Hypnosis

Anton Mesmer and Mesmerism

Healers of varied traditions have used suggestive therapies throughout history. The origin of medical hypnosis is generally attributed to Anton Mesmer, a Jesuit-trained eighteenth-century physician, who believed that health was determined by a proper balance of a universally present, invisible magnetic fluid. Mesmer's early method involved application of magnets. He was an important medical figure at the Austrian court, but he fell into discredit when a scandal occurred around his care of Maria Paradise, a young harpsichordist whose blindness appears to have been a form of conversion disorder.

Mesmer re-established his practice in Paris and employed a device reminiscent of the Leyden jar, a source of significant popular interest in the Age of Enlightenment. His patients sat around a water-containing iron trough–like apparatus (a bacquet ) with a protruding iron rod. He was a colorful figure who accompanied his invocation for restored health with the passage of a wand; there was no physical contact with his patients. Susceptible individuals convulsed and were pronounced cured. An enthusiastic public greeted Mesmer's practice and theory of “animal magnetism.” However, medical colleagues were less impressed. The French Academy of Science established a committee, led by Benjamin Franklin, the American ambassador to France, who was an expert in electricity. The committee found no validation for Mesmer's magnetic theories, but determined that the effects were due to the subjects' “imagination.”

The work of one of Mesmer's disciples, the Marquis De Puyseguer, brought a new approach to the practice of Mesmerism. The method involved induction of a somnambulistic state associated with post-trance amnesia.

James Esdaile, a nineteenth-century Scottish physician, was the first to take advantage of this somnambulistic state induced by Mesmerism to relieve surgical pain. Esdaile served as a military officer in the British East India Company, and took care of primarily Indian patients in and around Calcutta between 1845 and 1851. Over this period, Esdaile performed more than 3,000 operations (including hundreds of major surgeries) using only Mesmerism as an anesthetic, with only a fraction of the complications and deaths that were commonplace at the time. Many of these operations were to remove scrotal tumors (scrotal hydroceles), which were endemic in India at the time, and which in extreme cases swelled to a weight greater than the rest of the individual's body. Before Esdaile's use of Mesmeric anesthesia, surgery to remove these tumors usually resulted in death, due to shock from massive blood loss during the operation.

Although Esdaile's technique was clearly effective in many cases, it was controversial enough that, as in Mesmer's case a century earlier, a committee was appointed and sent to India to observe Mesmeric anesthesia first hand and to evaluate its efficacy. Esdaile performed six operations for scrotal hydroceles for the committee (which consisted of the Inspector General of hospitals, three physicians, and three judges). He carefully selected nine potential patients by attempting to induce a “Mesmeric trance” using the customary technique of passing his hands over their bodies for a period of 6 to 8 hours; as a result, three of the patients were dismissed when it was found that they could not be mesmerized even after repeated attempts over 11 days. Another three calmly faced the surgery, but when the first incision was made signaled severe pain by “twitching and writhing of their body, by facial expressions of severe pain, and by labored breathing and sighs.” The remaining three patients demonstrated to the committee “no observable bodily signs of pain throughout the operation.” Nevertheless, the committee dismissed Esdaile's technique as a fraud and stripped him of his medical license.

Early Applications of Hypnosis in Medical Practice

Early in the nineteenth century some surgeons advocated the use of this new procedure for pain reduction in the operating theatre. James Braid, a British surgeon, called it “hypnosis” after the Greek root for sleep. Some questioned its apparent utility, and thought it was “humbug.”

The prominent French neurologist Jean Martin Charcot studied hypnosis at the Salpêtrieère in Paris, where he worked with a large population of women who suffered from hysteria. Charcot linked hypnosis with hysteria and considered it an expression of neuropathology. Janet's concept of dissociation followed.

A prominent internist, Hippolyte Bernheim, studied hypnosis at a French school at Nancy. He worked with a country doctor known as “Pere Liebeault” for his pro bono work with patients who agreed to undergo hypnosis for therapeutic purposes. The Nancy School found hypnosis to be a normal phenomenon that operated through suggestion.

Hypnosis in Psychiatric Practice

Sigmund Freud studied with Charcot, and also at Nancy. He was a skilled hypnotist, but he came to believe that it had an unwanted impact on transference and it was therefore incompatible with his psychoanalytic method. Instead, Freud substituted his method of free association.

Eriksonian hypnosis, named for its founder, Milton Erikson, is a counterpoint to Freud's earlier position. Erikson advocated strategic interactions with his patients that employed use of metaphor and indirect methods of behavior shaping. While hypnotizability is generally considered to be an individual trait, Erikson believed that the efficacy of hypnotherapy depended on the skill of the therapist.

Theoretical Perspectives on the Hypnotic State

Theorists have debated the view of hypnosis as an altered state of consciousness. Alternatively, researchers have focused on social factors and on role-playing capacity as an explanation of the phenomena associated with hypnosis.

Martin Orne's work at the University of Pennsylvania identified the demand characteristics (based on a hierarchical relationship) of interaction between the hypnotist and the subject. He used sham hypnosis as an effective research tool. Orne also addressed the memory distortion that can occur with hypnosis and exposed its lack of validity for courtroom procedures, and he defined “trance logic” as a willing suspension of belief that highly hypnotizable subjects readily experience.

Ernest Hilgard and associates postulated the “neodissociation” theory of hypnosis. Hilgard saw hypnotic process as an alteration of “control and monitoring systems” as opposed to a formal alteration of conscious state. He differentiated between the unavailability of a truly unconscious process and the “split off”, but subsequently retrievable material involved in dissociation.

David Spiegel has pointed to absorption, dissociation, and automaticity as core components of the hypnotic experience. Absorption has been found to be the only personality trait related to an individual's ability to experience hypnosis. Box 15-1 contains several items from the Tellegen Absorption Scale to illustrate the characteristics of this trait.

Effects on Physiological Function

Hypnotic suggestion has been found to produce changes in skin temperature in some subjects. Immunological change has been evident in some studies of hypnosis and allergy and in the successful treatment of warts. Changes in evoked sensory potential have also been observed with hypnotic subjects. In addition, a few studies have found improved wound healing with hypnosis. However, these phenomena are not necessarily specific to the hypnotic process.

Measurement of Hypnotic Susceptibility

Reliable measurement of hypnotic susceptibility is available with several scales (including the Stanford Scales and Harvard Group Scales of Hypnotizability). These scales begin with the induction of hypnosis by reading the subject a script similar to that contained in Figure 15-1 .

Next, subjects are administered a series of test suggestions, graded from easy to difficult, similar to those shown in Figure 15-2 , and their objective and subjective responses are scored as present or absent. Finally, a total score is computed and compared with published norms for each scale. Across scales, approximately 10%–15% of subjects fall into the “high hypnotizability” range, another 15%–20% fall in the “low hypnotizability” range, and the remainder fall in an intermediate range.

Moderate levels of hypnotizability are important for clinical efficacy, although the level of hypnotic responsiveness does not ensure therapeutic success.

The Tellegen Absorption Scale correlates with hypnotic responsiveness. Absorption refers to a process of concentration and a narrowing of attention. Clinical observations of absorption (e.g., in competitive sports and other forms of performance) may be a clue to a patient's hypnotizability.

Frankel and Orne found that hypnotizability was generally greater among patients with monosymptomatic phobias. Patients with post-traumatic stress disorder (PTSD) and dissociative states generally have higher levels of hypnotizability. Patients with trauma early in life are typically good hypnotic responders.

Measurement of Hypnotic Depth

Measurement of hypnotic depth is a subjective process that does not correlate with clinical utility.