|HYPNOSIS IN THE TREATMENT OF ANXIETY
Hypnotherapy and training in self-hypnosis can help persons achieve remarkable success in alleviating anxiety, not only in anxiety disorders, but also in any problem involving anxiety. The author describes the role of hypnosis in the treatment of several disorders and provides clinical examples illustrating treatment of generalized anxiety, phobias, and posttraumatic stress disorders. He concludes that because hypnosis exploits the intimate connection between mind and body, it provides relief through improved self-regulation and also beneficially affects cognition and the experience of self-mastery. (Bulletin of the Menninger Clinic, 54, 209-216)
The public's association of hypnosis with the supernatural, with malignant control over others, and with "brainwashing,' as well as extravagant claims of dramatic cure, have inhibited many health care professionals in their acquisition and use of hypnotic skills. Some hypnotic phenomena, such as bodily anesthesia sufficient for major surgery--even amputation--are indeed dramatic, but are neither magical nor sinister. For the most part, the mechanisms of hypnotic influence are well understood and can be applied to a range of both physical and psychological human problems.
The historical precursor to hypnotic treatment was "magnetizing" The healer believed that magnetic forces within the body could be realigned by such procedures as bodily manipulations, "passes" around the body, and washing with or drinking magnetized water. Magnetic forces flowing from the healer to the patient could accomplish the desired cure. Early hypnotists similarly behaved as if they had powers that could be transmitted to others, and as if their commands produced change in submissive subjects (Edmonston, 1986).
Hypnosis in the 20th century bears little resemblance to the Svengali-like practices of earlier times. The power for healing, like the capacity for hypnotic experience, is now recognized to lie in the patient rather than the hypnotist, and cooperation by an informed subject is more the norm than submission by an intimidated one. Modern hypnosis aims to enhance patients' self-control, not to replace their will with that of the hypnotist. Accordingly, an integral part of hypnotic treatment involves training in self-hypnosis, so that the patient can carry on the treatment work in the absence of the hypnotist.
Despite the origins of its name--hypnos (to sleep)--and the drowsy appearance of many hypnotized people, hypnosis is not a state of sleep, but rather one of sharply focused attention. "Selective wakefulness" is one characterization of hypnosis, reflecting how in trance the subject can be oblivious to some elements of experience while carefully attuned to others. This dissociative process involves a decrease in what has been described as the "generalized reality-orientation" (Shor, 1959), a heightened awareness of internal states (both mental and physical), and a weakening of the boundaries between what is conscious and what is unconscious.
An increase in suggestibility accompanies the regressive aspect of the hypnotist-subject relationship, suggestibility in this context referring to the tendency to accept or respond to suggestions uncritically. For most subjects, relaxation is subjectively the most striking aspect of the hypnotic experience. Repetitive suggestions of relaxation and various strategies for promoting it are prominent in most induction procedures. However, a talented subject can go into hypnosis while standing up or even walking. A few patients actually require inductions that do not involve relaxation, because they find relaxation unpleasant, perhaps threatening a loss of control of some sort. The key role of relaxation for most subjects has led some theorists and investigators to conclude that most, if not all, hypnotic phenomena are directly attributable to the effects of relaxation (Edmonston, 1977).
Achieving relaxation and promoting the accompanying feelings of safety and well-being are the primary goals of treatment for patients suffering from all kinds of anxiety disorders. Because most people can experience hypnotic states to some degree, hypnosis can be a valuable tool for clinicians as an alternative to pharmacological interventions (Spiegel & Spiegel, 1988). Many patients oppose taking medications, many do not tolerate side effects well, and others should not be treated with medication because of psychological or physiological contraindications. On the positive side, learning self-regulation skills enhances self-esteem, promotes a sense of autonomy, and enables patients to be active agents in their own recovery.
Patients with mild anxiety often benefit from direct suggestions that they transfer the relaxation achieved in the hypnotic session into their waking lives. If not, they may be taught the "clenched fist" technique: Whenever they experience anxiety, they activate the therapist's suggestion to allow their tension to flow into a tightly clenched hand and then to empty it out as the hand is relaxed (Stanton, 1988). Patients with more severe anxiety may need brief daily periods of self-hypnosis in which they use calming imagery, such as a pleasant memory, a warm Jacuzzi bath, or waves rolling up on a lovely beach.
Simple phobias, such as fear of animals, driving, injections, closed spaces, and insects, can be treated with techniques borrowed from behavioral psychology called extinction or desensitization (Kluft, 1986). Before having a patient gradually approach a feared object or situation, the therapist rehearses such an approach through imagery with the hypnotized patient. The hypnotic state produces a vividness of imagery and a depth of relaxation that promote a more rapid reduction of fear. After having comfortably confronted the feared object or situation in imagery, the patient actually approaches it, perhaps with self-hypnotic relaxation before and during the encounter.
Ms. A, 37 years old, felt unaccountably anxious when riding her horse. She denied being concerned about falling, because she had done so several times and had accepted the risk and discomfort of occasional falls. She was not interested in exploring the possible dynamic underpinnings of her fear, insisting instead on purely symptomatic treatment. After a trance induction, she was instructed to imagine herself walking into the barn, saddling the horse, and swinging up onto its back while feeling deeply relaxed and eager to ride. Two sessions were conducted in the office, with the patient carrying out the same procedures at home for several days. She then proceeded in reality just as she had rehearsed in hypnosis, feeling as calm and content as she had felt in trance. Her success was confirmed through 3- and 6-month follow-up telephone calls in which she reported no recurrence of the fear and no "symptom substitution" Such circumscribed fears can apparently be given up without significant difficulty if they do not play major stabilizing or homeostatic roles in the individual's personality or ego structure.
Aerophobia is sometimes a relatively uncomplicated symptom like the simple phobias, and may respond to education about airline safety records and to direct suggestion and desensitization in trance. More complicated instances involve dynamically powerful issues such as loss of control, separation, and passivity. Such meanings can be uncovered in hypnosis using a variety of exploratory techniques (e.g., age regression, fantasy, affect bridge) and, once understood, can guide treatment strategies. The following case example did not involve exploration in hypnosis, but illustrates how hypnotic techniques can be tailored to fit individual needs.
Ms. B, a 33-year-old professional woman, became fearful at the prospect of flying home from a vacation. She had not previously experienced such a fear, but it persisted for 4 years through many flights. Careful interviewing revealed several issues of dynamic importance. Her mother had suffered from a lifelong fear of flying, and the patient had been feeling a need to be especially supportive of her because of recent illness and death in the immediate family. Also, when the fear began, Ms. B was leaving a vacation site earlier than her husband, whose work demands were less pressing than hers. Their marriage had become conflicted and, although Ms. B opposed divorce, she wondered about its future.
While in trance, and after achieving deep relaxation, the patient was asked to picture herself and her mother in an airport waiting area. Ms. B was instructed to notice her mother's discomfort about the upcoming flight, and to realize powerfully that she does not have to share her mother's fear but can instead be close to her in other ways. In the following session, the same image was repeated and another one was added. Ms. B was now told to picture herself at the airport with her husband seeing her off. She was told to understand that leaving him behind on a trip was not the same as leaving him or being left in a divorce, and that their marital problems could be dealt with in other ways.
The next session focused on the patient's concern that after boarding a plane, she could not see the pilot and could have no certainty about who was in control. Using an age regression technique, the therapist helped Ms. B find a safe and secure memory in her past; she recalled with obvious pleasure how her doting grandfather would carry her in his arms as they played together in the backyard. The therapist then advised her that on reaching her seat in an airplane, she was to relax and summon the wonderful feeling she had had with her grandfather, knowing that the airline personnel, although out of sight, were working hard to ensure her comfort and safety, just as her grandfather had. The patient repeated these images and their associated feelings and messages in daily self-hypnosis sessions. When she faced her next flight a few weeks later, Ms. B found herself virtually free of anxiety, enjoying the trip as she had in the past.
Extremely stressful or traumatic events may produce a range of reactions and symptoms that frequently involve anxiety. Memories of the event may be fragmentary or absent altogether, or may occur as flashbacks or intrusive thoughts. Hypnosis was used with veterans of World War I and World War 11 to treat "shell shock" and "traumatic neurosis, and it is now being used not only to help Vietnam veterans with posttraumatic stress disorder, but also to treat victims of our urban and familial aware,' those traumatized by rape, incest, and accidents (Ebert, 1988; MacHovec, 1984).
Hypnosis allows a modulated recovery of memories that facilitates catharsis, abreaction, and mastery within a containing and reassuring therapeutic relationship. With a heightened sense of self-control rather than the passive helplessness that accompanies most trauma, the patient becomes able to tolerate the memories, to experience ideas and affects that may have been dissociated at the time, and to accept suggestions and interpretations regarding how the event was experienced and how it may have affected the patient's subsequent life (Ebert, 1988; Peebles, 1989).
Ms. C, 25 years old, was awakened from a deep sleep around 2 a.m. by someone knocking on the door of her apartment. Puzzled at who could be there at that hour, she partially opened the door. Recognizing the young man who had done yard work for her family, Ms. C left the door open longer than if it had been a complete stranger. When the young man tried to force his way into the apartment, Ms. C attempted to close the door, but he grabbed her by the hair and repeatedly smashed her head against the door jamb. He forced her to the floor, hitting her several times in the face before sadistically biting her shoulders and breasts and raping her. Afterward, he smirked, pulled up his pants, and left without a word. Hearing the commotion, her roommates, who had been asleep upstairs, shouted to her for an explanation.
In therapy, Ms. C recalled being irritated at not being helped, but she seemed to feel no anger toward the man who had assaulted her so violently. Visible scars remained on her body for many years, but she quickly erased the memory of the attack from her mind, recalling only how she had opened the door in the night and had been grabbed by the hair. The young man was convicted of other crimes, so Ms. C never testified against him. She felt sorry for the underprivileged fellow and wondered if she had behaved seductively toward him.
Seven years later, Ms. C sought help from a rape counselor because she was unable to manage the anxiety she felt in the presence of men who had committed rape or incest, whom she was required to evaluate and treat during her advanced study in psychiatric nursing. She also experienced anxiety in the presence of victims of rape or incest. She suffered disturbing nightmares at least monthly, even more frequently around the anniversary of the attack, and often experienced flashbacks when viewing violent scenes on television. Ms. C was functioning well in every other respect and proved to be a good hypnotic subject.
After a few sessions, the patient was able to completely recall and to vividly relive the trauma. Starting from her lack of anger and the quickly emerging feeling that she must have done something to cause the young man to hurt her, she recognized in trance that she felt she was being punished for her teenage sexual activity, something her fundamentalist religion did not allow. As the therapist pursued the theme of responsibility and punishment through the affect bridge technique (Watkins, 1971 ), the patient was flooded with memories of fearing punishment at the hands of her frequently abusive mother, in part for dearly being her alcoholic father's favorite child. Ms. C recalled her guilty pleasure at being his favorite, but also her dread of abandonment by and physical harm from her mother. This sense of guilt led her back to memories of being fondled by an uncle in his workshop, a place where Ms. C retreated when conflict between her parents became unbearable and where she sought a sense of safety and specialness.
After the catharsis and abreaction produced by reliving the memories of the rape several times, Ms. C easily saw the connection between her guilt from the past and her inability to feel appropriate anger toward her attacker. She also accepted reassurance that sexual activity for someone her age at that time was normal and forgivable, that she had not caused the attack, that she was not being punished for winning out over her mother, and that her relationship with her uncle was a troubled little girl's best effort to feel safe and loved in a pathological home environment. She also accepted the observation that the attack had had little to do with sex, but rather that it had been an effort to hurt and subjugate her.
As the work progressed, to be terminated eventually in 18 sessions, the patient began to feel anger instead of anxiety in the presence of male offenders. She also felt comfortable around women with similar experiences and achieved a sense of perspective about her role in the parental home. She no longer had nightmares or flashbacks, and was symptom-free at 2-year follow-up.
Hypnosis also produces good results in various clinical situations when the anxiety is about some activity, event, or procedure, but is not phobic in the usual sense. In medical settings, hypnosis can help children reduce anxiety related to painful medical procedures such as bone marrow aspirations, chemotherapy injections, and lumbar punctures (Hilgard & LeBaron, 1982; Killerman, Zeltzer, Ellenberg, & Dash, 1983; Place, 1984). It has been used to help wean anxious ventilator patients (Acosta, 1987) and to calm patients with preoperative fears (Egbert, 1986). In cancer patients, anxiety reduction through hypnosis is a key variable in controlling pain, nausea related to chemotherapy, and preoccupation with the illness (Araoz, 1983; Kaye, 1987). Used in childbirth, hypnosis can produce a more comfortable pregnancy, painless and anxiety-free labor and delivery, and quicker recovery (Robertson, 1981). Dentistry is yet another medical area where hypnosis eases the way for anxious patients (Kent, 1986).
Outside the medical realm, hypnosis has impressively addressed a number of performance anxieties, as well as learning problems in children (Russell, 1984). Athletes in several sports (e.g., weight lifting, judo, fencing) in which anxiety adversely affects performance have benefited from hypnosis (Krenz, 1984).
Focusing on anxiety alone, the range of application of hypnosis is truly impressive, from relieving disabling symptoms to improving mental and physical skills. Many other uses go beyond the scope of this paper, but perhaps those described here will stimulate interested clinicians to seek out the necessary training to add hypnotic techniques to their therapeutic armamentarium. As essentially a variant of psychotherapy, hypnosis may ethically be used by any health care professional who has the appropriate education.
Hypnotic management of anxiety exploits the intimate connection between psyche and some and produces a beneficial effect on cognition as well as on the emotional comfort of the individual. Attention and concentration are disturbed by even small amounts of anxiety, and logical, realistic thinking can be seriously disrupted as anxiety increases. As a person learns to manage anxiety through hypnosis, the experience of success with such self-regulation provides or heightens the feeling of being in greater control. Self-esteem can grow as the sense of helplessness fades, and confidence builds in the possibilities and realities of competent, autonomous functioning. Hypnosis is appealing to clinicians and patients alike, and clearly deserves even greater use than it now has.
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Dr. Smith, director of clinical psychology at The Menninger Clinic and an associate dean of the Karl Menninger School of Psychiatry and Mental Health Sciences, is a diplomate of the American Board of Clinical Psychology and of the American Board of Psychological Hypnosis. Reprint requests may be sent to William H. Smith, PhD, The Menninger Clinic, Box 829, Topeka, KS 66601-0829. (Copyright [Copyright] 1990 The Menninger Foundation)
By William H. Smith, PhD
References Other applications Case example Posttraumatic and stress disorders Case example Fear of flying Case example Phobias Free-floating or generalized anxiety