A significant breakthrough in understanding the potential use of hypnosis with psychotic patients came in 1945 with the publication of Lewis Wolberg's book on the hypnoanalysis of Johan R. Johan R. had been confined on the chronic ward of a hospital with a diagnosis of hebephrenic schizophrenia when Wolberg first attempted to work with him. It took Wolberg more than a year to establish a beginning therapy relationship with the patient. Beginning with traditional psychoanalytic techniques, Wolberg decided to experiment with hypnosis when the patient experienced difficulty with traditional free association. Initial attempts at hypnosis were unsuccessful. However, eventually dream interpretation allowed the patient to utilize hypnosis and ultimately to conclude a positive hypnoanalytic treatment. Johan R. was eventually discharged with no outward trace of mental disorder. A post-treatment Rorschach test revealed no evidence of anxiety and no neurotic or psychotic tendencies. A follow-up by Wolberg 16 years later indicated that Johan was continuing to live a productive, independent life.
Following Wolberg's landmark book, the work of Margaretta Bowers provided another major advance in our understanding of the clinical potential of hypnosis with psychotic patients. Bowers (Bowers, Berkowitz & Brecher, 1954) expanded the concept of the use of hypnosis for the severely disturbed patient from the unique individual case to the general class of severe mental illness. In 1954, Bowers reported on positive hypnotherapy work she had done with a series of 10 psychotic and other severely disordered patients. In later publications, she summarized hypnotic work with a series of 30 chronic, ambulatory schizophrenics and addressed the issues of the use of hypnosis with schizophrenic patients as a general group (Bowers, Berkowitz & Brecher, 1954; Bowers, 1961; Bowers, Brecher-Marer & Polatin, 1961; Bowers, 1964). Bowers also reported on her early use of hypnosis with positive clinical results with Multiple Personality Disorders (Bowers & Brecher, 1955; Bowers, Brecher-Marer et al., 1971). Bowers concluded that psychosis was a defense and that it was the task of the therapist to assist the healthy self to regain its lost dominance over the defensive facade presented by the psychotic patient. Bowers felt that hypnosis was a powerful tool to assist the therapist in this task of connecting with and reestablishing the dominance of the 'healthy self'.
Following the pivotal and pioneering work of Wolberg and of Bowers in the mid-1900s, a continual flow of clinical work utilizing hypnosis with severely disturbed patients was reported in the literature. Schmidhofer (1952) reported symptom relief in groups of psychotic war veterans through relaxation and suggestion. Danis (1961) reported that some of his schizophrenic patients were able to utilize hypnosis to help them to sustain and continue their ongoing therapy work. Stauffacher (1958) described the successful treatment with hypnosis of a paranoid schizophrenic male patient. Hypnosis was utilized to help the patient uncover repressed material. The patient was able to utilize the insight from these recovered memories and to achieve a complete remission of his illness.
Then in 1959, Gill and Brenman reported that while most schizophrenics in their studies were apparently not amenable to hypnosis, nevertheless some schizophrenics were paradoxically highly responsive to hypnosis. Gill and Brenman reported specifically on successful hypnotic therapy intervention with a 'severely disturbed schizophrenic girl, regarded by most of the staff as hopelessly psychotic'. The positive response and clinical improvement in this severely disturbed psychotic patient, as reported by Gill and Brenman, was unmistakable and impressive.
Abrams (1963) also described hypnotherapy work with a female inpatient diagnosed as 'schizophrenic reaction, chronic undifferentiated type'. Her symptoms included hallucinations and delusions. During previous treatment, she had not responded to psychotherapy, electroconvulsive therapy, or to drug therapy. With the introduction of hypnosis into her therapy treatment the patient exhibited a reduction of resistance which enabled her to discuss previously unapproachable/inaccessible traumatic material. Subsequently all symptoms were eliminated and the patient was able to establish an independent existence outside the hospital.
Illovsky (1962) reported interesting results utilizing hypnosis in group therapy with 80 chronic schizophrenics. These patients had been hospitalized for an average of 6-8 years. They were seen in large groups (sometimes 100-150 patients at a time) and were given suggestions for relaxation and ego-building. They were treated with tranquilizers in addition to the hypnotic intervention. The convalescent placement of the patients in the hypnotic treatment groups appeared to surpass the placement rate of the non-hypnotically treated patients.
In addition, Milton Erickson (1964, 1965), while developing and publishing his well-known work on the utilization of indirect techniques in hypnosis, also contributed two clinical accounts of hypnotic work with psychotic patients. In 1964 Erickson reported a case of successful use of hypnotic intervention with a 24-year-old paranoid schizophrenic woman with complaints of visual and auditory hallucinations. Utilizing the patient's resistance and employing indirect induction techniques, Erickson was able to engage this highly resistant patient in hypnosis. Subsequently, the patient was able to accept hypnosis as a positive resource for therapeutic intervention. In a second reported case employing the use of hypnosis with a psychotic, Erickson (1965) described his work with a 25-year-old psychotic male, whose main symptomatology included confusion and word salad. Indirect hypnotic techniques were employed to engage the patient in a relationship and ultimately in therapy.
In 1967, Biddle described a successful example of hypnotic work with a severely psychotic patient. The patient was a single woman in early adulthood at the time of her psychotic break. She was admitted to a hospital with symptoms of confusion, hallucinations, belligerent behavior, and generally inappropriate behavior including: smearing her feces, crawling on her hands and knees, and taking off her clothes. The hypnotherapy work focused on the exploration of sleeping dreams and hypnotically induced dreams. A description of 15 months of treatment was described by Biddle, with the successful reintegration of the patient into a responsible life outside the hospital, including a job and later marriage.
Guze (1967) formulated therapeutic guidelines for utilizing hypnosis with schizophrenics. He saw hypnosis as useful in eliciting patient symptoms of hallucinations, delusions and thought disorders and then reshaping them. He emphasized the necessity of guiding the patient's imagery in a healthy direction as early as possible. However, Guze also stressed that the patient should only move at a pace he could handle. Guze also felt that hypnosis assisted the therapist in connecting with the patient's inner psychotic experience, thereby helping the patient both to validate the reality of that experience and to begin to shift to a healthier experience and reality.
Worpell (1973) reported an account of successful use of hypnosis with an hallucinating schizophrenic woman. The utilization of hypnotherapy produced a positive change in the patient's appearance and behavior. There was also a noticeable decrease in her hallucinations. Worpell noted that the use of appropriate medication was also an important factor in this case.
Zeig (1974) reported on his work with paranoid schizophrenics, utilizing informal hypnotic induction techniques. Zeig stated: 'In cases where I have used a more formal introduction to hypnosis and more formal induction with psychotic people, I have met with little success, seemingly due to resistance and fears which I have not easily allayed.' Zeig then described his indirect techniques of relaxation with the use of metaphor and puns. He reported that these indirect techniques were successful in helping paranoid schizophrenics deal with the control or removal of their 'voices'.
Scagnelli (1974, 1975, 1976, 1977) published a series of studies on the therapeutic integration of hypnosis into psychotherapy with schizophrenic and personality disorder patients. In the 1974 paper, Scagnelli reported successful clinical work with an acute schizophrenic male patient. The patient was diagnosed in two prior hospitalizations as an acute affective schizophrenic. He experienced alternating delusional patterns of grandiosity and threat. His threatening delusions centered around fears that he was about to die or that he was turning into an animal. His grandiose delusions centered around feelings that he was 'designated' to heal other patients. Hypnosis was utilized to help the patient access his anxiety-laden feelings of inadequacy. With the use of hypnosis the patient was able to access and reframe his past experiences. He was then able to build a more positive sense of self-esteem. Specific hypnotic techniques included: relaxation for the reduction of anxiety; hypnotic dreams for insight work; hypnotic imagery shifts to develop feelings shifts to a more positive self-concept; and hypnotic egobuilding messages. After 7 months of hypnotherapy, the patient no longer experienced delusional thought patterns and was able to function in a part-time job.
Following that individual case study, Scagnelli (1975, 1976) published two summary reports of therapy with several severely disturbed patients. The 1976 paper described specific hypnotic work with four schizophrenic and four borderline patients. Three of the schizophrenic patients were seriously disabled and had been hospitalized several times. Three of the borderline patients had been hospitalized for periods ranging from 3 days to 3 months. All of the borderline patients had several years of therapy prior to the introduction of hypnosis. Specific problems that were likely to be encountered in the use of hypnosis with this patient population were enumerated: fear of loss of control; fear of closeness; and fear of relinquishing negative self-concepts. Procedures for dealing with these fears were detailed. In addition, specific hypnotic techniques that could be used successfully with psychotic and borderline patients were outlined. Techniques for anxiety reduction were considered generally applicable to this patient population. Then with variations according to the needs of the individual patients, other hypnotic techniques could be employed. Techniques of ego-building, free association for insight, dream production and analysis, and the creation of imagery shifts were presented and their use detailed. Scagnelli also suggested that reevaluation of parental relationships and assertion training might lend themselves to use in future hynotherapy with severely disturbed patients.
In 1977, Scagnelli published a case study of hypnotherapy with a patient with a schizoid personality disorder. In his original non-hypnotic therapy work the patient exhibited extreme anxiety and a tendency to withdraw and decompensate whenever attempts at insight were explored. However, when hypnosis with its potential for dream production and analysis was introduced, the patient was able to work productively in therapy with reduced anxiety and less decompensation. In hypnotic dream work, the patient dealt with intense anxieties about identity confusion, incorporation, and issues of castration and death. The emphasis on autohypnosis and on the technique of 'creator control' of the dream-imagery process appeared to be essential factors in giving the patient a feeling of being in control of the hypnotic process and in permitting him to deal with his psychotic-like material without being overwhelmed. The patient reported that the use of the hypnotic process with its imagery, symbolism and metaphor allowed him to communicate in ways that verbal language alone would not have permitted.
Throughout the remainder of the 1970s, additional case reports of successful work with psychotic and personality disorder patients continued to be published. A case report in 1977, by Berwick and Douglas, described the successful utilization of hypnosis with two paranoid schizophrenic woman. The first woman believed that her late husband was Satan, and that he was possessing her mind. The second woman believed that 'black magic' was being used against her to cause her misfortune. In both cases, a traditional induction technique of eye fixation was used. The therapists then entered the patients' delusional systems and suggested the enhancement of the patients' powers to overcome the external power. Both cases responded positively. Insight was not attempted, but the delusional systems resolved as they became irrelevant and unnecessary.
Sexton and Maddox (1979) reported hypnotic work with three psychotically depressed women. The women displayed symptoms of confused and delusional thought patterns, catatonic behavior, and some suicidal ideation. No formal induction was used. However, the patients were directed forward in time (age progression) to some future resolution of their problems (with God or a loved one in heaven). The authors reported a restitution of ego functioning and a decrease in psychotic symptomatology for all three patients.
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Hypnosis has been defined as a state of heightened suggestibility in which the subject is able to uncritically accept ideas for self-improvement and act on them appropriately. When a hypnotist hypnotizes his subject, it is known as hetero-hypnosis. When an individual puts himself into a state of hypnosis, it is known as self-hypnosis.