The challenge to contemporary practice is to preserve what is useful and solid, to refuse to be panicked into throwing the baby out with the bathwater, and to utilize all available information in a constructive effort to be of help to the dissociative patient. Not only has hypnosis been instrumental in the recovery of many dissociative patients—a strong argument can be made that since hypnosis is an inevitable aspect of their treatment, it is best that the treater be prepared to use it therapeutically.
Although dissociative patients in general have been thought to be highly hypnotizable, formal testing has established this only for dissociative identity disorder patients (Bliss, 1984; Frischholz, Lipman, Braun & Sachs, 1992). With any highly hypnotizable group of patients, one would be naive indeed to assume that the only hypnosis that takes place is the heterohypnosis that occurs in therapy. Keen observers have long observed their proclivity for spontaneous trance and autohypnosis (e.g., Breuer & Freud, 1955; Janet, 1965; Bliss, 1986; Spiegel, 1986, 1991). Consequently, eliminating heterohypnosis leaves the clinician less than well prepared to confront a group of troublesome spontaneous trance and autohypnotic phenomena that could be restructured constructively with adroit hypnotic interventions (Kluft, 1992a,b; Spiegel & Spiegel, 1978).
Today's clinicians must consider whether there are any circumstances that would make it unwise to use hypnosis with a particular dissociative disorder patient. If the patient is involved in legal matters, or if such involvement is anticipated, it is best to withhold the use of hypnosis until it can be determined whether or not its use might compromise the patient's credibility as a witness in a matter of concern. The use of hypnosis may be held to have tainted if not destroyed the credibility of a patient's memory, and consequently, his or her testimony (e.g., Orne, 1979; Hammond et al., 1995).
Some patients belong to religious groups that understand hypnosis may lead to a weakening of the will so that evil may enter the patient's mind (e.g., Jehovah's Witnesses). Under these circumstances, the patient can be educated about hypnosis, but it may still be a better choice for the patient to avoid the use of hypnosis and the spiritual concerns its application might precipitate.
Under no (non-emergency) circumstances should hypnosis be employed prior to obtaning the patient's informed consent for its use. Although specific informed consent forms have been developed (e.g., Hammond et al., 1995; Brown, Scheflin & Hammond, 1997), there is much to be said for the concept of informed consent as a process, advocated by Appelbaum and Gutheil (1992). In this approach, it is assumed that matters that bear on the issue of informed consent emerge recurrently throughout the course of a therapy, and must be revisited and reexplained. This is especially valuable in work with dissociative identity disorder patients, whose treatment is prolonged, and whose identity and memory are fragmented, and who undergo an ongoing process of reconfiguration throughout their psychotherapy. A particularly crucial area of informed consent is making clear to the patient that any material recovered with hypnosis or any other intervention may be quite useful for the therapy, but cannot be assumed to be historically accurate without external confirmation. This caveat may require frequent reiteration over the course of the therapy. Often it is useful to apply a type of verbalization drawn from Appelbaum and Gutheil's ideas, and often taught by Gutheil in workshop settings for teaching patients about medication side effects, but modified for hypnosis by the author (e.g., Kluft, 1997b):
When we use hypnosis to explore this block in your memory, we will be looking for hypotheses for further exploration. If we find something, whatever we find will be the starting point for more ongoing work—not the end of a quest or search. The nature of your hypnotic experience may give whatever we come up with the personal experience that it is very real. That and the fact you may visualize it can make it seem like what you have actually experienced and seen it, but that can be real deceptive. We tend to think that if we see it it has to have occurred. But that is not the way it is. We can deceive ourselves. Remember, we're looking for hypotheses. Moses didn't come down the mountain with what you may find in hypnosis engraved on a slab of stone, but it can feel that way.
All in all, then, the clinician must make a circumspect assessment of the patient's needs and circumstances, and arrive at a veritable cost-benefit analysis vis-à-vis the use of hypnosis. At different moments in a given therapy, it may be that the clinician comes to different conclusions as to how to proceed.
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