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Hypnosis in Psychiatry

This lecture is an unusually clear and succinct presentation of the senior author's approach to hypnotic induction and hypnotherapy. Given at the height of his teaching career, it represents an important shift away from the authoritarian methods of the past to his pioneering work with the more permissive and insightful approaches characteristic of our current era. In the actual words of this presentation we can witness how important concepts are in transition. While Erickson still uses the words technique and control a number of times—and even manipulate and seduce appear once each—it is evident from the broader context that they are outmoded in the traditional authoritarian sense in which they had been used.

A paradigmatic shift is taking place in this presentation: It is now recognized that the most significant person in the hypnotherapeutic interaction is the patient, not the therapist. The patient's potentials and proclivities account for most of the variance (what actually happens) in hypnotherapy, not the purported "powers" of the hypnotist. The therapist does not command the patient; rather, as the senior author says, "It is always a matter of offering them [patients] the opportunity of responding to an idea." It is now recognized that the hypnotherapist offers the patient many approaches to hypnotic experience rather than imposing hypnotic techniques. The concept of technique implies the mechanical and repetitious application of a particular procedure in the same way to every patient with the intent of producing a preconceived and predictable response. The concept of approaches implies the profferance of alternatives to help each patient bypass his or her own particular learned limitations so that the various hypnotic phenomena and hypnotherapeutic responses may be experienced.

Therapists do not "control" the patients; rather, they help the patients learn to "utilize" their own potentials and repertory of unconscious skills in new ways to facilitate the desired therapeutic outcome. This new orientation requires the development of many observational and performance skills by hypnotherapists. More than ever it is required that they learn to recognize and appreciate each patient as a unique individual. Every hypnotherapeutic interaction is essentially a creative endeavor; certain known principles are being applied, but the infinite possibilities within each patient require an essentially exploratory approach to achieve the therapeutic goals.

This lecture is highly characteristic of the senior author's style of presenting his approach to hypnotic induction and hypnotherapy. Listening to it on the cassette accompanying this volume in a relaxed mood may have important values for the reader that are not contained in the edited version presented in this volume. Before reading any further, then, the reader may best listen to the cassette labeled "Hypnosis in Psychiatry: The Ocean Monarch Lecture." Those readers who are familiar with our two previous books in this series will know why we recommend listening to the cassette first. Other readers will understand the reasons after reading the discussion of this tape that follows its edited version on these pages. Please listen now to the lecture.

The Conscious and the Unconscious Mind

I do not necessarily intend to demonstrate hypnosis to you today so much as to discuss its use in psychiatry. However, the use of hypnosis in psychiatry actually applies to the use of hypnosis in any other medical field, whether dental, dermatology, or whatever it might be. The first idea I want to impress upon you is one way of thinking about your patients clinically. It is desirable to use this framework because of the ease of concept formation for the patient. I like to regard my patients as having a conscious mind and an unconscious, or subconscious, mind. I expect the two of them to be together in the same person, and I expect both of them to be in the office with me. When I am talking to a person at the conscious level, I expect him to be listening to me at an unconscious level, as well as consciously. And therefore I am not very greatly concerned about the depth of the trance the patient is in because I find that one can do extensive and deep psychotherapy in the light trance as well as in the deeper medium trance. One merely needs to know how to talk to a patient in order to secure therapeutic results.

Learning One's Own Method of Suggestion Following the Patient's Lead

Now the next thing I want to stress is the tremendous need for each doctor to work out a method of suggestion for himself. In developing my own technique, I worked out what I felt was a good hypnotic technique. It was about 30 typewritten pages, single-spaced, of the various types of suggestions necessary to induce a deep trance. And then I slowly cut it down from 30 typewritten pages single-spaced to 25, to 20, to 15, to 10, to 5, and so on, so that I could use the whole 30 pages or I could use just one page or one paragraph. But I learned thoroughly how to graduate my suggestions, and how to lead from one suggestion to another. When one does that sort of thing, one learns how to follow the leads given by his patient.

Trance Induction: Catalepsy to Heighten Responsiveness

In inducing a trance in your psychiatric patient or, for that matter, any patient, it is the fashion in which you present the suggestion to the patient that is important. For example, some of you have seen me demonstrate the proper way to take hold of a patient's wrist. Too often, a doctor will grab hold of a wrist and lift it up forcibly. But when I lift someone's hand, I purposely do so in a very, very gentle fashion so that there is just a suggestion that I am lifting the arm, and just a suggestion that I am trying to move it this way or that way. And the more gentle you can be in the physical touch of the arm, when you are lifting it up in the air to induce catalepsy, the more effective it is. Any forcible seizure of the patient's arm causes difficulty because you want to stimulate the patient to be responsive to you. Hypnosis is primarily a state in which there is increased responsiveness to ideas of all sorts. And one employs that responsiveness not by trying to force, but by trying to elicit an immediate response—and to elicit it by having the patient participate.

In exactly the same way, I do not like this matter of telling a patient, "I want you to get tired and sleepy, and to get tired and sleepier." That is an effort to force your wishes upon the patient. That is an effort to dominate the patient. It is much better to suggest that they can get tired, that they can get sleepy, that they can go into a trance. For it is always a matter of offering them the opportunity of responding to an idea.

Patient's Freedom to Respond: Positive and Negative Suggestions

I have found that patients often have the notion that hypnosis is a powerful tool that can compel them to act according to my wishes. I like to approach my psychiatric patients— whether they are neurotic, emotionally disturbed, prepsychotic, or even psychotic—in a fashion that lets them feel free to respond to whatever degree they wish. I never tell a patient that he has to go into a deep trance, or into a medium trance, or for that matter into a light trance. I suggest also that he never tell me anything more than he really wants to tell me. I usually tell my patient that he can withhold whatever he wishes, and to be sure to withhold whatever he wishes. I am emphasizing this point because I want you to have some understanding of positive and negative suggestions. To tell a patient, "Now, tell me all," is a rather threatening, even dangerous request to make. Rather, you want the patient to be willing to tell you this, willing to tell you that, so that as they begin telling you this and that, they also begin to develop a certain sense of confidence.

Rapport: Utilizing Ambivalence and Naturalistic Modes of Functioning

Now and again you will meet a patient with whom you have an immediate rapport, and then you can take the dominant attitude. But one really ought to be cautious. In using positive and negative suggestions, one tries to make it possible for the patient to exercise his own ambivalence for your benefit and for his benefit. He is both willing and unwilling to secure help from you, so you try to define the situation for him in such a way that he can get help in one direction and refuse help in another situation. In that way the patient develops a readiness to go along with you.

Now in hypnotizing the psychiatric patient I think one of the important things to do first is to establish a good conscious rapport. Let him know that you are definitely interested in him and his problems, and definitely interested in using hypnosis if in your judgment you think it will help. So often I have had patients come in and demand that they be hypnotized, to which I usually counter with the statement that it is better for the doctor to prescribe than for the patient to prescribe. And surely if they can benefit from hypnosis, I will employ it. But then I will ask their permission to employ it in the way that is most helpful to them.

And what have I really suggested? I have suggested that it be employed in a way most helpful to them. Usually I go through the preliminary explanation that they are going to remain conscious. But I point out to them that the fact that they can hear the clock on the wall, that they can see the bookcases in the room, that they can hear any disturbing sounds, is rather unimportant. The essential point is that they pay attention, not necessarily to me, but to their own thoughts—especially the thoughts that flash through their mind, including the manner and the sequence in which those thoughts flash through their mined. [Hypnotic suggestion always utilizes such naturalistic modes of functioning; it never imposes anything alien on the patient.]

Now, hypnosis is something that allows you to manipulate [sic—we now prefer utilize!] the personality in its various ways of functioning. One can ask a patient in the trance state to remember something of the past, or to speculate upon the future, or to shift from one gear to another gear. Too often there is an attempt to follow through in a consistent way on one particular problem, long after the patient has become too fatigued or too disturbed emotionally to do that. You must realize that hypnosis allows you to come back to a particular idea, or fear, or anxiety so that it is never necessary to ask a patient to experience too much distress or emotional discomfort at any one time.

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