What is Fractional Hypnosis

Therapeutic hypnosis: forms, possibilities and limits

The therapeutic application of hypnotic methods requires a process structured by the hypnotist with initiation and withdrawal of the state. The desired effects can be on the psychological, motor and psychosomatic symptom level. Embedding it in an overall psychotherapeutic framework is essential here.


The use of hypnotic methods in therapy, which has become increasingly frequent in the German-speaking countries in the last few decades, raises questions about the nature and possibilities of this method. Fortunately, it has officially become part of the psychotherapy curricula as a so-called second procedure. Nevertheless, we tend to be at the bottom of a development, especially in relation to English-speaking countries.
This delay has both historical and psychotherapy-ideological reasons. The openness to this ancient healing experience was blocked not only by general prejudices and stage hypnosis, but also by the dominance of conventional medicine and that of psychoanalysis.


Basics and essence of hypnosis


The general phenomenon of hypnosis
Apart from the mixture of fascination and eeriness that the keyword "hypnosis" triggers in many people, we are also faced with a scientific process, the nature and inner determinants of which are still largely unclear. The effectiveness of hypnotic techniques can be described in detail in many areas and also planned in a targeted manner. This applies not only to public show hypnosis, which is particularly appealing to laypeople, but also to therapeutic forms of hypnosis.
Regardless of the various popular theories of hypnosis in humans, this is undoubtedly an ability of biological systems in general. This apparently rests in common archaic layers and is relatively easy to trigger and activate. There would be no other explanation for the fact that there is also animal hypnosis with highly interesting phenomena (5, 11) and that not only beginners in further training in hypnosis, but even amateur laypeople manage to create corresponding states - in the latter, of course, with increased ones Risk of Incidents. The broad transition field from methodically induced hetero-hypnosis to self-hypnosis, spontaneous hypnosis, meditation and the various trance states and ecstatic exceptional states also shows that this must be about general reaction patterns of the psyche.


On the history of hypnosis
Hypnotic procedures are undoubtedly one of the oldest psychological healing methods known to man. They are known from ancient Egypt, the Asclepius cult (temple sleep) among the Greeks and a multitude of analogous practices up to modern times. They can also be found in other cultures, in shamanism, with medicine men and healing traditions of primitive peoples in general (2).
The systematic or scientific research into hypnotic phenomena can, apart from various precursors, be dated from F. A. Mesmer (1734 to 1815). Although he was attached to the physiological theory of a cosmic "fluid" and "animal magnetism", he helped hypnosis as a healing method to achieve a general breakthrough in Europe at that time. In the 19th century there was mainly the rivalry between the physiological explanatory pattern ("hysteria") of the school of Paris (J.-M. Charcot) and the psychological explanatory pattern ("suggestion") of the school of Nancy (H. Bernheim) of research the phenomenon of thrust.
With both of them S. Freud (1856 to 1939) had gained experience in hypnosis and also practiced it therapeutically. But he abandoned this path again for various reasons and gave psychoanalysis the clear preference. The later reservations of psychoanalysts against hypnosis in general have their roots in this, among other things. The European hypnosis tradition continued at the beginning of our century mainly through A. Forell and E. Bleuler in Zurich and through O. Vogt and J. H. Schultz in Berlin. The autogenic training developed by the latter is a self-hypnotic procedure derived from hypnosis.


Effect theories and hypnotizability
To date, there is no satisfactory or comprehensive theory of hypnosis, despite its proven effectiveness. The most common current model is the so-called dissociation or neodissociation theory (Janet / Hilgard) (4, 6, 7), which is based on the independent functionality of the individual cognitive and physiological systems and thus their specific controllability. Depending on the weighting of the individual hypnotic phenomena, the essence of hypnosis also became "organismic switching" (Schultz), "partial sleep" (Pawlow), "focusing" of attention (Erickson), increasing "ideoreflective excitability" (Bernheim), "being more awake State of consciousness "(Thomas) or" lowering of consciousness "by means of" regression of the basic function of the personality "(Stokvis / Langen). There are also learning-theoretical models that understand hypnosis, for example, as "abstract conditioning" (Welch) or "conditioned inhibition" (Edmonston), through to interpretation as "social-psychological role play" (Sarbin). Each of these explanatory or theoretical approaches (5, 6, 7) undoubtedly hit certain levels of hypnotic responsiveness, but not the complexity of the phenomenon.
The question of whether a person can be hypnotized in general, as a special case of general suggestibility, not only moves many laypeople, but is also of great importance for therapeutic indications. According to the overwhelming opinion, a maximum of ten percent of people are considered refractory, that is, not hypnotizable, whereby a further part of these can become responsive through frequent hypnotization. About 20 percent can be hypnotized very deeply, sometimes up to somnambulistic states with amnesia, the majority is in the range of moderate depths of hypnosis (5). But it is precisely these that usually prove to be more favorable for therapy, probably because of the conscious ego part that is preserved. For the hypnotizability and the so-called "depth" of hypnosis, a large number of scales and test procedures have been developed, but these are of little importance for practical therapeutic issues.


Types of therapeutic hypnosis


The direct or "classic" hypnosis
It is based on the historically developed and in many variants modified relationship patterns, which assign the hypnotist a clearly passive, subordinate, reactive position and the hypnotist an active, dominant, determining position.
This is particularly evident in the clear suggestive instructions for initiating hypnosis, but also in the application of therapeutically effective formulas or in the verbal guidance through visual experiences. The induction of changes in the body experience (heaviness, warmth and other) or in the muscle function (arm levitation, catalepsy) takes place predominantly in a directive manner. This method, which is characterized by rather clear guidelines, suits the structure and hypnotic responsiveness of many patients even today. The process and goals of hypnosis are transparently discussed in advance.


The indirect or "new" hypnosis
Here the experience is taken into account that not a few people increasingly develop a resistance to direct psychological external determination and therefore also in hypnosis better open to a permissive method that allows a lot of freedom of choice. The patients are influenced rather imperceptibly, mostly through a dialogue that gradually leads into the hypnotic state ("trance"), whereby special methods can also be used.
These include suggestive sprinkling techniques and confusing techniques, the empathic recording of body processes ("pacing"), for example the breathing rhythm, and its imperceptible influence in one's own walking ("leading"), also the leaving open of divergent reaction possibilities or the reassessment of symptoms in their symbolic content or internal meaning ("reframing"). The main idea here is the development of one's own resources for problem solving and symptom reduction ("utilization"), trusting in the positive compensation possibilities anchored in the unconscious from learning experience and creativity. This form of "new" hypnosis, masterfully developed by Milton Erickson (3), has found widespread use in a short time.


Critical assessment of the differences
The new methodical elements certainly represent a great enrichment and expansion of the hypnotherapeutic repertoire. However, one should be warned against simply viewing them as the more progressive and thus "better" models that would have to replace the classical methods. Rather, it is only when the patient gets to know the patient subtly and in the individual indication that it becomes sufficiently clear for which procedure he is best suited according to his structure. A skillful combination of both forms often proves to be particularly effective. The aim of future hypnosis training must therefore be to promote the acquisition of appropriate skills on both methodological levels.


Implementation and techniques


Structure and therapeutic context
Hypnosis is based on an intensive relationship on both sides ("hypnotic rapport"). A relaxed, low-noise, slightly subdued atmosphere should be created to ensure that this occurs as smoothly as possible. The quiet, rather monotonous language of the hypnotist, which is to be striven for, also serves to provide internal orientation in the report. The necessary building of trust for this requires a corresponding empathic attitude of the hypnotist. In principle, it can be performed lying down as well as sitting, as individual or group hypnosis.
Any therapeutic hypnosis that is not only aimed at a momentary symptom reduction needs to be embedded in a general psychotherapeutic context. In which section of the therapeutic process it makes sense to switch on a hypnotic sequence is determined by the range of indications applicable for this and the corresponding suitability criteria on the patient side. Regardless of this, every hypnotic session must include a direct, albeit brief, preliminary and follow-up discussion.


Introduction, deepening, withdrawal
Introducing the patient into the hypnotic state ("introduction", "induction") can be done using a variety of so-called induction techniques, but requires an internally clear, purposeful approach by the therapist himself. In direct hypnosis, optical methods (eye fixation, Color experience, inner images) or acoustic methods (monotonous noises, calm tone sequences, suggestive language), also concentrated suggestion of body sensations (heaviness, warmth, breathing) in the foreground. Indirect hypnosis works primarily with dialogical verbal inductions, including taking up physical and visual experiences; In this way, the patient often enters the trance less noticeably or surprisingly.
If a first hypnotic level has been reached through such introductory techniques, a further deepening can follow through targeted, verbal, suggestive guidance. These stages are particularly suitable for introducing the desired therapeutic elements (formulas, visual experiences, guided presentations, hypnoanalytic processes). Dialogic contact with the patient should be possible at any time, also to identify internal disorders.
The correct and complete "undoing" of all hypnotic changes, both on a psychological and a physical level, is of great importance (8). For safety reasons, this is best done in stages (counting methods, targeted feedback, tactile stimuli) and includes the hypnotist's reassurance that the normal state has been reached in order to avoid post-hypnotic incidents. In the case of indirect hypnosis, the withdrawal is usually less pronounced, because here the proportion of self-direction is greater.


Special variations
The hypnosis technique has been enriched in the course of time by a multitude of possibilities for modification. For example, so-called "fractional hypnosis" (according to Vogt and Brodmann) (6) has proven to be effective for deeper deepening, in which the hypnotism is partially returned one or more times after a shortened introduction; the then reported hypnotic sensations are particularly intensified in the renewed induction.
For the patient's own therapeutic responsibility to be striven for, it is important to use methods that can gradually detach him from the actual presence of the hypnotist. In the so-called "ablation hypnosis" according to Klumbies, the patient is given the opportunity to repeat the hypnosis he has experienced at home (via tape or hypnotically imprinted signal stimuli). The "stepped active hypnosis" developed by Kretschmer and Langen, on the other hand, goes the opposite way: the patient first has to learn the basic exercises of autogenic training and thus gets into hypnoid switching much more quickly in the hypnotic sessions (5, 6, 8). It must be remembered again and again that the autogenic training developed by J. H. Schultz is an autohypnotic procedure derived directly from hetero-hypnosis (9, 10).


Levels of action of hypnosis
Hypnosis, as a typical holistic procedure, already uses influence in the induction phase, both on the psychological as well as on the psychomotor and the somatic-vegetative symptom parts of the human being. In general relaxation, immobilization and immersion as the primary effect, the favorable directions of action on the respective functions are therefore already in place.
On the psychological level, the specific suggestive effects can then lead to the desired serenity and distancing, to influencing various fears, to increasing self-esteem or to special forms of experience with an intended behavioral change. On the psychomotor level, in addition to reduced muscle tension, contrary hypnotic processes, often experienced as spectacular, can also be generated, such as involuntary movement phenomena (levitation, catalepsy, automatic writing), some of which can also be used therapeutically. As is known from autogenic training, the vegetative system is evidently amenable to hypnotic influencing and switching in a special way, which not only takes place via the smooth muscles, but also via the sensory system, the internal secretion and the immune system (1, 5, 6, 7).
Both conscious inner attitudes and unconscious system and resource activations are equally important. The variety of therapeutic indications is obviously based on these complex overall processes, a synthesis of relaxation and activation processes at the same time. Hypnosis is anything but a state of sleep, which also results from the increased alpha rhythm in the hypnosis EEG, which clearly correlates with hypnotizability or suggestibility (5, 6).


Therapeutic indications


Basic forms of the hypnotherapeutic procedure
From the variety of possibilities, four types of hypnotic-suggestive influence on certain disturbance patterns can generally be singled out. A subtle individual assessment, including one's own level of training and experience, must then result in which type is specifically suggested for the respective patient.
The simplest basic form, which is also most suitable for beginners, is the so-called "indifference" position of the symptom, which means that this (for example fear, pain) is suggested as "completely indifferent" in order to achieve an inner distancing. The next to be mentioned are the applications of proven formulas, which, after they have also been accepted by the patient in the preliminary discussion, concretely and clearly run counter to the syndrome or undesirable behavior (e.g. test anxiety, addiction, psychosomatic disorder); they can also be transferred analogously to autogenic training (10).
Even greater demands are made on the hypnotic ability then targeted dissociation techniques, in which the patient finds himself through guided picture life in a different, more pleasant situation, where the symptoms are positively reinterpreted (for example hypnotic analgesia in dental treatment, headache, fear of flying) or where the Symptoms are transformed or moved. The targeted hypnotic mobilization of one's own resources and solution patterns, finally, the particular strength of Erickson's indirect hypnosis (3, 7), works with the aforementioned repertoire of utilization, refreshing and stimulating creativity, especially with more complex processes (e.g. maturation crises, psychosomatic syndromes, immunological disorders ). There are of course a multitude of possible combinations between these basic hypnotherapeutic patterns.


Special symptom and disease areas
Not only because of the necessary brevity, but also because of the highly divergent therapeutic experiences with hypnosis, it is an unprotected undertaking to go through the various areas of indications enumerating. Without any gradation, it can only be stated here where hypnotic interventions can at least in principle be effective.
One of the main fields of hypnotherapy - especially for beginners - is the multitude of anxiety states: circumscribed anxiety syndromes in the neurotic border area (fear of flying, fear of exams), special social fears, claustrophobia, claustrophobia, panic attacks, up to the classic object phobias and generalized fears. A next area are chronic pain syndromes (of course, as long as they do not have an acute signal character): headache, phantom pain, spastic pain, and on the other hand the direct elimination of pain (hypnotic analgesia) during interventions, now increasingly especially in dentistry.
Motor disorders are more accessible to hypnosis, the stronger their psychogenic component is (stuttering, tics, writer's cramps, bruxism, psychogenic paralysis). The same applies to the large area of ​​psychosomatic disorders, here practically all organ systems can be partially approached (especially gastrointestinal tract, skin, respiratory tract, cardiovascular system, urinary tract), and the more so, the stronger the circle of affect - tension - dysfunction or - pain plays a role. In the same way, sexual dysfunctions and even the immune system respond to hypnotic methods.
As with other treatment concepts, hypnotherapy is more difficult for addicts (especially smoking and alcohol addiction); The careful clarification of the motivation situation, the ability to cooperate and the planning of longer-term treatment sequences are prerequisites for success. Likewise, the possible, but sometimes controversial, use of hypnosis in depressive syndromes requires a lot of experience and flexibility; the hypnotic responsiveness decreases anyway with increasing depth of depression. The use of hypnotic methods in schizophrenic psychoses is particularly controversial (6, 7). To be mentioned, but no longer part of the topic, is the increasingly practiced use of hypnosis to improve performance (sport, learning, creativity).


Hypnoanalysis
Despite all the historical contradictions between hypnosis and psychoanalysis, a fruitful synthesis between the two methods has developed, which of course requires a lot of competence on both sides. It proves most clearly that the conventional assignment of hypnosis to the so-called "covering" procedures in psychotherapy is outdated. The uncovering of psychogenetic determinants for current symptom formation from the psychological biography (trauma, deficits) does not take place here with conscious, associative methods, but by means of hypnotically induced search movements (e.g. graded age regression) or targeted focusing out of the unconscious. In this way, access to buried experiences can often be gained and dealt with much more quickly and closer to the affect. In a sense, hypnoanalysis is the "high school" of hypnosis.


Limits and Dangers


Differentiation from show hypnosis and lay hypnosis
In the population there is often great irritation and reservations about hypnosis as a therapeutic method, due to previous experience with spectacular hypnosis effects on stage and on television. Unsurprisingly, hypnotic natural talents often create sensational phenomena, especially by skilfully filtering out highly suggestible people from the crowd. Likewise, amateurish laypeople who simply want to "try out" hypnosis can often generate unexpected or even unrecognized hypnotic states. The dangers, especially of not taking it back or taking it back inadequately, are obvious. One of the most important priorities for patients to be informed is to make the major differences to therapeutic hypnosis as clear as possible, and above all to discuss the frequent fear of losing control.


Therapeutic Limitations and Contraindications
Hypnosis is a psychologically enormously invasive procedure, and its responsible application is inconceivable without careful preliminary diagnosis and without embedding it in an overall psychotherapeutic process. On the other hand, as stated, there is a wide range of possible indications within which the instrument of controlled withdrawal can quickly return even the most intense effects and experiences to the normal state - mostly better than with other stressful psychotherapy methods.
Limitations exist on the one hand and naturally through poor response to the method itself, then through organic brain disorders, lack of concentration and lack of cooperation (small children), intoxication (alcohol), stronger affective disorders (severe depression); they also apply to clear resistance to hypnosis in general. The old advice from J. H. Schultz (9) that two groups of people should not be hypnotized: those who absolutely want to be hypnotized and those who do not want to be hypnotized under any circumstances is still very important to heed.
So patients who really push themselves to hypnosis (as supposedly "only help") can already represent a relative contraindication, both because of the strong regressive desires as well as because of the over-expectation that usually exist here. Stronger hysterical accentuations are also considered a relative contraindication. Apart from the mentioned controversial indication for psychotic states per se, paranoid syndromes in particular require critical consideration; an attempt at treatment must be reserved for a highly experienced hypnotherapist.


Hazardous areas and incidents
The overwhelming number of negative incidents is due to a missing or incomplete withdrawal of the hypnosis, or the inadequate reassurance about possibly persisting psychological or physical residual phenomena. Remaining ego dissociations, emotions or images as well as drowsiness, shifts in the body scheme, heaviness or changed sensory perceptions can be dangerous, especially in traffic. Next are the consequences of uncritical indications and briskly initiated but no longer controllable psychological processes, such as acute fear or discharge reactions, self-esteem, loss of orientation, depressive or psychotic attacks.
Incidents and unpredictable reactions can of course also occur when the hypnosis is carried out properly. But in the hands of the ignorant and unauthorized, the dangers described are incomparably greater. This is especially true if the overall therapeutic tools are missing or if - as is usually the case after show hypnosis - those affected are left to their own devices.
The often discussed danger of sexual abuse in hypnosis is undoubtedly given and proven. However, it is hardly higher than with other favorable constellations in medicine in general. However, especially the situation of psychological closeness and being at the mercy of a person, with a reduction in individual control mechanisms, can increase temptation.
On the other hand, the possibility of hypnotizing someone to commit a crime - a recurring topic in the media - is extremely limited. The experts largely agree that it is practically impossible to force a person under hypnosis to act contrary to his own personal value system, as long as the patient is not under any other social pressure or dependency situation (6, 7).


closing remarks
The therapeutically used hypnosis is a procedure with comparatively high efficiency and at the same time good control ability. Due to its psychologically strongly invasive character, it offers the possibility of mobilizing often unimagined healing potentials and resources, admittedly sometimes with the delivery of unexpected reactions. Dealing with both in a way that is productive and protective for the patient requires comprehensive competence and experience with psychodynamic-psychotherapeutic processes in general.
This also makes a statement about the technical and professional background that is generally acceptable for this procedure: In addition to the special hypnosis training, there must also be psychotherapeutic training or further education. This also generally limits the occupational groups in question, namely doctors and clinical psychologists with such qualifications, apart from the special situation with hypnotic dentists. Everything else must remain a person-related and qualitatively comparable and controllable exception.
If one therefore considers the framework conditions necessary for a responsibly carried out hypnosis treatment, including the respective preliminary and follow-up discussions, then in the current remuneration situation *) only an official disdain for the value of such a service can be seen. All the more appreciation is deserved for those who do not allow themselves to be deterred from using it because of their personal affinity for this procedure and because of their conviction of its therapeutic possibilities.


How this article is cited:
Dt Ärztebl 1997; 94: A-3351-3356
[Issue 49]
literature
1. Bongartz W: The influence of hypnosis and stress on the blood count. Frankfurt: Verlag Peter Lang, 1996.
2. Ellenberger HF: The discovery of the unconscious. Bern: Hans Huber, 1985.
3. Erickson MH: Advanced techniques of hypnosis and therapy (edit J Haley). New York, London: Grune and Stratton, 1967.
4. Hilgard ER: The problem of divided consciousness: a neodissociation interpretation. Ann New York Acad of Science 1977; 296: 48-59.
5. Jovanovic UJ: Methodology and theory of hypnosis. Stuttgart: Gustav Fischer-Verlag, 1988.
6. Kossak HC: Hypnosis. 2nd edition Munich: Psychologie Verlags Union, 1993.


7. Revenstorf D (Ed): Clinical Hypnosis. Berlin, Heidelberg, New York: Springer-Verlag, 1990.
8. Schäfgen E: Hypnotherapy. Cologne: Deutscher Ärzte-Verlag, 1992.
9. Schultz JH: Hypnosis Technique. 9th edition Stuttgart, Jena, New York: Gustav Fischer-Verlag, 1994.
10. Thomas K: Practice of autogenic training / self-hypnosis according to J.H. Schultz. Stuttgart: Thieme, 1989.
11. Völgyesi FA: Human and animal hypnosis. Zurich: Orell Füssli Verlag, 1963.


Author's address
Prof. Dr. med. Günter Hole
Specialist in psychiatry and neurology, psychotherapy
Kantstrasse 5/3
88213 Ravensburg