The theory of Hypnosis

Since this monograph is primarily devoted to a review of the literature on hypnotic therapy, a word of introduction for the advisability of including a section on hypnotic theory may be necessary. Perhaps the most cogent reason is that the manner in which hypnosis has been used —or discarded—by psychotherapists has been significantly influenced by their theoretical conception of the nature of the hypnotic state. Theories of hypnosis differ widely and in general, of course, the particular theory that an investigator holds is one which fits into the general framework of his conception of psychodynamics and psychotherapy. The past few years have seen a re-awakening of interest in developing theories of the hypnotic state, notably by Kubie (276) and White (290).

One of the great difficulties in the way of formulating a theory of hypnosis is that it is still highly controversial as to what actually constitutes the hypnotic state, in contrast to the manifestations within the hypnotic state that are the result of suggestion, whether direct or indirect. In other words, what can we find within the hypnotic state which is solely a result of the induction of hypnosis and has not been suggested by the hypnotist?

As early as 1926, Young in reviewing the literature (292) dismissed catalepsy, posthypnotic amnesia, and exclusive rapport of the subject with the operator as integral correlates of the hypnotic state, showing that all these were the results of suggestion and do not necessarily appear if appropriate suggestions are not made. In 1933 Hull (270) did the same with the lowering of sensory threshold, showing that actual measurement fails to reveal a significant change of it in the hypnotic state from the normal level. Ordinarily one attempts to understand a phenomenon by comparing it with similar conditions or states. As will be shown in some detail in what follows, this has also been attempted with the hypnotic state, but the difficulty always encountered is that there is question whether the phenomenon chosen as common to the hypnotic and another state is actually characteristic of hypnosis or whether it is perhaps only a suggested phenomenon.

For example, the hypnotic phenomenon of catalepsy—the tendency of the subject to maintain an extremity in whatever position it is placed and with less effort than would be required to maintain the position voluntarily—forms an important base of theories attempting to link hypnosis as a physiological state, with certain postencephalitic conditions or states. In these theories it is contended that certain of the changes in function of the central nervous system produced by the irreversible organic changes due to the encephalitic process are similar to those temporarily produced by the induction of the hypnotic state. But as already stated Young, Hull, and others find catalepsy to be a suggested and not a spontaneous phenomenon, On the psychological side, the hypnotic stale has hern linked with hysterical conditions and more specifically with hysterica] phenomena like multiple personality, fugue and Conversion symptoms in both the motor andsensory spheres. It is argued that hypnosis is an artificial hysteria and that both are produced by the same psychological mechanisms. But here again the objection is often heard that when phenomena like these are produced in hypnosis, they are the result of suggestion and are not indigenously and spontaneously characteristic of the hypnotic state. This difficulty in delineating the essential characteristics of the hypnotic state is one of the most important factors in accounting for the unsatisfactory state of the theory of hypnosis. It is agreed, however, by practically all investigators that the response of an individual to a particular suggestion is increased in the hypnotic as compared with the waking state. We reserve this for later discussion.

Theories of hypnosis fall naturally into two major classes, the physiological ones which view hypnosis as an altered condition of the brain, and the psychological ones which see it as a unique interpersonal relationship. Some theories attempt to combine the two points of view, but even in these the two parts of the theory remain quite distinct.

We need spend only a word on the theories which explain hypnosis as resulting from some mysterious emanation proceeding from the hypnotist and influencing the subject. The earliest form of this theory was the "animal magnetism" of the mesmerists. Even today it has its exponents. Alrutz (251) in Germany claims that a magnetic hypnotic influence perceptible up to a distance of one yard is given off by the human body. One of the more curious manifestations of this idea prevalent around the time of Charcot was the notion of "transference" (unrelated to the modern psychodynamic meaning of transference), according to which the pathological phenomena exhibited by an hysteric could be transmitted to another person by contact, this other person thereby serving as a vehicle of cure. No objective evidence for such emanations has ever been presented.

Early neurophysiological theories of hypnosis as an altered state of the brain were purely speculative and in general based on the idea of some inhibition of central nervous system activity. Heidenhain (267) and Verworn (288) believed hypnosis to be an inhibition of the ganglion cells of the cortex. Dollken (262) conceived of it as a brain anemia with "change in tonus of neural elements." Cappie (258) considered hypnosis a hyperemia of the motor centers with anemia of the rest of the brain.

These neurophysiological theories all imply a similarity between hypnosis and sleep. This presumed relationship between hypnosis and sleep continues to be a focal point for theories of hypnosis. Some of the earlier authors contented themselves with calling hypnosis an "artificial sleep," a "sleep-like state," a "state differing from sleep only in that rapport is maintained with the hypnotist," but most tried to give some neurological statement of the condition. Pavlov (280) considered hypnosis a state of inhibition of the brain related to sleep with the inhibition confined to motoric impulses. He spoke of a concentrated excitatory focus in the central nervous system with surrounding areas of inhibition, and regarded the inhibition as due to a limitation in either the amount or the type of sensory intake. Biermann (254) spoke of a waking focus in the cortex of the brain which continued receptive to stimuli from the hypnotist though the rest of the brain slept. Isserling (271) postulated an "island of wakefulness" in the brain.

Whether or not there is a relationship between hypnosis and sleep is a much debated point. Those who hold that there is such a relationship believe that the hypnotic state is an altered state of consciousness. Most hypnotists believe that the conditions favorable for the induction of sleep such as monotonous stimulation, restriction of avenues of stimulation, and so on, are indispensable in the induction of hypnosis. They cite such well-documented phenomena as the possibility of getting into hypnotic rapport with a sleeper (possible in some cases) without wakening him. But other investigators believe this to be false, and hold that hypnosis can be induced without any reference to sleep and without the production of circumstances conducive to sleep. A particularly strong exponent of this point of view is Wells (289) who induces "waking hypnosis" and believes that the lethargic manifestations of hypnosis appear only when they are suggested by the hypnotist. Even when hypnosis is induced by suggestions of sleep, the lethargic manifestations can be entirely abolished in a good subject, so that an observer who does not know that the subject is in hypnosis may not realize that anything out of the ordinary is taking place.

Attempts to measure physiological processes in hypnosis in order to determine whether they yield findings similar to those of the waking or sleeping state have shown conflicting results, but the bulk of the evidence to date speaks against hypnosis as a sleep state. Studies of pulse and respiration rates show no changes from the waking state (273). An experiment considered by many investigators to be the conclusive one in the field is that of Bass (252) who demonstrated that the knee-jerks disappear in sleep but not in hypnosis. He also found that the motor response to a stimulus in the hypnotic state was the same as that in the waking and contrasted with that of the sleeping state. One of the reports on the other side is that of Heilig and Hoff (268) who found the response to adrenalin of the hypnotised subject to be the same as that of the sleeper. An objective somatic criterion of hypnosis does not exist. The attempts to use cortical electroactivity as a somatic criterion have yielded contradictory results (277) (278). Stokvis (286) believes that changes in the psychogalvanic reflex come closest to definitively differentiating the hypnotic and waking states.

The modern theory of a sleep center in the neighborhood of the third ventricle has given rise to new forms of the theory of hypnosis as sleep. These are especially advanced by Schilder and Kauders (284) and by Stokvis. The latter believes that the monotonous stimulations of hypnotic induction tire the cortex generally and result in more stimuli going to the sleep center, bringing about an artificial sleep or hypnosis. He gives the same explanation for the fact that people can be hypnotized more easily at night and when they are tired. Stokvis holds that steadily maintained ocular convergence is the best method for inducing hypnosis because of the proximity of the center for such convergent gaze to that of the sleep center. He states that in his experience myopes are poorer subjects than others and explains this by pointing to the fact that the resting position of the eyes in myopes is divergent, so that forced convergence is painful and interferes with the attempt to sleep.

Schilder and Kauders believe that certain manifestations of some postencephalitics are due to the same alterations of neurophysiology to be found in the hypnotic state. They concern themselves particularly with muscular and ocular phenomena and with alterations of consciousness. They believe catalepsy and some types of tremor to be spontaneous manifestations of the hypnotic state in at least some individuals, and regard these motor manifestations as "extrapyramidal release phenomena" analogous to alterations of muscular tone and tremors in some postencephalitics. They relate the altered state of consciousness in hypnosis to the sleep center in the third ventricle and ascribe the lethargy of encephalitics to the same region of the brain. They postulate that vegetative changes are so easily producible in hypnosis because centers for vegetative innervation are present in the same region—third ventricle area and hypothalamus—and this is at least one of the regions whose neurophysiology they hold to be altered in the hypnotic state.

Schilder and Kauders (284) and others find evidence for their view that hypnosis is an altered state of the brain in the hypnotizability of some animals. Whether animal hypnosis is a phenomenon really comparable to human hypnosis is again a moot point. Tromner (287) believes that a decisive differentiating point is that with increasing practice animals become less susceptible, while human beings go into hypnosis more readily. Schilder and Kauders (and Stokvis) hold that the essential factor in the production of animal hypnosis is the prevention of the animal from carrying out the righting reflexes which would normally follow from putting the animal into certain positions. They hold that the excitability of righting reflexes is diminished in human hypnosis and that this links it with animal hypnosis. They also report instances in which elicitation of the tonic neck reflexes in human beings (they do not make it clear whether they mean normals or postencephalitics) is accompanied by alterations in the state of consciousness. Stokvis states that he has been able to induce cataplexy in a few of his easily hypnotizable subjects by suddenly frightening them and, regarding cataplexy as due to a lesion in the region of the third ventricle, he finds this another argument for the involvement of this area in hypnosis.

The physiological theories thus far discussed make no attempt to describe the altered physiological state in psychological terms. We shall later see that in theories like those of McDougall, Kubie, and White, physiological factors are stressed, but they are also expressed in psychological terms. We believe the exposition will be clearer if we turn first to psychological theories of the nature of hypnosis. We find the first milestone to be the concept of suggestion, first systematically elaborated by Braid (255) and later by Bernheim (253). Bernheim went so far as to say that "there is no hypnosis but only suggestion." The great merit of this theory at the time of its proposal was that it proclaimed hypnosis to be a psychological phenomenon in contrast to the theory of Charcot (259) who believed that hypnosis was a purely somatic phenomenon. Charcot believed that hypnosis consisted of three well-defined stages which were producible by physical manipulations. Rubbing of the scalp or spine, and loud auditory stimuli were believed to initiate hypnosis while forcibly opening the eyelids of an individual in hypnotic catalepsy was supposed to put him into somnambulism. The views of Bernheim and Charcot were basically opposed in another respect, too. Bernheim believed hypnosis to be producible in normal individuals and a non-pathological phenomenon, whereas Charcot considered that it was pathological and producible only in hysterics. The demonstration by the Nancy School that Charcot was wrong, and that his subjects responded as they did because they believed his manipulations would produce the results they did, was most important in firmly establishing the significance of psychological factors in hypnosis. Charcot's error is one which every investigator of a therapeutic procedure must take into account. He must ask how important a role is played by the patient's belief in the efficacy of the therapy.

The prime difficulty with the concept of suggestion is that it has been elevated to an explanatory role and it is often deemed sufficient to account for a piece of human behavior, whether psychological or physical, by stating that it is the result of suggestion." While the concept of "suggestion" continues to be used both in connection with hypnosis and other phenomena, its meaning is now considerably altered in that it is considered merely a descriptive term for the fact that an individual responds positively to a particular communication, whether verbal or non-verbal, direct or indirect. All modern investigators recognize that this is only a description and that one must go beyond this fact to discover why it is that "suggestions" are accepted.

One must ask whether the hypnotic state facilitates the acceptance of suggestions, which suggestions are especially facilitated, and how it is that the hypnotic state produces these changes in suggestibility. Sidis (285) has attempted to break down the concept of "suggestion" in an effort to give it more specific meaning. He has suggested that a distinction be made between "direct" and "indirect" suggestion: the former refers to direct statements made, for example, to an hypnotic subject; the latter to the introduction of an idea by tricks, disguises, ambiguities, "double-entendres" and the like. Young (293), who has written one of the most searching criticisms of the loose concept of "suggestion," has stated:

"Suggestion is definitively a method of communication of meanings or attitudes, so imparting the 'idea' as to elude rational criticism. It is a method of indirect appeal to the person to be influenced. Suggestion has a negative and a positive aspect. The negative aspect consists in inhibiting the action of the more strictly critical intellectual functions in one of two ways: either by so craftily clothing and introducing the communication that its true nature is unrecognized, or by so drugging the critical consciousness—through emotional appeals or through a technique of monotony—that almost any communication will be acceptable. The positive aspect, also, has two sides: the trend may be awakened by the communication, or it may be merely freed by the inhibition of other motives. Although the complete method of suggestion, exemplified best in its professional use in psychotherapy, shows both the inhibiting and the positive aspects, many suggestions manifest mainly one or the other. Some depend on the subtlety of the expression, as in hints and intimations; some depend on the thoroughness of the precursory process of inhibition, as in hypnosis and autosuggestion; still others depend on taking advantage of states of inhibition brought about by chance or by informal means, in order to insinuate the communication, as in crowd appeals, or suggestions given after a good dinner." (Page 89)

The essential point here seems to be the distinctions made between the Various kinds of factors which may bring about a condition which makes almost any communication acceptable. It would appear thus that there may be a significant difference between the different methods of "drugging the critical consciousness." For example, the administration of a placebo in the normal state to a patient plays upon his gullibility and presumably would be totally without effect if he recognized its true nature, whereas a direct statement in hypnosis that a symptom will disappear is presumed by Young to be effective because of the "precursory process of inhibition." The further delineation of these distinctions is a task for the future.

Practically all investigators hold hypnosis to be a state of hypersuggestibility, though there are opponents even of this point of view. Brown (257) believes, for example, that in deep hypnosis suggestibility decreases. Hull (270) finds in hypersuggestibility the only specific characteristic of the hypnotic state. He says: "The only thing which seems to characterize hypnosis as such and which gives any justification to the practice of calling it a 'state' is its generalized hypersuggestibility. The difference between the hypnotic state and the normal one is therefore a quantitative rather than a qualitative one. Responsiveness to suggestions emanating from other people, to 'prestige suggestion,' is a very common phenomenon but this is not the distinguishing mark. The essence of hypnosis lies in the fact of change in suggestibility. The experimental fact of a shift in the upward direction which may result from the hypnotic procedure . . . Hypnotic hypersuggestibility has a relative and not an absolute significance."

We may digress here for a moment to consider the controversy between the concepts of autosuggestion and heterosuggestion. Coue and Baudouin revised Bernheim's dictum—"there is no hypnosis; there is only suggestion"—to "there is no suggestion, only autosuggestion." This correction arises in reaction against the earlier concept that the hypnotic subject is a passive automaton blindly responsive to the suggestions of the hypnotist. With the development of our modern understanding of personality as the expression of an individually specific dynamic interplay of strivings, it has become clear that the hypnotized subject is by no means an automaton, that a suggestion takes effect only if it is consonant with the balance of forces of the individual's strivings, and that his understanding, elaboration and acting upon a suggestion are likewise determined by his own personality structure. The attempt to emphasize this truth may be considered to lead to a statement that the only kind of suggestion is autosuggestion; but as Schilder and Kauders point out, one could as well say that there is no education but only autoeducation, since it does not matter how much an individual is taught if he does not learn anything.

Although the concept of "suggestion" continues to play an important role even currently, the next significant step in the development of the theory of hypnosis was the concept of dissociation as advanced by Janet (272). The rise and fall of this concept, as well as its extension to include ideas other than those intended by Janet, is well described in an article by White and Shevach (291). Janet was led to his explanation of hypnosis by way of his theory of hysteria, since he regarded hypnosis as an artificially induced hysteria. Janet's idea was that various psychological "systems" could split off from the main psychic stream and exist independently. In some instances, as in hysterical blindness, the dissociated system drops out of function. In others, such as hysterical somnambulism, the dissociated system "takes over" and the rest of the personality ceases to function. This formulation has descriptive value and Janet deserves great credit for being one of the first to really see that ideas and memories can be split off from the stream of consciousness and nevertheless continue to exert influence on behavior; but as an explanatory concept it is vulnerable to two major objections. First of all, the dissociations producible in hypnosis (and in hysteria) do not necessarily follow either natural biological or acquired psychological lines of cleavage, but are subject to the caprice of the hypnotist. While hysterical blindness, for example, can be quite plausibly conceived of as a dissociation of the optic system, it is difficult to see how any natural biological or acquired psychological system can be involved in such hypnotic phenomena as the inability to see one particular person in the room though vision is intact for everything else;. Secondly, the concept of dissociation carried with it no explanation of the cause for the dissociation. Janet's concept of dissociation is usually looked upon as a psychological one, but it seems to us that although his clinical descriptions are on the psychological level, his explanation of dissociation was a purely speculative neurophysiological energy theory, in which he considered the energy available for psychological synthesis to be deficient and spoke of "psychic hypotension." Despite Janet's acute clinical observation he was led to a barren speculation in terms of nervous energy, instead of to a psychopathological theory of conflict such as was evolved by Breuer and Freud (256) from similar case material.

Closely allied to the concept of dissociation are the intellectualistic theories of suggestion and hypnosis. By "intellectualistic" we mean theories which fail to take into account motivational factors. One of the best examples of this is the theory of McDougall (279). He regards hypnosis as a state of hypersuggestibility and defines suggestion as the acceptance of an idea without adequate logical grounds. He believes that the idea is accepted because it remains isolated, that it is dissociated, and is not confronted with other ideas which might modify or contradict it. That this theory, like that of Janet's dissociation, is physiological rather than psychological seems to us evident in the following statement by McDougall of his theory:

The monotonous stimulations seem to aid in bringing the whole brain to a quiescent condition by facilitating the continued direction of attention to an object or impression of an unexciting, uninteresting character, and thereby preventing the free play of ideas which otherwise may maintain itself for a considerable period in the way noted above. In terms of neural process we may say the monotonous stimulation tends to keep some one minor disposition or small system of dispositions in dominant activity and keeps open this one path of discharge so that this one channel constantly draining off on the sensory side of the brain the supply of neurokyme, depresses or tends to prevent the activity of all others . . . We must remember that in the waking state of the brain all dispositions and systems of disposition are in relation of reciprocal inhibitions with one another, so that the activity of any one tends to inhibit the activity of any other. And we may fairly suppose that between dispositions whose activities underlie incompatible or contradictory ideas about any object, this relation of reciprocal inhibition is intimate and direct ... In hypnosis, on the other hand, this depressing, weakening influence of partial inhibition is abolished or diminished in virtue of and in proportion to the degree of relative dissociation or functional isolation of dispositions from one another, since any idea suggested by the hypnotizer is not only accepted uncritically but operates with greater force than any idea accepted with conviction in the waking state." (Page 109)

This theory is an advance over the simple suggestion theory in that it stresses psychic interaction and interplay, but it remains on the intellectualistic, ideational level. As we shall see later, however, this is only the first half of McDougall's theory. He was one of the first to formulate a psychological theory of hypnosis which goes beyond the bare statement that "it is only suggestion."

As already indicated in the discussion of autosuggestion, those theories of hypnosis which have been formulated on the basis of our modern conception of personality view the hypnotic state as a set of emotionally imbedded goals and strivings. It is this idea which White (290) states on a descriptive level when he speaks of "hypnosis as a goal-directed striving in which the individual attempts to behave like a hypnotized person as this has been continuously defined by the operator and understood by the subject."

We must ask what are the general and what are the specific aspects of this "definition of the hypnotic state." Is it a definition deeply anchored in an important interpersonal relationship, or is it a relatively superficial behavior pattern learned in the immediate situation?

This really raises the question of how it is that the subject has this wish to behave like a hypnotized person as defined by the hypnotist. An attempt to understand this leads inevitably to a discussion of the nature of the interpersonal relationship between hypnotist and subject. The most searching discussions of this topic have been psychoanalytically oriented. Psychoanalytic theories of hypnosis are built on the premise that instinctual wishes of the subject are elicited and given some gratification by the hypnotic situation. They view hypnosis as a variety of transference, meaning that the subject acts under the dominance of unconscious, infantile, instinctual drives. Ferenczi (264) viewed the hypnotic relationship as a reactivation of the Oedipus complex with the subject standing in the relationship of child to parent toward the hypnotist. He differentiated "maternal" and "paternal" forms of hypnosis, the first based on love and the second on fear.

The next important psychoanalytic contribution to the theory of hypnosis was presented by Freud in "Group Psychology and the Analysis of the Ego (265)." Freud compares hypnosis to being in love. He says, "there is the same humble subjection, the same compliance, the same absence of criticism towards the hypnotist just as toward the loved object." (Page 77) The hypnotist steps into the place of the "ego-ideal" and the testing of reality becomes altered in accordance with the suggestions of the hypnotist. "The hypnotic relation is the devotion of someone in love to an unlimited degree but with sexual satisfaction excluded." In addition to this comparison with being in love, however, Freud stresses the "element of paralysis derived from the relation between someone with superior power and someone who is without power and helpless." (Page 79) The explanation of this last is derived from Freud's conception of hypnosis as "a group of two." Referring to the "uncanny" aspects of hypnosis, he suggests that something uncanny is something "old and familiar that has undergone repression." (Page 95) He proceeds to trace the "uncanny" and coercive characteristics of the phenomena of group psychology and of hypnosis to their origin from the primal horde, conceiving of the relation between subject and hypnotist as well as that between group and leader as a reactivation of the relation of the individual member of the primal horde to the primal father. It is this primal relationship which is the "something old and familiar that has undergone repression." Without attempting to discuss this latter part of the theory any further, we see that Freud views hypnosis as a transference relationship involving libidinal and submissive instinctual strivings, in a sense a combination of Ferenczi's "mother" and "father" hypnosis. As a logical corollary of Freud's theory of hypnosis follows his definition of suggestion — "A conviction which is not based upon perception and reasoning but upon an erotic tie." (Page 100) He states that he disagrees here with Bernheim who considered suggestion as not capable of further explanation. As is well known, the term "erotic"is used in a broad sense in psychoanalytic theory, thus can cover both the libidinal and submissive aspects of hypnosis. While the psychoanalytic theory of hypnosis as a particular transference relationship seems to us an important advance in the understanding of the relationship between hypnotist and subject, its chief failure as a theory of hypnosis is that it, like other purely psychological theories, fails to account for the specificity of the hypnotic state.

These libidinal and submissive strivings appear—as Freud himself says in comparing the hypnotic state to love and the behavior of people in groups—in other conditions too. We are not told how hypnosis is specifically characterized.

McDougall denies the existence of libidinal drives in hypnosis, but considers the hypnotic state an interpersonal relationship based on the "instinct of submission." It is this explanation of hypnotic "rapport" which the second half of his theory develops. Rivers (282), likewise rejecting the libidinal forces, but impressed by the relationship between hypnotic and group phenomena, derives hypnosis from the "herd instinct."

Schilder has made important contributions to the psychoanalytic theory of hypnosis. He bases his considerations on bodily responses of the subject such as the "glance of surrender," trembling, and hysteriform rigidities, typical verbalizations of subjects in hypnosis such as a "delightful sense of fatigue," typical fears and fantasies about hypnosis held by normal people, the typical equation by schizophrenics of hypnosis and being influenced sexually, and material obtained in psychoanalysis of people who had previously been hypnotized.

Schilder emphasizes the varieties of libidinal relationship which may exist between subject and hypnotizer. Homosexual as well as heterosexual strivings appear. He says: "We must be mindful of the fact that the sexual constitution of the individual finds an expression in the nature and form of the hypnosis. Persons strongly disposed to love, persons with the tendency to fixate love objects powerfully, customarily are easily inducted into profound hypnosis. Hysterical individuals with a strong tendency for object fixation as a rule are particularly susceptible to hypnosis, while the hypnosis in the case of compulsion neurotics frequently encounters difficulties which is connected with the sadistic attitude of the compulsive neurotics toward their love objects." (Page 38)

In addition to the factors already delineated, Schilder emphasizes the identification the patient makes with the hypnotist. The patient is able to realize his infantile fantasies of power, magic, and the omnipotence of thought and words, by identifying himself with the hypnotist to whom he grants these powers. Schilder also discusses the psychology of the hypnotist, and finds that the hypnotist must have an unconscious wish for magical power and to sexually dominate the patient "It is worthly of note that an unsuccessful attempt at hypnosis produces in the hypnotizer a feeling of personal disappointment, which far transcends those bounds that would express a mere natural interest in the business at hand. To be sure all these experiences will, in the case of the hypnotizer, lie far out in the periphery of his experience."

Jones (274) stresses narcissism in his discussion of "suggestion." He finds: "Suggestion (is) essentially a libidinal process: through the unification of the various forms and derivatives of narcissism the criticizing faculty of the ego-ideal is suspended so that ego-syntonic ideas are able to follow unchecked the pleasure-pain principle in accordance with a primitive belief in the omnipotence of thought."

Rado (281) discusses in a rather technical way the metapsychology of hypnosis and particularly the mechanism of cure in suggestive and cathartic hypnosis. He believes that in hypnosis as used in these ways a transference neurosis is set up, just as it is in psychoanalytic treatment, but that, in contrast to psychoanalysis, the transference remains unresolved, so that the patient periodically re-lives the transference fantasy which is responsible for his cure.

One of the most recent theories of hypnosis, and one which attempts to combine physiological and psychological factors, has been formulated by Kubie, a psychoanalyst (276). In his theory, transference factors are given somewhat less importance than in the usual psychoanalytic theory, and physiological factors are stressed. He makes a sharp division between the induction of hypnosis and the established hypnotic state. He considers the induction phase of hypnosis a condition of partial sleep in which the nuclear phenomenon is the restriction of sensory-motor relationships between subject and outside world. Postulating that our differentiation of self and outside world is chiefly dependent upon multiple avenues of sensory intake, he further describes this stage as a blurring of the boundaries between the ego and the outside world as well as between "ego past" and "ego present." He regards immobility and monotony as the chief factors in bringing about the induction of hypnosis. He agrees that during the induction of hypnosis a "constellation of conscious and unconscious attitudes arises between the hypnotist and the subject in which manifold libidinal displacements and substituted object relationships (i.e., transference phenomena) are active," but he states that "the maneuvers of the hypnotist are designed to concentrate the subject's attention on one field of sensation and to withdraw attention from all others." During the induction he believes there takes place a psychic incorporation of the hypnotist into the subject. In the established hypnotic state there is "an extensive carry over (of the transference relationship) from the prehypnotic (presumably induction phase) relationship into the content of the hypnotic state, comparable precisely to the carry over into the content of any dream of the residues from the emotionally incomplete experiences of the preceding day ... in the fully developed stage, a diffusion (expansion) of sensorimotor relations occurs with a retention of the dominant but repressed link to the incorporated figure of the hypnotist." For Kubie, despite the transference phenomena, hypnosis is only a special variety of an extension of the normal psychophysiological process of maximal attention, which "should be attainable by simple physiological procedures, without the agency of suggestion or even of any human contacts." He states that in a subsequent communication he will offer experimental evidence for this contention.

Freud (265) likewise views the hypnotic process as one of maximal attention, but in his theory, the attention must be directed to the hypnotist, not as in Kubie's theory to "one field of sensation." Freud says, "Hypnosis can ... be evoked ... by fixing the eyes upon a bright object or by listening to a monotonous sound. This is misleading and has given occasion to inadequate physiological theories. As a matter of fact, these procedures merely serve to divert conscious attention and to hold it riveted. The situation is the same as if the hypnotist had said to the subject: 'Now concern yourself exclusively with my person; the rest of the world is quite uninteresting.' It would of course be technically inexpedient for a hypnotist to make such a speech; it would tear the subject away from his unconscious attitude and stimulate him to conscious opposition. The hypnotist avoids directing the subject's conscious thoughts towards his own intentions, and makes the person upon whom he is experimenting sink into an activity in which the world is bound to seem uninteresting to him; but at the same time the subject is in reality unconsciously concentrating his whole attention upon the hypnotist, and is getting into an attitude of rapport, of transference on to him. Thus the indirect methods of hypnotizing, like many of the technical procedures used in making jokes, have the effect of checking certain distributions of mental energy which would interfere with the course of events in the unconscious, and they lead eventually to the same result as the direct methods of influence by means of staring or stroking." (Page 96)

It is here that Freud believes he has found the key to the relationship between hypnosis and sleep. "The command to sleep in hypnosis means nothing more nor less than an order to withdraw all interest from the world and to concentrate it upon the person of the hypnotist. And it is so understood by the subject; for in this withdrawal of interest from the outer world lies the psychological characteristic of sleep and the kinship between sleep and the state of hypnosis is based upon it." (Page 98)

As wehave seen, it is still an unsettled problem as to whether the relationship between sleep and hypnosis is purely this psychological one postulated by Freud, or whether in hypnosis there are also physiological changes related to the physiological changes occurring in sleep. The evidence from the physiological point of view is contradictory. On the psychological side, phenomena similar to those of sleep can be obtained in hypnotic and hypnoid states. Farber and Fisher (263) have reported on the production of dreams and the ready explanation of their unconscious meaning in hypnosis. The hypermnesia with increased access to repressed material in hypnosis is well-known. Kubie reports that in hypnagogic reverie (275) there is a much-increased intensity of the sensory components of the images and memories which may flow through the mind, as in dreams. But it seems to us that these phenomena are not decisive in determining whether, or not, in hypnosis there is an alteration of the state of consciousness, in the sense in which this is present in sleep. There does seem to be a re-alignment of dynamic relationships within the psyche, but whether this is to be described as an alteration of the state of consciousness is another matter. The precise meaning of "alteration of the state of consciousness" is itself a difficult problem.

Schilder believes that the sleep center in the third ventricle is responsive to psychological as well as physiological stimuli, that the "sleep wish" is important in both sleep and hypnosis, and that in hypnosis one must distinguish the existence of various egos as the "sleep ego," the "dream ego," and that part of the "waking ego" which is still active.

The apparently well-established enhancement of susceptibility to hypnosis through the use of sedative drugsmust also be reckoned with in the formulation of an hypnotic theory. Though not specifically concerned with hypnosis, the recent work of Grinker and Spiegel (266) with intravenous pentothal in treating psychoneurotic combat casualties is important in this connection. Under the influence of pentothal the soldiers re-enacted and abreacted their harrowing experiences in a state apparently very much like that of hypnosis. If it is true that the barbiturates act on the hypothalamic region, this may be another piece of evidence that physiological changes in the region of the hypothalamus and third ventricle do play a role in hypnosis.

In his recently published theory of hypnosis (290), White points out that an adequate theory of hypnosis must account for the fact that the range in which suggestions can be successfully executed is wider in hypnosis than in the waking state, though the field in which hypnosis is successful in contrast to the waking state has been limited and defined. In particular it has been discovered that the more a suggestion deviates from functions under the individual's voluntary control, the less is the degree of success achieved. Memory phenomena, for example, can be manipulated far more easily than the psychogalvanic reflex. In defining a "function under voluntary control," one must carefully distinguish between the direct and indirect methods of fulfilling a suggestion. A subject in hypnosis can make his pulse rate increase, but to do so he has to think of a frightening experience, not of the cardiac muscle. One must also clarify the sense in which a particular suggestion has been successful. For example, if a subject sees everything in a room except one particular person this does not mean that a change takes place somewhere between the retina and the visual cortex, but only that the subject is not consciously aware of seeing this particular person. That he is unconsciously cognizant of the person is clear from the way in which he avoids directing his gaze towards him or bumping into him.

White suggests that the range of actions accessible to the "hypnotic striving" is increased by way of "some slight degree of functional decortication." He derives this from the "relaxation and the restriction of sensory input . . . conducive to drowsiness . . . (which) may be conceived as a slight lowering of functional level, the effect of which is disinhibitory." He believes that "the operator in hypnosis is indispensable because he prevents the subject's passing from light drowsiness into real sleep and because he maintains a continual motivational pressure, a focal press of dominance."

Again the question arises as to whether this "functional decortication" means an altered state of consciousness. White apparently believes that it does. He himself points out one of the difficulties in the problem by asking whether the soldier who receives a severe wound in battle but feels no pain, and does not even know that he has been wounded until some time later, is in an altered state of consciousness. This temporary anesthesia can be compared to hypnotic anesthesia. Certainly there are vital differences between the soldier's emotional and attentional dispositions in the heat of battle as contrasted with his usual state, but is his state of consciousness altered in either the sense or the direction in which it is altered in the sleep state as contrasted with the waking state ?

The last type of theory which we will mention is that of hypnosis as a conditioned reflex. This theory has lately been revived by Salter (283). It was the basis of Hilger's theory (269) in the first decade of this century. In essence it states that since an individual forms associations between words and sensations, the word as a conditioned stimulus can call forth the reaction which is evoked by the situation which the word describes. It seems to us that this is a superficial statement of the problem which fails to take into account the specificity of the hypnotic state, the possible physiological basis of hypnosis as a conditioned reflex, or the motivational factors involved in hypnosis.

It may be that conditioned reflexes do play some role in some of the phenomena elicitable in the hypnotic state. Kubie (276) has also suggested that "the subject who has been hypnotized many times inevitably develops certain automatic or conditioned reflexes by which a short-cut is established to the hypnotic state."

To discuss the conditioned reflex theory of hypnosis adequately would raise the whole problem of explaining complex human behavior as conditioned reflex, a problem which we do not feel it advisable to discuss here.

We have seen that the initial conflict in the theory of hypnosis was between those who ascribed it to the power of the operator and those who viewed it as a change in the subject, with the hypnotist acting only to create the necessary conditions. The next conflict was between those who viewed hypnosis as a somatic change in the subject produced by physical manipulations and those who saw it as a psychological state resulting from the attitude of the subject toward the hypnotist. With the victory of the latter view came the concept of suggestion. The theory of dissociation, while representing an advance in the statement of the psychological problem on a descriptive level, boils down as an explanatory concept to a neurophysiological theory. Both suggestion and dissociation are now reduced to the rank of descriptive rather than explanatory concepts.

The development of modern psychology of the personality has overthrown the idea of the hypnotic subject as an automaton completely subject to the power of the hypnotist, and resulted naturally in the view of hypnosis as the subject's goal-directed striving, in which the subject attempts to behave like a hypnotized person as this is "defined by the hypnotist and understood by the subject (290)." The subject's motivations have been variously interpreted by the various theories of conation. It has seemed to us that the most penetrating statements of interpersonal relationship between hypnotist and subject have come from the psychoanalysts. But their theories fail to define the specificity of the hypnotic state. The transference relationships which the analysts describe are present in other interpersonal situations besides hypnosis. It is this which makes necessary the consideration of hypnosis as an altered state of the person. We have presented evidence for and against the possible relationship to sleep of this altered state. Our own impression is that while drowsiness and sleep can be produced by hypnotic suggestion, an alteration of consciouaness in the direction of sleep is not necessary Feature of hypnosis. It appears to us that hypnosis may be an altered state only in the sense of an as yet incompletely defined specific constellation of the strivings of the subject, that the transcendence of the normal limits of voluntary control follows from this particular constellation (in a sense analogous to that in which under stress of violent emotion people surpass by a wide margin their usual levels of muscular strength and endurance), and that the elucidation of hypnosis will come from a more complete psychological analysis of this constellation. We should then know how the hypnotist must behave and what the personality of the subject must be in order to bring about the hypnotic state. The psychosomatic phenomena involved in suggestion directed to autonomic functions will of course require more than psychological analysis, but these problems seem to us not specific to hypnosis, but common to all psychosomatic investigation.