains, stability of the family system, etc.)? If such pain reduction is likely to facilitate such loss, the use of hypnotic treatment ought to be deferred until treatment addresses the patient’s other needs.

4. The patient is willing to take responsibility for initiating his or her own treatment. Use of hypnotic methods for pain reduction requires significant effort on the part of the patient, often requiring frequent and repeated use of self-hypnosis, perhaps far into the future. Inability to initiate and maintain such effort renders the effective use of hypnotic treatment unlikely.

Our patients and our colleagues—and ourselves—have all been influenced by the popular cultural characterizations of hypnosis. We need to acknowledge the effect of such influence if we are to successfully evolve through it and if we are to adequately understand patients’ attitudes about hypnotic treatment. Patients are frequently wary, sometimes even quite afraid, of the prospect of hypnotic treatment. They fear the possibility of being made to do something embarrassing, as they have seen or heard about from others. Perhaps they fear behaving at odds with their usual sense of themselves. In the context of the ethical use of hypnotic methods this fear is groundless. But how is a patient to know this? As odd as it sounds, I have often been asked by a patient when we discussed the possibility of hypnotic treatment if he or she would need to act like a chicken. The pervasiveness of this image, apparently gained from years of stage hypnosis, is an important reminder of the potential disparity between a patient’s expectations and our own.

A more realistic fear of the patient, however, is that he or she will experience emotions that are ordinarily kept suppressed or repressed. In my experience this is particularly so when a patient is unfamiliar and uncomfortable with his or her own emotions and lives with the habit of suppressing or repressing them. When a patient expresses wariness about hypnotic treatment, we need to respectfully consider this perhaps unexpressed fear of emotional release.

There are many reasons why people feel a hesitation about being hypnotized including some of the following:

1. Concern about giving up control and responsibility for his or her experience or actions. Individuals who have a healthy interest in exerting control and direction over their own lives express concern that being hypnotized will render them out of control of their feelings and their behavior. When need for control is a preoccupying theme in the person’s life, the concern about being hypnotized becomes greatly enlarged.

2. Concern about submitting to authority. People sometimes express concern that being hypnotized will place them under the authority of another person.

3. Concern about the competence of the clinician. Who is this clinician? What training does she have? How responsible is he? Can I trust her to take adequate care of me when I am in this vulnerable condition? Does he know what he is doing?⁷

These concerns can usually be effectively managed by respectfully acknowledging them, openly discussing the issue from the patient’s point of view, providing useful information about hypnotic phenomena and how we use them in the clinical context, and remaining clear about the relative importance of hypnotic methods in this particular patient’s case. Though hypnotic interventions often greatly facilitate effective treatment, they are rarely indispensable. In the case of a patient whose concerns about hypnotic treatment cannot be readily managed, we should be prepared to consider other treatment methods.

Because the word “hypnosis” may have such frightening and unrealistic connotations and because it does not ordinarily convey an accurate idea of what the patient is likely to experience in the clinical context, it is generally helpful to discuss the treatment in more operational terms. This obviates the use of the word “hypnosis” altogether. There are accurate ways of describing the treatment without using the word “hypnosis.” The intention is not to deceive or obfuscate but, rather, to communicate clearly and to avoid a misunderstanding. Therefore, if the patient uses the word “hypnosis” or raises a question about “hypnosis” we need to be honest and clear, and we may need to use the word “hypnosis” and explain what we mean by it. If a patient has had prior experience with hypnotic treatment—especially if the experience was a pleasing or satisfying one—we can utilize this experience.

Here is an example of what we might say to introduce the topic of hypnotic treatment:

“You probably know that the relationship between mind and body is a powerful one. I can show you how to use the power of your imagination, for instance, to help you feel better.”

Or, “Mental imagery can be very helpful in retraining your nervous system so that the nerves that carry the useless information about your pain will do so less and less in the future.”

Or, “Your ability to become deeply absorbed by your imagination can be really helpful now. May I ask you to close your eyes right now, take a very deep breath, and begin to notice how really relaxed your mind can become?”

In each example, the guiding principle is: Convey to the patient that there is a means—a technique, a mental capacity, a clinical tool, etc.—which can naturally be used for his or her benefit. By communicating in this way we may diminish the unrealistic concerns about the patient’s losing control over his or her mind. We should be mindful, though, that merely asking a patient to close his or her eyes—and, implicitly, to be “open” to one’s imagination—can provoke anxiety (Reyher & Smeltzer, 1968). Also, using this approach requires that the hypnotic techniques we use are consistent with the language we have used to introduce them.

… a medicament is not really potent unless it is able to be dangerous on occasions; and it is very difficult to think of any method of treatment which would be efficacious although it could never by any possibility do harm. (Pierre Janet, 1860, in Nahum, 1965, p. 221)

Any clinical technique that has the capacity to help must also have the capacity to harm. Among clinicians who use hypnotic methods, there is a lot of claptrap to the effect that these methods can only help and can do no harm. There is no evidence to support this naive claim. On the contrary, there is evidence that hypnotic interventions can be harmful to patients, depending upon their use. In Chapter 6, Karen Syrjala and Sari Roth-Roemer describe a case in which misguided use of hypnotic interventions led to sad consequences. I have explored this issue at some length elsewhere (Barber, 1996), and there is no need to do so here, except to make these brief remarks.

While the experience of being hypnotized per se is probably harmless, how that experience is used determines its beneficial or harmful effects. In principle, the hypnotic methods can be harmful when:

1. The clinician’s motives are not in the patient’s best interest. The clinician may or may not be aware of this.

2. The clinician does not have an adequate understanding of the patient’s needs and proceeds with treatment anyway.

3. The patient’s capacity for coping with deep absorption in fantasy, or with intense contact with the clinician, is insufficient.

The best insurance against harmful hypnotic treatment is appropriate clinical training. This training includes not only technical skill in making hypnotic interventions, but also thorough knowledge of psychological phenomena, including psychopathology, that the clinician may encounter. Equally important, however, this training should include experiences of personal growth, such that the clinician’s own unresolved psychological issues have become known to him or her; moreover, the clinician should be open to future opportunities for such personal development.

Hypnotic treatment begins with the “hypnotic induction.” This is a process that involves the communication of suggestions not for clinical treatment per se but for the change in state of consciousness, leading from ordinary wakefulness to the hypnotic state that supports the acceptance of clinical suggestions. A hypnotic induction provides both information and time (to respond to the information) to the patient about how to begin the alteration in experience. (The induction also provides time for the clinician, since he or she also begins to shift to a quieter, calmer demeanor.) Time is necessary for the neurophysiological and psychological changes that both create and are created by the hypnotic experience.

To illustrate this point, I think it is useful to see the parallel in the process of going to sleep (at the risk of creating the mistaken impression that the hypnotic condition is like physiological sleep). We know that the length of time it takes an individual to fall asleep is highly idiosyncratic—some people characteristically fall asleep very quickly and easily, while others do so much more slowly, perhaps with interruptions in the process. Even in an individual who characteristically falls asleep quickly circumstances can impede the process: for example, if he is not really sleepy, if he does not feel sufficiently secure, or if the environmental events (e.g., loud noises) interrupt. In the context of developing a hypnotic state, many variables interact to facilitate or impede the process, such as the individual’s motivation or sense of need, the degree to which the individual feels safe, and environmental factors. It is only by observing the patient’s responses to suggestion, and by talking with the patient about his or her experience, that we can determine how effective the induction is and how much longer we need to continue it.

Simply stated, the induction of a hypnotic experience involves the following steps, and they occur approximately in this order:

1. Eliciting the patient’s attention, interest, and cooperation. This may be accomplished by saying something like, “Now we will begin to use your capacity for imagination.” At this stage there is also an implicit agreement on the patient’s part to respond to the clinician’s suggestions—at least to some extent.

2. Reducing the patient’s range of attention. This may be accomplished by suggesting, for example, “You can pay attention to the sound of my voice, and you can notice that nothing else really matters right now, as I continue to speak to you.”

3. Suggesting an increasingly narrow focus of attention, and directing that attention inward. For example, you may suggest, “Feel each breath, as you inhale, and as you exhale notice the feeling of deep relaxation. Feel each breath, feel the relaxation, and notice that nothing else matters right now.”

4. Suggesting dissociation. In my view, this is the crucial step. It distinguishes the experience from normal wakefulness and supports the unusual and dramatic capacities associated with hypnotic processes. It is somewhat misleading to separate this stage from the others, insofar as this phenomenon tends to occur naturally as a function of the other stages. I emphasize this aspect of the experience, though, because of its clinical importance. I would even go so far as to suggest that much of what people interpret as the lack of efficacy of hypnotic intervention is a result of the failure to actually develop the dissociative processes inherent in the hypnotic experience. I believe that it is not reasonable to expect hypnotic effects in the absence of dissociative processes.

You might facilitate dissociation by saying, “You can hear the sound of my voice without really listening to my words.” Or, “You are aware of my voice, and yet you can allow yourself to feel more and more absorbed in [whatever experience has already been suggested—relaxing in a pleasant place, for example] and less and less aware of anything else.”

1. Offering therapeutic suggestions. Once the patient has begun to experience the fullness of dissociation, suggestions can be offered for whatever therapeutic change is desired. If the goal is analgesia, for example: “You notice more and more comfort with each passing moment. The sensations that were bothering you seem to be farther and farther away.” Posthypnotic suggestions may also be offered at this stage: “Whenever you take a deep breath [or whatever cue you determine to be appropriate], you might notice how curiously comfortable you feel, with nothing to bother you, and nothing to disturb you.”

2. Providing suggestions to end the experience. Normally, you will offer suggestions for feeling well, for being alert, and so on: “As your eyes open, you notice how alert and how energized you are, almost as if you’ve just awakened from a very refreshing nap.”

How much time should a hypnotic induction take? My glib answer would parallel that of the professor in answer to the student’s query about how long the essay needs to be: as long as is necessary, and no longer. But let us explore this issue further.

I do not know if anyone has measured the difference in induction length between experimental and clinical settings, but my experience leads me to believe that clinical inductions tend to be both longer and shorter—depending on the patient’s needs. Does an induction need to be of a particular length? What is the function of an induction? Is it only to communicate, to convey suggestions?

You will notice that the examples of hypnotic inductions offered in this book tend to be longer than inductions you will find in many textbooks on hypnosis. The extended length of these inductions, by psychologists and physicians alike, reflects our belief that, aside from being sufficiently long to contain the desired suggestions, the induction needs also to contain sufficient time to allow the alteration in consciousness that distinguishes the hypnotic experience from other experiences.

Since the amount of time needed for such alteration varies among individuals and within the same individual in different contexts, we need to observe the alteration as carefully as possible. Other things being equal, for instance, the most evident disadvantage of using a tape recording to convey the induction is that the recorded suggestions cannot take into account the patient’s responsiveness. The tape-recorded suggestions continue independently of when or how the patient responds.

Because Samuel LeBaron and Lonnie Zeltzer discuss the induction of the hypnotic experience in children, I will not take this space for such a discussion. It is worth mentioning, however, in this exploration of hypnotic inductions, that children often respond very rapidly to both hypnotic and nonhypnotic suggestion—usually requiring very little or no actual induction.

When you intend to hypnotize a patient, watch carefully to observe whether or not the patient responds to each suggestion. Since most responses are relatively invisible, taking place only within the patient’s imagination, it is helpful to include suggestions for which the response can be observed. For example, the initial suggestions made to a patient about how to sit comfortably provide an important opportunity to observe the patient’s responsiveness. While this responsiveness is not hypnotic, it provides information about how initially responsive the patient is to your suggestions.

Next, we can suggest that the patient close his or her eyes. I tend to do this very simply and directly, since if there is to be initial resistance it might well be about closing the eyes. Rather than taking time to create a compelling experience of eye closure, I simply ask the patient to close his or her eyes. If the patient responds, I continue. However, if, as sometimes happens, the patient remains staring, wide-eyed, I comment on this fact. I might say, “I asked you to close your eyes, but I notice that you haven’t. Is it OK if you close your eyes now?” The patient’s response to this query might be very informative. For example, he or she might say, “No, I feel worried about closing my eyes.” This provides an opportunity for us to discuss discomfort about the process in general (since eye closure is probably the focus but not the actual cause of the discomfort). This resulting conversation may be more important than any hypnotic effect I was hoping to obtain. It may be an important opportunity to discuss the patient’s fears about the hypnotic experience, or about losing control, or about trusting me—or a variety of other concerns.

In addition to evaluating a patient’s ongoing responses to my suggestions, I often find it helpful to elicit hypnotic phenomena that may have no direct clinical benefit but serve as opportunities to evaluate responsiveness. Then I observe the response and perhaps inquire about the experience. For example, catalepsy is a hypnotic phenomenon which can usually be easily elicited and incorporated within the therapeutic relationship (so that the experience does not seem odd or inappropriate). It can be monitored for the purpose of understanding the extent to which the patient is experiencing hypnotic processes—in contrast to merely complying with the therapist’s request.

We talk with the patient during the hypnotic induction to better understand his or her experience. Because most patients will probably not have had previous experience in talking while hypnotized, it may be helpful to provide suggestions to simultaneously inform and guide the patient through the process:

“While you continue to remain comfortable and relaxed, and to remain deeply absorbed in [whatever experience has been occurring], I also want you to allow the muscles of your voice—the muscles of your breathing, of your larynx, of your jaw, of your tongue, and of your lips—to become independent and active, so that you can talk to me, even while you remain deeply absorbed.”

You can now ask the patient what he or she is experiencing and determine the fullness and degree of reality of the experience—in short, the extent to which the experience is hypnotic. For example, if you have suggested arm catalepsy and the patient’s arm seems cataleptic (the classic “waxy flexibility”—when you attempt to move the patient’s arm, it feels as though it is waxen and able to be easily moved—as opposed to being voluntarily held in the air), you can ask the patient, “What do you notice about your arm?” If the patient’s remarks suggest that he or she is primarily aware of holding the arm voluntarily, so as to comply with your suggestions, this is probably not a hypnotic phenomenon. If, however, the patient’s remarks suggest that he or she is primarily aware of the lightness of the arm, of the lack of awareness of the arm, of the involuntariness of the experience, this is probably a hypnotic phenomenon. Or suppose you have suggested that the patient imagine being in a particular place—a sun—filled meadow, for instance. You can ask the patient, “What are you aware of?” If the patient talks about the meadow and indicates that this experience feels “real” as opposed to imagined, this suggests the experience is a hypnotic one.

Of course, these determinations are not only subjective with respect to the patient, but also, unfortunately, subject to our own needs and expectations. It is helpful if we can remain open to the possibility that the patient will not respond (despite our best efforts) and that this eventuality is interesting in itself. If we so deeply need a patient to respond to our hypnotic methods, our judgment about the reality of the experience to the patient may become impaired. If this is the case, we are probably less helpful and more frustrated (and perhaps frustrating to the patient).

This induction should be read as an example, not as a template. It reflects my own personal style, which may not be the most effective one for you. This is a somewhat abbreviated induction: many repetitions have been omitted.

1. Eliciting the patient’s attention, interest, and cooperation.

Now you might feel ready to begin to use some of the talents we’ve been discussing, in order to retrain your nervous system. Why not just rest back in your chair, and allow your body to be as comfortable as you know how. That’s right.…

2. Reducing the patient’s range of attention.

Close your eyes, and take a very deep, relaxing breath, and … hold it … hold it … and now, let it all the way out, as you sink deeper and deeper into the chair.

3. Suggesting an increasingly narrow focus of attention, and directing that attention inward.

As you continue to allow yourself to breathe comfortably and restfully, as you notice the pleasant heaviness that can become more and more a part of your awareness … as you notice these things, I will be talking to you, and you can notice how easily you hear the sound of my voice, without having to listen. And you can understand what I say to you without any particular effort.

And all the while, the sounds around you … all the sounds you can hear … can become more and more a part … of your experience of comfort and well-being … with nothing to bother you … and nothing to disturb you.⁸ Just notice your breathing, pay attention to your breathing, and notice how easily you can discover that nothing else matters … nothing at all … just your comfort.

4. Suggesting dissociation.

As you allow yourself to become more and more absorbed by the comfort of your breathing, you can also notice that it is more and more interesting to continue … to continue to feel each breath … as you breathe in, and as you breathe out. It’s almost as if your breathing, and your awareness of your breathing, is all that matters. As if there really is nothing else at all … just your breathing, and your comfort.

You might also have begun to notice the interesting tingling sensations in the tips of your fingers. A pleasant, glowing sensation … and this interesting sensation can radiate up your fingertips, and into your hands … almost all of the way up into your wrists. A tingling sensation that seems to remind you of how deeply absorbed you can be … how deeply comfortable you can be.

You might notice a similar tingling sensation around your mouth and lips … and perhaps, too, in your lower back. You might even notice this pleasant tingling sensation in the soles of your feet. You might begin to feel almost as if you are glowing with energy. Glowing, tingling, breathing, all in a comforting rhythm. Allowing the sound of my voice to continue to be a part of your comfort.

Assuming the patient is now absorbed in a hypnotic experience, the following steps can occur:

5. Offering therapeutic suggestions:⁹

As you continue to feel more and more absorbed by the sensations of your breathing, I’m going to talk to that part of you that controls the sensations in your nerves. You can listen to me, or you can just float so comfortably, knowing that your nervous system is hearing everything that I’m saying to you.

It is so curious, and so very interesting … that you have the capacity to increase or decrease the sensations throughout your body. And I imagine you will feel very interested in the way that you decrease the sensations in just that one part of your face. You won’t really know how you do it … at least, at first. You can be curious, you can be surprised … and you can simply notice that, whenever those electrical feelings begin to shoot down your face … for some reason, they will just stop. Almost like a sneeze that never quite happens.

The first few times, you’ll have the sense that a pain is coming, but, somehow … you won’t know how, at first … somehow, the sensation just seems to stop, almost before it can quite get started. Almost as if your nervous system is beginning, already, to retrain those nerves to no longer send those awful, painful messages across your face.

And, sometime later today … I don’t really know when that will be … maybe ten minutes before five this afternoon … or maybe it will more likely be ten minutes after five this afternoon … but I really don’t know when it will be … that you will suddenly notice … how really well you are feeling … but then, again, I don’t really know. It may not be so much the time on the clock that’s important here. It may be that what you are doing at that time is what is important.

Maybe you will be lifting a cup to your lips. Or, I don’t know … maybe you’ll be turning the pages of a book … I really can’t know what you’ll be doing, when you will suddenly … turn your head very slightly, almost as if you’re trying to catch sight of something just out of your awareness … and, at the same time, notice how much better you’re feeling than you ordinarily expect you will feel.

And you won’t know how … you won’t know why, really. You’ll just know how you feel. Better … just better.

And tomorrow morning, after you awaken, you can feel really surprised at how well you’ve slept, and how really rested you feel … with nothing to bother you, and nothing to disturb you.

6. Providing suggestions to end the experience.

So, in a moment, when I ask you to, you can notice how really easily you find yourself breathing just a bit differently. As if each breath begins to feel more and more refreshing, more and more energizing. And, then, as your eyes open, you’ll notice how really clear and awake you feel … and, maybe, how ready you are to feel surprised.

That’s right, really deep breaths … more and more refreshed. Notice, now, as your eyes open, how alert … how refreshed you are. Almost as if you’ve just had a very restful nap.