METHODS OF INDUCING AND TERMINATING HYPNOSIS

The induction of the hypnotic state is, in its essence, a simple procedure. Although the literature offers no unequivocal answer to the question, "What factors are the sine qua non of hypnosis?" one can say that most methods of induction include the following elements: a) the limitation of sensory intake and motor output; b) the fixation of attention; c) the repetition of monotonous stimulation; d) the setting up of an emotional relationship between therapist and subject.

It has been argued by Hull (57), Young (84) and others that no one of these factors is prerequisite in order to produce phenomena ordinarily regarded as "hypnotic." Although further research into the nature of hypnosis may show these to be unnecessary trappings, it remains a fact that most standard induction procedures involve these factors. There have been mechanical, chemical, and psychological aids introduced into the process, and these have been minutely catalogued (41) (67). We shall restrict this discussion therefore to a presentation of classic, standard techniques in current use, and will add a presentation of those adjuvants not previously summarized.

Workers in the field generally agree that a discussion preliminary to the induction is prerequisite. The therapist elicits from the patient his preconceptions and his fears regarding hypnosis, and reassures him on one or more of several standard prejudices: that he will not be revealed as a "weakling" if he prove to be a good subject, nor be deprived of his "will," nor be forced to do anything which will humiliate him or frighten him, nor lose consciousness at any time, nor run the risk of remaining in hypnosis forever. (The completely groundless belief that it is harder to terminate hypnosis than to induce it is extremely common.) He should be told that, on the contrary, only people of good intelligence and well-developed "will"—in the sense that they can concentrate well— are hypnotizable. If the patient is very anxious for the hypnosis to be successful, he is asked to adopt an attitude of calm detachment insofar as possible, since over-eagerness appears to hinder relaxation. If the patient has undue anxiety regarding the possibility of posthypnotic amnesia, the therapist agrees to let him recall all of his experiences. It is often helpful when using the standard "sleeping method" to discuss hypnosis with the patient as a phenomenon analogous to sleep. A patient may be told that hypnosis is a kind of sleep in which communication with one person (the hypnotist) remains. This may be compared to the normal phenomenon of a sleeping mother awakened by a faint cry from her infant though louder noises leave her undisturbed, or by a fireman who is awakened only by a particular arrangement of bell signals. When the patient considers hypnosis as a condition allied to sleep, he finds, more understand able the hallucinatory experiences, amnesias, motor helpnessness, characteristic of a deep hypnosis.

The particular variety of doubts raised by the patient is dependent on his intelligence and sophistication; a skillful therapist adapts himself to the needs of the patient in this as in any other psychotherapy, setting up in this initial interview an inter-personal "atmosphere" of sympathy and trust. Often, time can be saved if the therapist assures the patient in advance that no hypnotic phenomena will occur if he decides to try the experiment of pitting his "will" against that of the therapist. When the patient has been given ample opportunity to voice his qualms, he may be told approximately what to expect. It is usually a surprise to the patient to hear that most people are hypnotizable to some degree, rather than "either you are or you aren't." In order to forestall a feeling of inadequacy or failure in the patient, the therapist should describe in approximate terms the great range of hypnotizability in people. He may tell the patient that some people feel only a great lethargy at first, but that approximately 90 per cent of them shortly are unable to open their eyes; and that some very quickly experience a complete immobility, and may develop anesthesias. In general terms the stages of hypnosis are described (*) as a continuum extending from a generalized bodily relaxation to somnambulism (the latter usually designating a complete posthypnotic amnesia and/or the ability to have hallucinatory experiences).

(*)There is no general agreement, either in the classical or modern literature, on the precise succession of "stages" of hypnosis. It appears that there exist great individual differences in this progression, and that no strictly uniform patterns have been established. Recently Friedlander and Sarbin (51), Davis and Husband (45) and others have attempted to establish quantitative scales of hypnotizability on which subjects may be ranked. However, the fact of individual differences, as well as the difficulty of establishing a standardized technique of induction, limits the value of these. A sample scale is shown in Table 1.

When the therapist is satisfied that he has established a fairly good pre-hypnotic rapport, and has made the subject comfortable on a couch or in an easy-chair in a semi-darkened room, he proceeds then to attempt to induce hypnosis in one of several ways: 1. The "sleeping method;" 2. Drug hypnosis; 3. "Hypnoidization;" 4. "Waking hypnosis."

1. The "sleeping method".(*)

(*)This will be a detailed description given with the aim of providing a guide for those who for the first time will attempt to hypnotize patients.

Before the hypnosis is attempted a number of maneuvers are often carried out, to serve as an introduction. The Kohnstamm phenomenon is a good beginning (81). The patient is asked to stand sidewise against awall and then to press his arm against the wall as firmly as possible, while keeping his eyes closed. This is continued for about three minutes, the therapist exhorting the patient all the while to "press with all your might, press with your shoulder muscles, your upper arm muscles, press till you tremble from the strain." When the time is up the patient is asked to step away from the wall and stand with arms relaxed and hanging at his sides. In the majority of people, the arm that has been pressed against the wall will rise spontaneously in the air, often even to a 90° angle. The surprised patient is told that this feeling of relaxation and spontaneous movement of a limb is the kind of relaxation and feeling of yielding to external forces which he should attempt to adopt in the hypnotic induction.

TABLE 1.

The Davis Hypnotic Susceptibility Test (51)

Tests of "suggestibility" may then be carried out Although there is no established relationship between these and hypnotizability, they often serve as good transition. The patient is asked to stand with heels and toes together, head forward and eyes closed. He is told to imagine that his body is an upright board hinged to his feet which he is to imagine as a board at right angles to his body. Then he is told that he will feel a force pressing against his forehead and forcing him backward. He is told not to try to prevent himself from falling since the therapist will stand behind to catch him. The hypnotist then repeats in many variations, "You are falling, you are moving back, you feel as if there were a force pressing against your forehead." At first the patient is told not to try to stop himself; but if by this method one is successful in making him fall until caught, then the attempt is made to get the patient to try progressively harder and harder to prevent himself from falling, the therapist insisting all the time that he cannot prevent himself. When it becomes clear that the patient is at a point where if he is allowed to exert more effort he will be able to prevent himself from falling, the attempt is abandoned. Naturally, one must be practiced and alert to detect this point.

Another introductory procedure is to have the patient sit with arms outstretched before him and fairly close together, with his eyes closed; he is told to picture a toy balloon resting on his hands and that the balloon begins to rise; then the therapist repeats, with many variations, that as the balloon rises the patient's arms will rise. In most instances, there will be at least a slight elevation. The patient is now told to picture the balloon descending and that, as he does so, his arms will gradually fall. This procedure is then repeated with the instruction that he picture the balloon motionless, and that his right arm will go up and his left arm down.

These techniques are called tests of "suggestibility," but it is probable that they represent the same phenomena induced by the method of waking hypnosis, described later in this chapter. Any simple motor suggestion can, of course, be substituted for those given here.

The balloon-rising test is carried out with the patient seated in a comfortable chair; and the procedure may continue from here, though some patients relax more easily lying on a couch. An anxious patient is usually more comfortable sitting up. At this point one usually begins with some technique of ocular fixation, accompanied in the "sleeping method" by suggestions of drowsiness, relaxation and heaviness.

Bernheim in 1884 (40) described his procedure as follows:

"I say, 'Look at me and think of nothing but sleep. Your eyelids begin to feel heavy, your eyes tired. They begin to wink, they are getting moist, you cannot see distinctly. They are closed.' Some patients close their eyes and are asleep immediately. With other , I have to repeat, more stress on what I say, and even make gestures. It makes little difference what sort of gesture ismade. I hold two fingers of my right hand before the patient's eyes and ask him to look at them, or pass both hands several times before his eyes, or persuade him to fix his eyes upon mine, endeavoring at the same time to concentrate his attention upon the idea of sleep. I say, 'Your lids are closing, you cannot open them again. Your arms feel heavy, so do your legs. You cannot feel anything. Your hands are motionless. You see nothing, you are going to sleep.' And I add in a commanding tone, 'Sleep.' This word often turns the balance. The eyes close and the patient sleeps or is at least influenced.

"I use the word sleep in order to obtain as far as possible over the patient a suggestive influence which shall bring about sleep or a state closely approaching it; for sleep properly so called does not always occur. If the patients have no inclination to sleep and show no drowsiness, I take care to say that sleep is not essential; that the hypnotic influence, whence comes the benefit, may exist without sleep; that many patients are hypnotized although they do not sleep.

"If the patient does not shut his eyes or keep them shut, I do not require them to be fixed on mine, or on my fingers, for any length of time, for it sometimes happens that they remain wide open indefinitely, and instead of the idea of sleep being conceived, only a rigid fixation of the eyes results. In this case, closure of the eyes by the operator succeeds better. After keeping them fixed one or two minutes, I push the eyelids down, or, stretch them slowly over the eyes, gradually closing them more and more and so imitating the process of natural sleep. Finally I keep them closed, repeating the suggestion, 'Your lids are stuck together; you cannot open them. The need of sleep becomes greater and greater, you can no longer resist.' I lower my voice gradually, repeating the command, 'Sleep,' and it is very seldom that more than three minutes pass before sleep or some degree of hypnotic influence is obtained ...

"... I sometimes succeed by keeping the eyes closed for some time, commanding silence and quiet, talking continuously, and repeating the same formulas; 'You feel a sort of drowsiness, a torpor; your arms and legs are motionless. Your eyelids are warm. Your nervous system is quiet; you have no will. Your eyes remain closed. Sleep is coming, etc' After keeping up this auditory suggestion for several minutes, I remove my fingers. The eyes remain closed. I raise the patient's arms; they remain uplifted. We have induced cataleptic sleep."

The importance of keeping a steady, monotonous flow of "patter" is not clear from this account. It has been our experience, and that of other workers (48), that the average neurotic who comes for help to a Clinic or to a private practitioner is not hypnotized to any significant degree within three minutes. Usually, several sessions of from fifty minutes to an hour and a half are required to induce a deep hypnosis. Erickson (48) has emphasized that, in many instances, one can expect success only after several hours of patient, non-routinized effort, with single sessions often lasting three or four hours.

It is of interest to compare with the original a modern, fairly standard edition of the "sleeping method," published 57 years after Bernheim's "Suggestive Therapeutics." Kraines (60), whose summary of hypnotherapy is one of the best in current psychiatric texts, describes the procedure as follows:

"I want you to relax. Relax every part of the body. Now when I pick up your hand I want it to fall as a piece of wood without any help from you. (The examiner then picks up the hand and lets it drop to the couch.) No, you helped raise the hand that time; just let it be so relaxed that you have no power over it. (The test is repeated as often as is necessary for the patient to learn to let it drop.) That's the way. Now relax your legs the same way; just let them be limp. Now take a deep breath and let it out slowly. Now concentrate on your toes. A warm sensation starts in the toe and sweeps up your legs, abdomen, chest, into your neck. Now relax your jaws. Relax them more, still more. Now your cheeks; now your eyes. Your eyes are getting heavier and heavier. You can hardly keep them open. Soon they will close. Now smooth out the wrinkles in your forehead. Good. Now make your mind a blank. Allow no thoughts to enter. Just blank. You see a blackness spreading before you. Now sleep. Sleep. Sleep. Sleep. Your entire body and mind are relaxed, — sleep, sleep. (This phrase is repeated several times in a soft and persuasive voice.) Your sleep is becoming deeper, still deeper. You are in a deep, deep, sleep."

There is one striking difference between this description and Bernheim's: in the modern version, most of the authoritarianism has dropped out. The word "command," extremely common in the older literature (it occurs three times even in the short passage quoted) does not appear even once in the newer version. This is a trend, and not the result of an accidental choice of illustration. In their excellent discussion of the technique of induction, Schilder and Kauders (73) lay great stress on this point. They emphasize a strict avoidance of intimidation of the subject, and substitute "calm, firm persuasion." Although it could be argued with justice that a deeper hypnosis might be induced in some individuals by the inclusion of the "technique of terror," this gradual change in tactics is consonant with the development of a rational psychotherapy. On the other hand, the therapeutic success of the old who confidently assured their patients that they had been helped by the vital fluid streaming From the therapist's fingertips, and the analogous phenomenon of faith-cures, give pause to the modern psychotherapist, who is usually embarrassed by such irrationalities, and is accordingly unable to use any approach which frankly appeals to a primitive layer of the patient's psyche. Some of the modern Germans like Winkel (83) recommend such appeals with unsophisticated patients.

These accounts of Bernheim and Kraines are really only a crude skeleton of the therapist's talk to the patient. As already stated, while these paragraphs can be read in several minutes, the effort to hypnotize a patient may last an hour or longer. The hypnotist has to repeat his formulae in many ways, and often many times. But much more is necessary. An attempt must be made to adapt the hypnotist's remarks to the patient's personality, insofar as the hypnotist understands it from his prehypnotic contacts with the patient. The hypnotist must decide whether to adopt an attitude of unquestionable authority, betraying no hint that he doubts the effectiveness of his suggestions; an intellectual approach in which he explains everything he does; an emotional approach in which he may utilize a patient's particular need for sympathy, comfort, and security; or a passive approach in which he reiterates his ineffectiveness except as he is given authority by the subject, so that the subject is led to feel that he is "doing all this" himself. Many other variants in attitude are possible, of course.

In general, in the early phases of attempting induction, the patient should be discouraged from speaking. A patient will often say, "But that's my trouble, I just can't relax" when the hypnotist says, "Now you are relaxing." The reply should be, "Just sit quietly and comfortably and you will find that you will be able to relax more and more," etc.

One of the most difficult points is to know when it is wise to challenge the patient to test his hypnotizability. The general rule is that one should never wittingly challenge unless one is sure that the suggestion will be successful. Naturally, hypnotists vary much in their own temperaments, so that one will challenge early and peremptorily, while another will advance cautiously by small steps.

One of the best places to make a first challenge is in the heaviness of an arm. The patient is told that the arm will become progressively heavy. Variations and amplifications of the following formula are used: "Your right arm will become very heavy. The heaviness begins in the shoulder, flows down your upper arm to your elbow, then down the forearm to your wrist, then into your hand, and then into the fingers, into each individual finger, the thumb, the index finger, the third finger, the fourth finger, and the fifth finger. You will imagine that your arm is turning to lead, beginning at the shoulder, passing down the upper arm to the elbow, etc. You feel as if your arm were bound down ;to the arm of the chair. In your imagination you see steel bands passing over your wrist and your elbow, binding your arm to the chair. You feel that a great suction keeps your arm stuck to the chair, that heavy weights are pressing it down. You will find that it is more and more difficult for you to will to move your arm, and the harder you try the more difficult it will be." This last phrase, actually a variation of Coue's "law of reverse effort" (44), seems to be peculiarly effective and should be frequently repeated.

If at any time during this attempt the patient shows anxiety, the vigor of the suggestions should be toned down somewhat. The patient can also be told that this loss of the ability to move his arm is not a necessary feature of hypnosis, but that it could also be suggested that his arm would be unusually light and rise into the air almost of its own accord, but that "we are working with the heaviness now."

When the hypnotist feels in a position to challenge the patient, he tells him that he will try to raise his arm at the count of (say) seven, and that "the harder you try the more difficult it will be." Further suggestions are gauged by the success of this one. It is important to get an admission of at least some heaviness, so that the hypnotist has his "foot in the door" and can suggest progressively more. In a completely successful suggestion the patient cannot move his arm at all. Any contraction of the flexors is counteracted by an equally strong or stronger contraction of the extensors. The arm becomes stiff, may tremble with the strain of contraction of the antagonists, but will not move. The more evidence of strain without success, the more encouraged can the hypnotist be. A cooperative patient anxious to succeed can get lost in the borderland between a feeling of inability despite conscious effort, and a lack of trying because of a desire to please. Usually the latter will be seen in absence of strain and stiffening of the arm, but this is not always the case. Again the hypnotist must know just when to challenge a patient who is not trying to exert greater and greater effort; but this can be learned only through practice.

It is sometimes wise, before the challenge of inability to raise the arm, to have the patient press down against the arm of the chair very firmly for a few seconds, as though this gives him the cue to what should happen; he is of course not told what this is for.

From here on the progress of the induction is an attempt to produce deeper and deeper hypnotic phenomena, utilizing the same general principles described in producing inability to raise the arm, and progressing by the smallest steps necessary in the hypnotist's opinion to permit him to challenge with fair certainty that he will be successful. In most subjects, of course, the timecomes quite soon when one can go no deeper, When suggested inability to move the arm is almost or entirely successful, inability to open the eyes is the next step to be suggested.

The arm is chosen before the eyes because it is much easier to work with degrees of lifting the arm than with degrees of opening the eyes; and opening the eyes, in the face of the suggestion to be unable to do so, is often seriously disruptive to the whole procedure and shakes the patient's confidence. It is often wise to have the patient first squeeze his eyes shut as tightly as possible, and to use the phrase "tight until they tremble." When the hypnotist counts and then challenges the subject, he should not merely sit quietly while allowing the subject to try, but leap in with his counter-suggestions at once, saying, "You see that you are unable to do so, your best efforts only make it more difficult," and so on.

After these muscular phenomena are successful, one can turn to suggesting anesthesia. It is considerably easier to produce a hypoaesthesia than an anesthesia, so that at first one should only suggest a dulling of sensation and not attempt to go beyond this unless successful. The back of the hand is a convenient place to use, and the testing may be carried out with the sharp and dull ends of a pin.

The hypnotic phenomena usually considered of the next degree of profundity involves amnesia. The immediate amnesia refers to that produced within the hypnotic session. The patient is first told that alterations in memory are possible in the hypnotic state, that they are important in therapy particularly because they allow the recovery of buried material, and that, in working with the problem now, the hypnotist will show the subject how it is possible for material present in the mind to be first accessible to consciousness and then not. This is compared to the everyday experience of knowing something but being unable to say it, having it "on the tip of the tongue." In attempting to produce this immediate amnesia, visual aids are often valuable. In fact, throughout the induction of hypnosis, one should attempt to use colorful, sense-laden figures of speech, because they make the suggestions more vivid and compelling. The subject may be told to imagine a blackboard on which he writes three indifferent words suggested by the hypnotist. He is then told that he is to erase these in his imagination, that the words can drop out of his memory so that later, when he is asked to reproduce them, he will find that he has to grope for them and may indeed be unable to recall them. The hypnotist then proceeds for a time with suggestions of relaxation and drowsiness as before, and then returns to the words. As with heaviness of the arm, it is important to get the admission of at least some difficulty with the words, so that one can then build up and insist that this difficulty will grow greater and greater until the words cannot be recalled. When this is successfully achieved, the patient is told that, at the count of a given number, the words will return; and they then do. It is understood of course that when the therapist fails with one of the steps here outlined, it is unlikely that the patient will be susceptible to the next one. This is by no means invariably true, and it has frequently been reported that cases exist in which amnesia is obtainable when muscular phenomena are not, and vice versa; but these are not the common results.

If immediate amnesia is successful or approximately so, one may suggest a corresponding degree of posthypnotic amnesia, this latter sometimes being more easily obtainable than the immediate amnesia. The patient is told that, after awakening, it will seem to him he has been asleep or dreaming and his memory for what has happened will be hazy, or if, in the hypnotist's opinion, the suggestion appears warranted, that there will be no memory at all for the hypnosis.

As already emphasized, the phenomena described are progressively deeper only in a relative sense, as many variations occur. The one usually obtainable next is the carrying out of a post-hypnotic suggestion. This concept is well known, and need not be further defined here. The carrying out of the command is more likely if amnesia for it is suggested, and if the command is "reasonable"—that is, not a bizarre act which would excite unusual attention and be unlike the behavior one might expect from the subject.

Next come the positive sensory hallucinations; and here, as before, the more patiently, vividly and "reasonably" the suggestions are given, the more likely will they be to succeed.

"Negative hallucinations" refer to the denial by hypnotic suggestion of the reality of some sensory impression, such as the inability to recognize the presence of a particular person in the room. Such phenomena represent of course a deep stage of hypnosis, and can be carried out with the eyes open and the subject in a "trance state" which to the casual observer may appear to be the behavior of a normal, wide-awake person.

There is much question as to the wisdom of making any tests of the depth of hypnosis in subjects with whom one is interested in doing therapy. Probably one would do well to confine tests to the production of inability to lift the arm and open the eyes; if this is successful, one might see what degree of amnesia could be produced, and there let the matter drop. In the therapeutic situation it is of course always necessary to make it perfectly clear to the patient that a deep hypnosis is not required for therapeutic results. This in fact, as will be seen in subsequent chapters, is consistent with our knowledge of hypnotherapy.

As a technical aid both in inducing hypnosis and in judging its depth, Sargent and Fraser (72) have recommended hyperventilation; they suggest that the increased willingness of the patient to breathe deeply is a sign of his responsiveness. Another good means of deepening the hypnosis is Vogt's "method of fractionation (78)." The patient is hypnotized, "awakened," and then immediately hypnotized again. This may be repeated several times within the same session. The termination of each hypnotic session is brought about in the "sleeping method" by simply telling the patient that at a given signal (e. g., "when I count to five") he will "wake up." It is wise to assure the patient, while he is still in hypnosis, especially during the first few sessions, that he will feel "well and rested, as if he had taken a nap."

All of the progression described may be accomplished in one hour, if the patient is an excellent subject; or it may take very much longer. Our own procedure is to work for one hour, and at the end of that time to wake the patient, telling him that at the next session it will be necessary only to count from one to 10 in order for him to reach the depth reached in the first session; then the hypnosis can be still further deepened. This is repeated at the end of each session. If the patient has reached the stage of eye-closure, one can say that "by the time I have reached 10, your eyes will have closed." Usually the patient does not really return at once to the stage reached at the first session, and a more extended period is necessary to bring him to that stage before one can continue. The time taken to wake a patient without any "aftereffects" varies with different subjects and with the degree of practice. If a particular session is followed by a little dizziness, it is wise to take a little longer the next time. Some hypnotists feel that it is necessary to remove every suggestion by careful and detailed counter-suggestion, but it is our experience that general blanket suggestions of well-being and disappearance of the phenomena of the hypnosis is enough.

The "sleeping method" has sometimes been used to induce hypnosis in a group of patients. Wetterstrand (80) used the group technique extensively. Hadfield (54) reports its use with war neuroses. The procedure is essentially the same as in working with the individual patient. In group work, the therapist must rely far more on his authority and on the contagion of emotions than in individual hypnosis, because he cannot adapt himself to individual needs.

2. Drug Hypnosis

This is usually a variety of the "sleeping method," the only difference lying in the fact that chemical means are employed in order to induce hypnosis when verbal methods have failed, or simply to accelerate it. Bechterew (39) has suggested, in fact, that not only is there a physiological relation between hypnosis and sleep, but also that hypnosis, narcosis, and normal sleep comprise a continuum.

If one compares the summaries of drugs used during the ''90"— mainly chloroform and Cannabis Indica (41) with the more recent reports, it appears that the only significant change which has occurred has been in the direction of employing drugs with a more rapid action, the effects of which wear off more quickly and which, on the whole, have less the character of "knock-out drops." This trend has not been clear-cut or consistent, however. Kubie (61) has summarized most of the drugs recently employed in this field; in most instances, he gives specific dosages recommended.

Schilder and Kauders (73) reject the use of chloroform, employed with good success by earlier investigators, and recommend medinal (usual dosage -0.5 to 1 grams with a maximum of 1.5 grams). For a more prompt effect, they suggest between 4 and 12 grams of paraldehyde, doses of over 8 grams being exceptional. With this drug, one must take care to produce the hypnosis quickly, lest the patient attain a depth of slumber which makes him inaccessible.

The best recent discussion of the use of drugs in hypnotherapy is that by Horsley (56). He believes with Grinker and Spiegel (53) that the barbiturates act specifically on the hypothalamic region.(*) Horsley (56) reports his investigations of nembutal, sodium amytal, and in particular, of sodium pentothal. Using the last he was able to establish good hypnotic rapport with ,18 of 20 nurses, and produce hypnotic phenomena (catalepsy, hallucinations, hypermnesia, etc.) in many. The production of hypermnesia in narcotic hypnosis differentiates it from simple narcosis, in which there are varying degrees of drowsiness with confusion, disorientation, and incoherence. Also in narcotic hypnosis, he was successful in restoring memories of previous states of narcosis for which the patient had become amnesic. Horsley recommends the use of drug adjuvants for patients who have resisted other methods of induction, for those who are inaccessible (e. g., sodium amytal in catatonic schizophrenics), for mute, agitated or depressed patients, and for acute war neuroses in the field. It is not always easy to distinguish between simple narcosis and narcotic hypnosis, if no tests are made beyond that of eliciting material from the patient. There does not exist in the literature as yet any crystallization of the significant differentials.

(*) Although Grinker and Spiegel tends to the view that the effects of sodium pentothal are distinct from the phenomena of hypnosis, we mention their recent monograph in connection with "drug hypnosis" because we feel, on the basis of our own experience, that there is sufficient phenomenal overlapping between the two to make their monograph a valuable reference for those working with drug hypnosis. Grinker (52) has recently stated the view that the relationship between states of narcosis and hypnosis has not yet been clearly defined, and bears further investigation.

One of the most enthusiastic recent investigations of drug hypnosis is Brotteaux's work on the use of a compound of scopolamine and chloralose ( orchloral), which he has christened "scopochloralose (42) " As a result of more than a decade of work, he maintains that his "scopochloralose" has been successful in inducing a reliable hypnosis where not only verbal but other drug methods have failed. He has conducted tematic experimentation with normal people in order to establish therelation of the effects of "scopochloralose" to ordinary hypnosis; and he found that in most instances he was able to produce posthypnotic suggestion, amnesias, and hallucinations even where many other induction techniques had been tried without success. He speaks of bringing about a state in which it is possible to "give suggestions to the unconscious" and feels that this accessibility is greatest at the beginning of drug-induced anesthesia. The narcotic hypnosis follows within two to four hours after taking the drug, and verbal hypnotic methods are introduced only after the patient has begun to be drowsy. With patients, therapeutic suggestions or explorations are now begun. The patient is then permitted to sleep for four or five hours, providing—according to Brotteaux—an opportunity for "unconscious rumination." Schilder and Kauders (73) have mentioned this also. He emphasizes that he regards not the drug, but the specific hypnotic investigations and suggestions, as the critical therapeutic agent; and reports many startlingly rapid, permanent cures. It is of interest that, although it was found possible to produce a profound hypnosis in psychotics by using "scopochloralose," they remained completely unresponsive to therapeutic suggestions.

Another recent attempt to establish links between the phenomena of hypnosis and those of narcosis has been made by Stungo (77), working with evipan sodium. He says: "There is no practical distinction between the hypnotized and narcotized patient." He uses a 10 per cent solution, injected intravenously at the rate of 1 cc. per minute. The patient counts backwards, and usually reaches the proper stage after 1 to 3 cubic centimeters. Stungo attempts to maintain this level by continuous injection. Horsley (56) has justly criticized the technique of having the patient count backwards as too stereotyped and mechanical. He prefers to carry on a continuous conversation with the patient, and to note the point at which he becomes confused, as well as the nature of this confusion.

Most workers who have employed the method of "drug hypnosis" agree on certain points of general procedure. For instance, it has been found that, once a deep soporific hypnosis has been attained with the aid of a drug, subsequent hypnoses may be readily induced without the drug by verbal methods alone (73) (61). The drug should be dispensed with, whenever possible, to avoid a possible addiction. It has been recommended also that the patient be permitted to "sleep off" the effects of the drug before he returns home, both for his protection and for observation of his reactions by the therapist. This has been found unnecessary, however, with rapidly-acting drugs like paraldehyde or sodium pentothal.

We come now to a consideration of the advantages and disadvantages of the use of drug adjuvants. The advantages lie first in the fact that the response to chemical means of altering states of consciousness is more general than to verbal methods;(*) secondly, any physician may give an intravenous injection and expect some results, without having been trained in the specific techniques of hypnosis. In addition, there are no longer social taboos on the use of "medicine" in treatment, whereas some fear arid suspicion of the strictly verbal methods of unvarnished hypnosis still exist. Maclay (65), who has described the use of sodium amytal in "narcoanalysis," feels that this is a point of central importance, and makes it clear that in the administration of this therapy at the Mill Hill Sanitarium no links with hypnotherapy are made. When the practical situation dictates such a severance of the allied methods of hypnosis and narcosis, it seems unnecessary that the therapist sacrifice the accumulated data on hypnotherapy even in his techniques and in his therapeutic approach. Perhaps it is possible to retain the advantage of a greater social acceptance of the use of drugs, without foregoing the orientation provided by the historical development of hypnosis. So much for the advantages of the drug method.

(*) Hadfield (54) has recently pointed out that this is not always the case; that in some instances verbal methods succeed where drugs have failed.

One of the primary disadvantages of the use of drugs lies in the danger that the therapy, whether of the suppressive or "uncovering" type, may take on the character of a compartmentalized or "split-off" experience. Maclay (65) and Grinker (53) have both mentioned the fact that the patient often has amnesia for the period of narcosis. (This difficulty is clearly recognized by Grinker, who attempts to counter with a follow-up of integrative, synthesizing psychotherapy; to a lesser extent, this is done by Maclay also.) The radical physiological alterations in the patient during narcosis make difficult the bridging of this gap, as the patient must often be given benzedrine or some other stimulant in order to keep him awake. Sometimes the patient is accessible only for a short period as he enters the state of narcosis and as he emerges from it, and often he becomes drowsy too soon to make any real contact possible. Another disadvantage of the drug method is the fact that it cannot be repeated—without unfavorable side reactions —asoften and at as close intervals as may be indicated.(*) Kubie (61) points out that it is definitely contraindicated "for any debilitated patient and for any patient suffering from severe cardiorespiratory Involvement or hepatic disease." As an antidote, 1.5 to 3.0 cc of a 25 per cent solution of nikethamide intravenously is recommended.

(*) Rogerson (69) has attempted to meet this difficulty by using nitrous oxide, which does not carry the hazards of the barbiturates.

The drug methods have been used more frequently than the verbal in the treatment of the psychiatric casualties of World War II. The reason for this is not entirely clear, although it may be that here again historical accident plays a role, in that most physicians in the neuropsychiatric units have been trained in the administration and use of drugs, and feel more at home with them than with the verbal methods of hypnosis. It is part of the routine medical training of the psychiatrist to give intravenous injections, but it is only by accident or by dint of a special interest that he acquires any knowledge of the techniques of hypnosis. Fisher (49) has pointed out, in addition, some of the emotional "blocks" which may operate; it is his opinion that many inexperienced therapists hesitate to enter into an intense relationship with the patient, and to be confronted by explosive unconscious material. Actually, in some of the therapeutic applications of hypnosis, no such necessity is met; a drug-induced state of hypnosis may be utilized for many different kinds of psychotherapy. Just as with the verbal methods of hypnosis, the end-state may be used to facilitate the suppression of symptoms by direct suggestion; it may be a means of maintaining a calm and prolonged sleep; or it may be used to aid an "uncovering" type of psychotherapy.(*)

(*) See Chapter IV on "Therapeutic Applications."

3. "Hypnoidization" Despite the fact that Sidis (74) (75) (76) took great pains to argue that the hypnoidal state is not a variant of hypnosis, the procedure and phenomena are so close to those we call "hypnotic" that we feel justified in including a description of them here. Sidis believed that the hypnoidal state is the most primitive kind of rest-state out of which conditions of waking, normal sleep, and hypnosis have become differentiated. He characterized it as a highly fluid and volatile transitional state, which fluctuates between waking on the one hand and sleep or hypnosis on the other. There are thus "varying degrees of access to the subconscious (47)," and attitudes of "criticism and resistance" are suspended during hypnoidal states. As with any other induction method, the therapeutic applications have consisted of a variety of methods, including direct suggestion and protracted and intensive investigations of the etiology of the disturbance.

Donley (47), a disciple of Sidis , describes the technique as follows: "The patient is asked to close his eyes and keep as quiet as possible, without, however, making any special effort to put himself in such a state. He is then asked to attend to some stimulus such as reading or singing. When the reading is over, the patient with his eyes still shut, is asked to repeat it and tell what came into his mind during the reading, during the repetition, or after it. Sometimes, as when the song stimulus is used, the patient is simply asked to tell the nature of ideas and images that entered into his mind at this time or soon after." During this time the patient reclines on a couch in a half-darkened room, very much as in the "sleeping method." There were many variations of this technique. Coriat (46) would read newspaper clippings of indifferent content to his patients, or ask them to attend closely to the ticking of a watch or the beat of a metronome. Sidis (75) regards these hypnoidal states as closer to waking and therefore more "normal" than hypnosis.

Sidis further discusses, as an aspect of the transition between sleep and waking, the "hypnogogic state" in which "dream-hallucinations hold sway." Kubie and Margolin (63) have recently conducted systematic investigations of the production of such "hypnagogic reveries" by use of a physiological method, with the aim of securing free associations and early memories. The patient's own breath sounds are picked up by a contact microphone placed against the neck, amplified, and brought back to the patient through earphones. After a short time, the patient gradually falls into a "hypnagogic state." The authors report that this method of induction results in a free and vivid flow of free associations, which gravitates to early experiences of an intensely emotional variety. In a recent article (62) Kubie says: "The hypnagogic reverie might be called a dream without distortion. Its immediate instigator is the day's 'unfinished business,' but like the dream it derives from more remote 'unfinished business' of an entire lifetime as well. The hypnagogic reverie differs from a dream in the fact that there is less elision of the remote and recent past, and far less use of symbolic representation. This would seem to be due to two facts: in the first place, since the reverie does not attempt to say as much as a dream, it does not need to depend upon condensed hieroglyphics to express multiple meanings. In the second place, when the hypnagogic reverie is artificially induced for therapeutic purposes, guilt and anxiety seem to play a less active role than in a dream, with the result that the content of the reverie can come through with less disguise. Whatever the explanation, the consequence is that through the induction of states of hypnagogic reverie, significant information about the past can be made readily and directly accessible, without depending upon the interpretations which are requisite in the translation of dreams." He points out that "in a number of patient, in whom prolonged analysis had not succeeded in penetrating to the roots of a neurosis , the addition of this technique has proven Invaluable," but he feels that further investigation will be necessary before the specific applicability of this method will be known. It is of particular interest that the theoretical frame of reference of these recent studies leans to the physiological aspects of hypnoidal and hypnotic states, with a conscious attempt to minimize personal contact. This revival of interest in the physiological aspects may well serve as a starting point for a genuine synthesis of the historically warring camps, inasmuch as this interest is not considered as independent of, or in contradiction to, the psychological emphasis.

Sidis (76) and Donley (47) have pointed out the advantages of "hypnoidization": it may be used with success with greater numbers of people than classic hypnosis; it is a simpler process; and the word "hypnosis" need not be mentioned to the patient. Sidis reported, moreover, unusual therapeutic success, presumably as a result of the use of this method.

4. "Waking Hypnosis"

The "waking" method of induction developed from the view that sleep and hypnosis are distinct phenomena. From this assumption, it follows that all the standard hypnotic responses may be induced in a patient without any reference to sleep. Although this method is less commonly used than the "sleeping methods," we include a discussion of it because it has several distinct advantages. Wells (79) has pointed out that Braid attempted to suppress the word "hypnotism" over a hundred years ago, when he concluded that sleep is not essential to all the phenomena he had previously called "hypnotic"; he tried to substitute the word "monoideism," but this was never accepted by workers in the field. Wells has reported the development of "waking hypnosis" in great detail, and points out that Bernheim, Lloyd-Tuckey, Moll, Forel and others had independently observed and reported the production of hypnotic phenomena in the waking state.

Wells describes his technique of "waking hypnosis" by contrasting it with the usual "sleeping methods." He says that whereas the usual technique includes an explanation in terms of sleep, direct and indirect suggestions of sleep, and an experiencing of drowsiness by the patient, the "waking method" excludes all of these. He suggests that:

"Examples of involuntary ideo-motor action may be given, such as the tendency of the hand to illustrate a spiral if one is attempting verbal definition of it. Examples of absent-minded actions and of lapses of memory may be given, as illustrations of dissociation in the waking state. Then, without any reference whatever to sleep or to drowsiness one may proceed to an artificial manipulation of the subject's attention to as to produce by direct suggestion the various dissociative effects that one may desire."

After a few preliminary experiments, he usually asksthe patient to fix his attention on a simple object—a ring, a fountain pen, a point of light—and repeats to the patient some variation of the following: "You must exclude all other thoughts and keep your gaze riveted on this point, eyeballs turned up as though you were looking at the middle of your forehead. Watch it steadily, fixedly, thinking of nothing else. Note every detail so that if I ask you to close your eyes you will be able to picture it as though you were still looking at it. You will be able to do this only if you give it your complete attention and literally feel that you are memorizing it. Watch it closely, try not to blink. Don't let your gaze shift to right or left . . . etc." When the patient seems to have succeeded in fixing his attention completely on the stimulus and has watched it steadily for several minutes, he is told: "Now close your eyes voluntarily as tight as you possibly can. Tight until they tremble. Tight until they tremble. It's all right if you have to make a face in order to do so. Just as tight as you can, eyeballs turned up, remember, just as if you were still looking at my fountain pen. Now I'm going to count to 7 and when I reach 7 you will find that your eyes are stuck tight and that the harder you try to open them, the tighter they stick. Your very effort to open them will have just the opposite effect. They will be stuck tight, just as if they were glued. One . . . two . . . tighter . . . three . . . four . . . five . . . tighter . . . six . . . seven. Now try to open them and you will find that the harder you try, the tighter they stick." If this direct suggestion is successful, and the patient is convinced that despite his voluntary effort he is unable to open his eyes, the therapist may proceed to induce the other muscular contractures in much the same way—e. g., to give the direct suggestion that if the hands are clasped tightly together they cannot be unclasped, and so on and then advance to the other hypnotic phenomena listed in Table 1. If this first direct suggestion is not immediately successful, the therapist should assure the patient that sometimes it takes a little longer for these phenomena to appear. Then he should work with other muscular contractures, and return to eye-closure later. At the close of the session, as in "sleeping hypnosis," the patient will come out of the trance at an arbitrarily established signal—such as, "when I say the letters from A' to 'G' you will gradually come back to your normal self: at A,' you will move your feet; at 'B,' your arms (and so on); and at 'G,' you will open your eyes and feel perfectly normal once again." If therapeutic suggestions have been given, care should be taken to avoid such expressions as, "You will be just the same as when you came in." Although the caution may seem superfluous, this is a frequent technical error.

There exists a close kinship between "waking hypnosis" and the specific techniques of Coue and the "New Nancy School (44)." We refer here only to the method ofinduction and not to the therapeutic approach. Although in his later writings Coue did not use the word "hypnosis" at all, it is clear from the statements of Baudouin (38), his theoretician, that Coue's techniques were historically rooted in hypnosis and that in fact Coue began by "putting his patients to sleep (44)." Direct suggestion in the normal state was characteristic of Coue's later method.

Although it would take us into too great a digression to discuss in detail the historical significance of Coue's "auto-suggestionist" movement, we should like to point out in passing that, like the system of Mary Baker Eddy, it was actually a crude attempt to deal with the dawning recognition that the forces both of illness and recovery lie essentially within the person and not in an external agent.(*) It is a recognition of the power of the unconscious. Thus, Coue's famous little pamphlet, "Self-Mastery Through Conscious Auto-Suggestion," is sub-titled, "The Conscious Self and the Unconscious Self." On a far more urbane level, Baudouin has explicitly expressed the sympathies of the "New Nancy School" for the work of the psychoanalysts: "Contemporaneously with, but independently of, the idea of psychoanalysis (developed along divergent lines by Breur and Freud, on the one hand, and by the Zurich school, on the other), the idea of the "New Nancy School," clearer than the former and more akin to the French spirit, leads us by a path parallel with that opened by psychoanalysis, into the little-known domain of the subconscious, and contributed likewise to the renovation of psychology, medicine, and pedagogy. The two outlooks are complementary."

(*) A more recent investigation along the same line is Salter's work on auto-hypnosis (70) (71). This work differs from the "auto-suggestionist" inquiries in the fact that Salter begins by using a standard "sleeping method."

The essential difference between Coue's method and "waking hypnosis" lies in the fact that whereas Coue restricted his "waking suggestions" to early stages of light hypnosis (mainly contractures), Wells has shown that one may produce by direct suggestion the "characteristic phenomena usually associated with deep sleeping hypnosis." He summarizes its advantages on the basis of his experiments with several hundred subjects. The "waking method" is, according to him, easier to learn and gives less the impression of an occult procedure; it usually takes a significantly shorter time and requires far less effort on the part of the therapist. He has found it to be successful with a larger percentage of subjects than the "sleeping methods."

"Waking hypnosis" may be used either in groups or with individuals The practical importance of trying to hypnotize 20 people at once, in an effort to pick out the best subjects, will be at once obvious to anyone who has attempted to hypnotize 20 individuals consecutively. In situations where such time and labor-saving techniques are prerequisite (as in the armed forces), group hypnosis seems preferable. Once the best candidates have been chosen, individualized hypnotherapy may then be instituted.

We have described the most important variations in techniques of inducing hypnosis. The individual therapist usually develops his own from one or more of these, adapting himself to the needs of each patient, combining techniques where it seems necessary, and varying his approaches even with the same patient. At present we have so little genuine understanding of the specific psychological processes which constitute these various methods that it is as yet difficult to evaluate them. The advocates of each approach offer clinical evidence for the special effectiveness of each technique. It would be important to delineate the ways in which the underlying attitudes of the patient in "sleeping" and "waking" hypnosis differ from each other, and from those in the "hypnoidal state;" and the essential differences between all of these and the attitudes of patients given psychotherapy in the normal state, whether it be the relaxed, uncritical attitude of the analysand or the "conversation" of a patient in standard psychotherapy. Only by a systematic comparison of these states, and of their effect on the course of psychotherapy, will there emerge conclusions regarding the comparative value of these methods.