Five main techniques are utilized in hypnotic treatment. First, and most rarely used, is the prolonged, deep hypnotic trance, where the patient is placed in a deep hypnotic state and kept there for a period of hours or days. This treatment has been utilized for some fifty years, particularly in some of the neuroses, e.g., the vomiting of the gastric neuroses. It has also proved some value with some of the emotionally based tics.
The second method, also utilized for some time, is indirect suggestion. Here the technique employed is that of indirect, permissive suggestion, or indirect permissive removal of symptoms. The suggestions must be very detailed. For example, in treating an insomniac and teaching him how to go to sleep by means of posthypnotic suggestion, one must bear in mind that he must also be told that if he should awaken„ during the night for any reason, this teaching will also include the ability to return to sleep. Direct hypnotic suggestion constitutes a third method. This particular technique can be effectively employed in a small percentage of cases, but it requires especially careful handling of the patient to avoid arousing resistance.
The Fourth method of treating patients hypnotically is the use of a cathartic hypnotic state wherein, as Breuer stated, the hypnosis diminishes the inhibitions and repressions and releases the emotional block. This is a psychiatrically oriented type of therapy.
Hypnoanalysis, the fifth type of therapy, constitutes an approach in which analytic techniques are utilized on a psychiatric level, the hypnosis constituting an adjunct to shorten the therapeutic course.
Kline's expression ''directive hypnotherapy" as a term to replace "direct suggestion" is very well taken. The terms may be considered synonymous; however, they have different connotations. Despite the fact that it is called "directive hypnotherapy," the best type of therapy would actually be one that is utilized as an indirect suggestion in therapy—not a means of directly attacking the problem or symptoms or directly suppressing them with orders, but rather a technique bringing about a condition within the patient that can lead him to evaluate more productively the effectiveness of the activity, and resulting in a behavioral response more adequate for him as a total personality.
Two elements are requisite to the elicitation of productive activity in the hypnotic subject when direct suggestion is used. One is the depth of the hypnosis required; a somnambulistic state is probably necessary for most psycho-physiologic conditions. 'The second requisite is adequate understanding by the patient of the purposes to be served and their relationship to his personality needs.
Direct suggestion will probably never be as efficacious as indirect suggestion, which can eliminate some of the natural resistances of the patient. As one might expect, resistances increase in proportion to the neurotic nerds of the patient and the resulting altered state of psychologic and neurophysiologic functioning. In a patient with fewer neuroses and less neurotic behavior, there is more willingness to comply with direct suggestion.
An adaptation of the second hypnotic technique, indirect permissive suggestion, is probably most important to the general practitioner and the one with which we shall concern ourselves primarily in this discussion. The internist or the general practitioner is not usually qualified to give extensive psychiatric therapy to the patient, but he can utilize many of the techniques of indirect permissive suggestion to render the most satisfactory treatment to his patient. Most physicians have been treating symptoms by givug,ISpirin for headaches, codeine for coughs, and in many of these cases merely treating the symptom without getting to the underlying cause. With the utilization of hypnosis one has a valuable therapeutic adjunct. This type of therapy frequently presents the best opportunity for application and is usually the most effective in the ordinary complaints presented to the physicians.
Such suggestion can be employed (1) to obtain the deepest possible state of hypnosis within the time allotted to the patient, directing the symptoms and the suggestions with all eventualities considered; (2) to repeat these things frequently to the patient, thus reinforcing them.
Of course it is also important, before determining the type of suggestion to offer a patient, to get a well-oriented history without necessarily going into a detailed psychiatric history. It is important, as well, to utilize the patient's questions, both in the induction stages and in his treatment.
The depth of trance is probably not too important in the treatment of the minor neuroses that the average practitioner handles providing the doctor can clear up the mental state of the patient. Frequently, definitive results can be obtained. Schilder and Kauders claimed that they could obtain results in from one to four sessions. Of course, this may not satiate for a permanent cure. Many persons learn by slipping or erring and some patients need to experience this. Treatment should be continued subsequent to this "slip.''
Severe neuroses generally require name extensive hypnotherapy and many more sessions are usually indicated. The therapist may find that it is important to the patient to learn the purpose of his symptoms, when they do serve a purpose for him. It is not necessary for this awareness to be on a conscious level, however; the actual purpose may never become consciously recognized, but the patient's realization of the possibility that his symptoms may be important may lend itself to a revaluation of his symptoms. Consequently, substitutions may be evoked on the part of the patient through permissive suggestions, allowing for an improvement of the total personality. Schilder and Kauders also state that medical hypnosis helps the patient to rebuild his personality on the basis of an increased ability to adjust himself and to accept reality. This reconstruction takes place under the direction of the physician.
It is important also to note that reassurance, persuasion, re-education, and the like, which are certainly of value in the nonhypnotized patient, will have increased value in the hypnotized individual. These measures can be used effectively with even a light trance.
In the production of the trance state, the utilization of indirection allows for a better acceptance on the pail of the patient; it removes the possibility of defenses that are a normal response to a direct ordering away of either a physical sign or a symptom.
In contrasting the two methods, one might employ the following direct approach to the production of hypnotic deafness: "When I count to ten, you will find yourself getting more and more deaf, until finally, at the count of ten, you will be unable to hear anything at all."
On the other hand, the indirect approach might proceed in this fashion: "I wonder how it feels to a person who is about to lose his hearing? I wonder if he notices the fact that sounds seem to grow very, very slightly less distinct at first, if he finds that they seem to be fading off into the distance? And I wonder if the person then sits in his chair, leaning forward toward the sound? Does he cup one ear or both cars, or does he test his hearing by putting a finger in his ear to see if there is an obstruction there? Does he find himself straining more and more and holding his head to the side, all in an attempt to try to get an accumulation of more of the sounds? Does he find that, despite this, the sounds continue to fade farther and farther into distance? Do things finally sound as though they are only being whispered? Then does he notice despite the fact that he can see the speaker's lips moving, that he is unable to hear anything except an occasional noise coming through? I wonder if this is distinguished by a slight buzzing noise, or if there is no buzzing noise? Then how does lie feel; how does he look at one? Does he gaze intently, staring at people in an attempt to read their lips?"
All the while, of course, as this is drawn out very carefully and in detail, the speaker can be reducing the volume of his own voice, to help in the realization of the situation. In a careful, indirect procedure of this sort, one can produce hypnotic deafness. It will stand all the tests of physiologic deafness, because the subject was allowed unconsciously to utilize his own feelings, his own sensations, and his own knowledge of things, in order to limit and delimit his ability to hear sounds and the spoken word. He did not experience the normal resistances evoked by ordering him directly not to be able to hear. This type of procedure should also be used in the production of the hypnotic trance state. It should be employed in the treatment of any of the ailments where hypnosis is utilized.
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