SUSCEPTIBILITY TO HYPNOSIS

Before turning to a discussion of the various methods of hypnotherapy we shall deal briefly with the questions which logically precede such a discussion: "Which persons are most susceptible to hypnosis?" and "What are the crucial factors in determining hypnotizability ?" The therapist would like to be spared fruitless effort with patients who will probably be refractory and to choose only those known to be responsive to this form of treatment. Unfortunately, no definitive answer has been given by the literature, and the average hypnotherapist has his unverbalized "hunches" which he then tests on a more or less trial-and-error basis.

The most complete summary of susceptibility to hypnosis has been made by Bramwell (89) who draws the following conclusions on the basis of reports by many independent investigators: a) From 78 to 97 per cent of the total population are hypnotizable to some degree. b) Only 10 to 20 per cent of young adults can achieve the deepest state of hypnosis. c) There is apparently an age factor in hypnotizability—55 per cent of children from 7 to 14 years of age could be hypnotized to the deepest level whereas this was true of only 7 per cent of persons ranging in age from 56 to 63. It is extremely difficult, however, to evaluate these figures inasmuch as no standard criteria of hypnosis have been yet devised.

Only a few general characteristics have been agreed upon by most investigators as favorable for the induction of hypnosis. Bramwell has summarized these: a good hypnotic subject has at least "a fair intelligence;" he is usually under 50 years of age; he does not have a severe attention disturbance; and he is, above all, willing to cooperate in the experiment. Erickson (93) believes that cooperativeness is an important characteristic. He says: ". . . any really cooperative subject may be . . . (hypnotized) . . . regardless of whether he is a normal person, a hysterical neurotic, or a psychotic schizophrenic patient." Most workers in the field are somewhat less optimistic; they agree, for the most part, that mentally ill persons are significantly more difficult to hypnotize than normals (*) (100) (101) (96) (88), and that it is almost impossible to hypnotize psychotics (91). Voisin (110), Schilder (107), Jenness (98), Flateau (95), and Winkel (115) have, however, reported some success in hypnotizing the last mentioned group. Race, sex, nationality and social class seem to have little or no influence on susceptibility (89).

(*) William Brown is the only consistent opponent of this view. Holding to Charcot's belief in the close similarity between hypnosis and hysteria, he believes that hysterics are especially easy to hypnotize but that they become less hypnotizable as they become cured.

The attempt to discover what it is that "makes a person go into hypnosis" has thus far been largely restricted to studies of the personality characteristics of the subject!. If "hypnosis" is in part aunique interpersonal relationship, it may be that the approach which studies only one aspect of this relationship (namely, the subject himself) is foredoomed to failure. At any rate, the results of studies of good and poor subjects have not yielded any consistent results. We present them only to provide a summary of current hypotheses.

Hull (97) has reported studies which tried without success to establish significant correlations between personality "traits" and hypnotizability. One study by M. M. White (111) reported a positive correlation between "extroversion" as measured by a "paper-and-pencil" personality inventory but a subsequent investigation by Barry, MacKinnon and Murray (85) who employed the same test did not confirm White's finding. Davis and Husband (92) even found slight though unreliable evidence for a correlation between "introversion" and hypnotic susceptibility. In this same study, they attempted to investigate several other factors in relation to hypnotizability (intelligence, maladjustment, prejudice, and affectivity). They conclude that there is no evidence for Janet's belief that susceptibility is linked with neurotic tendencies and that the only factor which does seem to be related to hypnotizability is that of general intelligence. (They obtained a low positive correlation of .34 between these two variables.)

Another line of approach has been the attempt to correlate the rise and fall of auditory threshold in reverie with hypnotizability. In Morgan's investigation (102) the auditory threshold was obtained and then the patient was told to abandon himself to reverie and day-dreaming. Morgan reports that in schizophrenics the threshold goes up and that in psychoneurotics it goes down during reverie. Every person whose threshold was lower during reverie and who was tested for hypnotizability could be hypnotized and not a single one whose threshold was raised could be hypnotized.

This work issued in an effort to set up constellations in which hypnotizability does or does not appear. In one group, were placed those individuals who can readily lose themselves in day-dreaming and who respond during such a period of reverie to a weaker sensory stimulus than when paying strict attention to the stimulus (lowering of the threshold). Such persons were characterized as having a "dissociative" type of personality and could readily be hypnotized. The other group, who could not be hypnotized, was comprised of persons who cannot abandon themselves to reverie and who respond during such an attempt at day-dreaming only to a more intense stimulus than when paying strict attention to the stimulus (raising of the threshold). They showed a "shattering" of personality rather than a "dissociation."

Jennets and Dahms (98) have since reported, however, that of eight good hypnotic subjects, the auditor] thresholds of six rose during reverie. This directly opposed finding causes considerable doubt concerning the utility of this test as an index of hypnotizability. Bartlett's findings (86) also suggest that these liminal changes are not related to clinical types but to fluctuations in certain immediate physiological factors.

Bartlett in another investigation (87) compared the responses CO direct suggestion of a group of normals with two patient groups: one, psychoneurotic and the other schizophrenic. There was little difference in the response between the normal and neurotic groups, although the normal subjects tended to respond more positively to the suggestions. It is curious that within the neurotic group the best response came from the "psychasthenics," with the "hysterics" running a poor second. Whereas over 30 per cent of both normal and neurotics reacted positively, this was true only for 16 per cent of the schizophrenics, all of the paranoid group. In the simple hebephrenic and catatonic types, there were no positive responses whatever. Here again, these are only tentative conclusions based on small samples. Similar results, however, were obtained by Williams (114). There is also some clinical evidence for questioning the belief that hysterics are necessarily good hypnotic subjects. H. C. Miller (100) agrees with Moll (101) and Forel (96) that the hysteric is the "most difficult to influence."

The most frequent criticism of all of the above mentioned studies has been that the instrument employed to arrive at "personality characteristics" has never been sufficiently sensitive to tap any significant aspects of the subject's personality. Recently, there have been several investigations conducted which have utilized the "projective test" methods on good and poor hypnotic subjects. Responses on the Rorschach Inkblot test (*) were analyzed in relation to hypnotizability by Sarbin and Madow (106) and by Brenman and Reichard (90).

(*) In this test the subject is asked to look at an inkblot and to tell what "it might be." Characteristic kinds of responses are given by individuals, according to their personality structures.

The former found a positive correlation between the "whole-detail ratio" and hypnotizability. This was not confirmed by the latter who conclude: "Although our results suggest that 'egocentric affective responsiveness' may be involved, it would seem that the factor of 'free-floating anxiety' is of even greater importance in hypnotizability. Thus, if one assumes with Rorschach that responses purely to color or even to a combination of color and form are characteristic of ordinarily 'suggestible' persons, it would appear that there does not necessarily exist a one-to-one relationship between hypnotizability and everyday suggestibility. That is to say, "suggestibility" alone, as Rorschach understood it, appears insufficient to make the individual a good hypnotic subject."

Yet another (and, in the opinion of the present reviewers, more promising) application of projective techniques has been the use of the Thematic Apperception test.(*) R. W. White (112) found that the average correlation between the actual rank order of hypnotizability and the guessed rank order of several judges, who estimated the probable hypnotizability of each subject on the basis of his "hypnosis story" was .34. The correlation was higher (50) where the judges were better acquainted with the problems of hypnosis. White concludes: "Though the procedure was too crude, and the subjects too few, to warrant more than a tentative generalization, it seems indicated that stories which subjects make up on the theme of hypnosis bear a considerable relationship to their own hypnotic performance. This relationship could hardly obtain unless two hypotheses were correct: first . . . that 'when someone attempts to interpret a complex social situation he is apt to tell as much about himself as he is about the phenomena on which attention is focused,' for which reason the Thematic Apperception Test 'is an effective means of disclosing a subject's regnant preoccupations and some of the unconscious trends which underlie them;' second, that what the subject tells about himself in this way, in other wordsthe attitude which he reveals, is a genuine determination of his responsiveness in the hypnotic test."

(*) In this test, the subject is shown a series of pictures and asked to "make up a story" about them. During the course of this procedure, the subject reveals his fantasies (conscious and unconscious), usually without becoming aware that he is doing so. One such picture shows what appears to be one man trying to hypnotize another.

It would be our supposition that if a subject's responses to the hypnosis picture did indeed disclose some of the significant "unconscious trends," and if our knowledge were more complete regarding the specific "unconscious trends" which are related to hypnotizability, that this correlation would be significantly higher. Although this statement may appear to be self-evident, it is made in order to call attention to the fact that the above described approach, while it is the most promising to date, is limited by the fact that it elicits data from a level which seems closer to conscious attitudes than to "unconscious trends." It might be that on the basis of stories given in response to pictures unrelated to hypnosis that deeper and more significant attitudes might be elicited.

White has tried to isolate some of the "deeper" factors crucial for hypnotizability. He has formulated his hypothesis in the vocabulary worked out by Murray and his associates in their cooperative study at the Harvard Psychological Clinic (103). He concludes that "the attraction of Passivity is of central importance in determining the outcome of an hypnotic experiment with those subjects who are not fundamentally unwilling." (Page 460) He adds, however, that in the deeply hypnotizable subjects, one finds those who respond in a drowsy. sluggish way and those who are alert and obedient. Only the former are really maximal in the variables which indicate "Passivity}" the latter are about average on "Passivity" but show a great need for "Deference" and receive uniformly low ratings on the need for "Autonomy." These results suggest that a person may enter into the hypnotic relationship "on the strength of two quite different motives."

Rosenzweig's "triadic hypothesis" (105) has been developed along similar lines in that he, too, employs an experimental rather than a clinical approach and in that his formulations are conceived largely in terms of the Murray concepts although he uses psychoanalytic vocabulary as well. He has employed the correlational and the Thematic Apperception approaches in collaboration with Sarason. He states the "triadic hypothesis" as follows: "Hypnotizability as a personality trait is to be found in positive association with repression as a preferred mechanism of defense and with impunitiveness as a characteristic type of immediate reaction to frustration."(*) On the basis of correlation coefficients obtained from measures of reaction to frustration, liability to the repression of unpleasant experiences and hypnotizability "or suggestibility," he concludes that the "components of the triadic hypothesis" are positively associated (105). (Page 19) He adds: "It was found reciprocally that those individuals who do not utilize repression as a mechanism of defense are characteristically extrapunitive and nonhypnotizable." From the Thematic Apperception approach the authors conclude : "The experimenter and an independent judge were able to differentiate hypnotizable from nonhypnotizable individuals on the basis of the response to an 'hypnosis' picture to a statistically significant degree.

(*) The term "impunitiveness" refers here to that characteristic of a person which leads him to react in a frustrating situation by glossing over or rationalizing rather than with externally directed (extrapunitive) or internally directed (intrapunitive) aggression.

The characteristics of the verbal and adverbial phrases employed by the nonhypnotizable subject were typically extrapunitive in their expression of fear, aggression, and suspicion. Those of the hypnotizable individual were typically impunitive in conveying cooperativeness, conciliation, and acceptance of the presence and success of hypnosis. An analysis of the stories in terms of needs reveals deference, affiliation, and abasement to be characteristic of the hypnotizable subjects, and autonomy and anxiety of the nonhypnotizable." (Page 165) They state that, although both the quantitative and qualitative approaches offer confirmatory evidence for the "triadic hypothesis," further study is indicated.

It must be apparenteven from this brief survey of the meagre literature that there is neither clinical nor experimental to draw any conclusions regarding either the personality characteristics of the good hypnotic subject or the psychiatric syndromes which are most susceptible to hypnosis. There exist reports of successful hypnosis in almost every nosological category and there also are reports of utter failure in all.

Although we do not know what makes an individual susceptible to hypnosis, we do know that such susceptibility is not a static property of the person which consistently appears under any and all conditions. The therapist must be constantly aware of the need to alter the "psychological atmosphere" in line with the immediate emotional needs of the patient which seem to influence susceptibility. If the patient is frightened or consciously over-anxious to please, he will be a more difficult subject. Often, a skillful therapist may neutralize such obstacles by deferring his attempts until he has explored what Fisher (94) has called "the areas of anxiety." Curiously enough, "faith" or lack of it seems to make no difference whatever. Forel (96) has pointed out that many patients who deride hypnosis are often markedly susceptible whereas many who "believe" remain entirely refractory. This observation is confirmed by the present reviewers' experience.

It is a curious fact that a patient who is refractory during the first two or three trials may go into deep hypnosis during the fourth attempt. Tuckey (108) would usually stop after the fourth or fifth unsuccessful session. On the other hand, Moll (101) has sometimes succeeded only after 40 sittings and Vogt (109) tried 700 times fruitlessly to obtain somnambulism and succeeded on the seven hundred and first attempt. Most hypnotherapists do not persevere or find it expedient to invest time much beyond Tuckey's limits. We offer these figures only to suggest that susceptibility to hypnosis seems to be a fairly fluid characteristic of the person which, if latent, may be brought out under conditions which are, for him, psychologically optimal.