Essentials of Complementary and Alternative Medicine (June 1999)

W
ICKRAM
 E
XPERIENCE
 I
NVENTORY
Another brief (24 item) paper-and-pencil test called the Wickram Experience Inventory (
1
) also correlates moderately with measured hypnotic ability and very highly 
with the absorption scale. Persons who answer “True” to more than 18 of these questions generally have moderate-to-high hypnotic ability. The paper-and-pencil test 
avoids the large problem of noncompliance with standardized behavioral tests (e.g., Harvard, Stanford) of hypnosis that is encountered with medical-surgical patients 
(
19
).
C
LINICAL
 A
PPLICATIONS OF
 H
YPNOTIZABILITY
 M
EASURES
Estimating the Patient's Hypnotic Ability
The ability to accurately estimate a patient's hypnotic ability noninvasively can have great value in clinical practice. It enables the clinician who is familiar with the 
empirical literature regarding the base rates of hypnotic ability in specific syndromes (e.g., bulimia) to make more accurate predictions about a specific patient during 
the initial sessions. The therapist's knowledge of both the patient's cognitive style and the empirical base rates of certain verbally reported experiences and potential 
behaviors are predictive: individuals who have high hypnotic ability can be told, “you can wake up without an alarm at a preselected time without training; you can find 
meaning in randomly distributed events or stimuli; you are likely to cry at movies; you are hypersensitive; you can fall asleep easily in a variety of places; you are too 
empathic; you are prone to mood swings, you spend time in fantasy; you have had several extrasensory perception (ESP) experiences.” Persons who have low 

hypnotic ability can be told, “you are skeptical and pragmatic; you are practical; you rarely day dream; you need to be shown, not just told; and you seldom recall even 
night dreams.” With persons of high or low hypnotic ability, these therapist verbalizations may grasp the patient's attention and interest, enhancing the therapeutic 
rapport in the critical first few sessions of therapy. Some patients may feel the therapist is “reading their mind.” Rapport with the patient may potentiate the therapist's 
ability to influence the patient's perceptions, memories, and moods about the past, present, or future (
19
, 
86
, 
87
 and 
88
). The skilled therapist can often make 
accurate predictions and postdictions about the patient's present, future, and past life experiences, based on the patient's (high or low) hypnotic ability, that help the 
patient to very quickly feel deeply understood. The patient is likely to see the therapist as having specialized knowledge, wisdom, and understanding. A patient is 
more likely to follow the instructions of such a highly credible therapist. The induction of a sense of hope, trust, and mysterious power is sometimes a prerequisite to 
mobilize a demoralized patient who has chronic disease. This perception of strength and wisdom can be used to help the patient take the initial steps to become an 
active participant in his or her own rehabilitation. It is done through a hypnotic induction and later through training in self-hypnosis, and it can be confirmed by 
objective quantitative biological feedback (
1
, 
65
).
Estimating How Often the Patient Uses the Hypnotic Mode of Information Processing
It is also useful to know how often your patient typically uses the hypnotic mode of information processing, particularly during stress in everyday life. High hypnotic 
ability is a cognitive style that has predictable consequences for health and disease (
1
, 
3
, 
12
, 
65
). I recommend the use of a technician to administer either a formal 
test, such as the Harvard scale, or even a paper-and-pencil test, such as the absorption test or the Wickram Experience Inventory (
1
), to secure a quick measure of 
hypnotizability. The information from the tests is useful even if the clinician never labels the interventions used as hypnotic. For the patient who easily and often uses 
the hypnotic mode of information processing, the ritual of writing a prescription for an active medication (e.g., benzodiazepine, beta-blocker) can be a type of waking 
hypnotic induction. The ritual of prescription writing and delivery can be used to secure eye contact with the patient and to give direct, clear, and simple verbal 
suggestions to potentiate the effects of even small quantities of sleep, pain, or anti-anxiety medication (
1
). In the case of the patient who has high hypnotic ability, 
special care should be taken during the interview and patient education to avoid inadvertently delivering negative suggestions that may contribute to iatrogenic 
illness. If the patient of high hypnotic ability is interpersonally engaged in a negative way, he or she can be a formidable antagonist—one who is creatively resistant 
and who can even negate the clinical efficacy of specific chemical and surgical procedures of scientifically proven potency (
1
).
Matching Patient Hypnotizability to Therapy
The ability to use hypnotizability measures to match clinical procedures with patient characteristics has great clinical potential (
89
). It is essentially matching the 
patient's cognitive style to specific, empirically validated therapy procedures to maximize the clinical outcome. For example, a patient who has high hypnotic ability but 
is technologically and quantitatively minded and skeptical of hypnosis should get delayed biofeedback (
1
, 
3
, 
89
). Delayed biofeedback involves the therapist verbally 
instructing the patient to relax with eyes closed while withholding immediate biologic (e.g., EMG) feedback. The feedback can be provided after 4 to 5 minutes of 
passive relaxation to confirm the objective changes in physiology. This reduces skepticism and objectively builds the highly hypnotizable patient's faith in his or her 
ability to alter one's physiology. Immediate auditory EMG feedback can initially interfere with muscle relaxation learning of highly hypnotic subjects (
1
, 
121
). Labeling 
the procedure as delayed biofeedback rather than hypnosis enables the therapist to access instructionally the patient's hypnotic ability while avoiding the mobilization 
of the patient's skepticism. The patient who has low hypnotic ability can learn to decrease his or her frontal EMG signal (muscle relaxation) most rapidly with 
immediate EMG biofeedback (
1
, 
121
). If a patient with low hypnotic ability has a strongly positive attitude toward hypnosis, hypnotic suggestions can be given along 
with the immediate biofeedback training procedure, thus capitalizing on the separate placebo or nonspecific components of both biofeedback and hypnosis (
1
, 
48
, 
65
). This approach enables the therapist to rationally use both ability and motivational components in hypnotic performance. Although the ability component may not 
be altered permanently or significantly, the motivational component may be potentiated, attenuated, or neutralized through creative use of labeling procedures and the 
instructional manipulation of implicit or explicit expectancies. Hence, there are good clinical and scientific reasons (e.g., matching cognitive styles with therapy 
procedures) to unobtrusively estimate every patient's hypnotic ability in routine clinical practice, especially when dealing with chronic stress-related disease (
1
, 
3
). 
Many stress-related diseases may be driven by high or low hypnotic ability (
1
, 
12
).
If a patient has low hypnotic ability but has a positive attitude toward hypnosis, certain psychophysiologic procedures may temporarily increase hypnotic ability. In 
fact, these pretreatment procedures may be indicated for the majority of patients because only approximately 10% of the population is estimated to have high hypnotic 
ability. These procedures include sensory restriction, EMG, and EEG theta wave feedback training (
1
, 
3
, 
48
, 
49
, 
65
). Both alpha wave and frontal EMG feedback 
training concurrently increase theta wave production. These procedures are the pretreatment procedures of choice for all patients who have low or moderate hypnotic 
ability. They probably work by temporarily inducing a relative inhibition of the patient's skeptical-critical-analytic-cognitive functions, which potentiates the therapist's 
verbal instructions (
1
, 
48
, 
49
, 
65
).
Summary of Clinician Assessment
The clinician should start by making two assessments. First, he or she should determine with a simple visual analogue rating scale how positively, neutrally, or 
negatively the patient feels about hypnosis, and how much hypnotic ability (high, moderate, or low) the patient thinks he or she has. Attitudes and self-predictions of 
hypnotic ability modestly predict hypnotic performance. If the patient has a negative attitude toward hypnosis, the specific sources of the negativity should be 
investigated. For example, is the negativity based on misinformation (e.g., fear of unconsciousness—I will blurt out private information) or on a humiliating personal 
experience with stage hypnosis? These negative attitudes can be neutralized by counter-information from the therapist, a high credibility source with whom the patient 
has rapport. Second, it is necessary to get a valid and reliable measure of hypnotic ability. This test measure can enhance rapport through therapist statements that 
seem uncannily accurate in a predictive and/or postdictive sense, even if hypnotic procedures are never used in therapy. If the patient has low or high hypnotic ability, 
clinical interventions can be planned more economically and rationally than if the information on hypnotic ability was unavailable. For example, long hypnotic 
inductions and elaborate suggestions are redundant with high hypnotic ability subjects. Patients with low hypnotic ability require biofeedback or sensory restriction 
procedures before hypnotic induction to temporarily increase their hypnotic response (
1
, 
48
, 
49
).
Therapy and Outcomes
Description of Treatments
H
YPNOTIZABILITY AND
 C
LINICAL
 E
FFICACY IN
 S
PECIFIC
 H
YPNOTHERAPY
Specific hypnotherapy is the use of hypnosis with persons who have high measured hypnotizability. Several empirical studies have shown a correlation between 
measured hypnotizability and the clinical efficacy of hypnosis for treating asthma, acute and chronic pain, obesity, and warts (
5
, 
24
, 
28
, 
95
, 
96
, 
97
, 
98
 and 
99
). 
Hypnotizability has also been found to be related to the clinical efficacy of hypnotherapy for severe itching of chronic urticaria (
29
), pain of atopic eczema (
30
), obesity 
(
100
), smoking cessation (
101
), allergic skin reactions (
52
), migraine headaches (
102
), acupuncture (
54
), and aversive medical procedures (
103
).
N
ONSPECIFIC
 H
YPNOTHERAPY
It is likely that the label hypnosis (
9
) and the relaxation and sensory restriction components of the hypnotic induction ritual can elicit a temporary increase in hypnotic 
ability (
1
, 
49
, 
88
, 
104
, 
105
) in some persons of low or moderate hypnotic ability. It is theorized that the label hypnosis can activate cognitive motivations, positive 
attitudes, and placebo expectancies that are independent of baseline hypnotic ability (
106
). However, it is not commonly observed that motivated but low hypnotizable 
persons volunteer for major surgery with hypnosis as the only mode of anesthesia.
Treatment Evaluation
Hypnotic induction has been shown to potentiate the effects of psychodynamic psychotherapy (
7
) and CBT for treating pain, insomnia, hypertension, and—most 
notably and surprisingly—for the long-term efficacy of obesity therapy (
4
, 
6
) (see 
Figure 25.1
). This is noteworthy because there is evidence that obesity is an 
increasing problem in the United States (
107
), and long-term weight loss is rare except with surgery (
108
). The Kirsch (
6
) and Levitt (
5
) studies challenged a previous 
literature review (
24
), which concluded that the efficacy of hypnosis is limited to involuntary or autonomically mediated symptoms (e.g., pain, asthma, warts). In 
controlled studies, hypnotic induction and therapy effectively reduced insomnia (
109
), severe nausea and vomiting secondary to chemotherapy (
110
), refractory 
irritable bowel syndrome (
111
, 
112
 and 
113
), fibromyalgia (
114
), allergies (
115
), and severe burn pain (
116
). However, the most intriguing findings involved metastatic 
breast cancer patients—those who used self-hypnosis for pain control in addition to group psychotherapy and standard medical management compared with those 
who used standard medical management alone (
117
) (
Fig. 25.2
). The delayed mechanisms through which hypnosis and group psychotherapy presumably altered 

neuroendocrine and immune function in this study remain to be explicated.
F
IGURE
 25.2. Kaplan-Meier survival plot of metastatic breast cancer patients in psychosocial treatment study. A = control (N = 36); B = treatment (N = 50); * = 
overlapping control and treatment probabilities of survival. Some points represent more than one patient. (Adapted with permission from Spiegel D, Bloom JR, 
Kraemer HC, et al. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 1989;2:888–891.)
Hypnosis may also be effective in identifying and uncovering unconscious threatening perceptions and memories that drive somatization and autonomic nervous 
system dysregulation (
1
, 
3
, 
14
, 
16
, 
17
, 
18
 and 
19
, 
25
, 
46
). Hypnosis may uncover unconscious real or fantasized trauma. There are clinical reports and controlled 
studies indicating that hypnosis can influence basic autonomic, neuroendocrine, and immune mechanisms that are implicated in physical healing (
23
, 
43
, 
51
, 
90
). The 
efficacy of hypnosis has been measured in terms of clinical examinations, clinical rating scales, reductions in medications, reduced hospitalization, and changes in 
biomedical tests (e.g., event-related brain potentials, Mantoux test skin reactions, gastric motility index). Generally, the response of acute clinical symptoms (acute 
pain, anxiety) to hypnosis has a rapid onset. However, randomized controlled prospective studies of adjunctive hypnotherapy have suggested that for chronic 
diseases, such as metastatic breast cancer (
117
) and obesity (
4
, 
5
), positive effects could be delayed for several weeks or months (
1
, 
3
, 
4
, 
12
, 
13
).
In summary, hypnotic ability has been shown to be related specifically to the clinical efficacy of hypnosis. The hypnotic induction ritual is related in a nonspecific way 
that amplifies the therapy response to a variety of stress-related disorders, even when baseline hypnotic ability is not measured before intervention. Because high 
hypnotic ability appears to be a risk factor (i.e., contributes to the etiology of the disorder) for several stress-related disorders (
1
, 
3
, 
12
, 
16
, 
25
), it is also likely that the 
hypnotic induction component in these nonspecific hypnotherapies may enhance their clinical efficacy by positively recruiting and redirecting the hypnotic 
mechanisms of risk that contributed to the development of the stress disorder in the first place (
1
, 
3
, 
13
, 
14
). In many cases, the negative recruitment of high hypnotic 
abilities may have contributed to the stress-related disease (
1
, 
3
) and therefore can be used to help alter the illness.
USE OF THE SYSTEM FOR TREATMENT
Major Indications
Hypnosis is particularly indicated if the patient has high hypnotic ability and a positive attitude toward hypnosis for treating any clinical condition in which an alteration 
of perception, memory, or mood can reduce the intensity of a psychological or somatic symptom and/or provide information about the etiology of a disorder. For 
example, a chronic pain patient with high hypnotic ability and a positive attitude toward hypnosis will profit from suggestions that alter present or future pain 
perception, blur the memory of past pain, and provide ego strengthening to elevate mood and increase the patient's perception of self-efficacy. Hypnosis appears to 
be particularly effective for involuntary or autonomically mediated symptoms, such as headache pain, asthma, warts, and irritable bowel syndrome (
24
, 
51
, 
112
, 
118
). 
Hypnosis may be effective for patients with moderate or even low hypnotic ability on a temporary or nonspecific basis (placebo basis) if they have positive but realistic 
attitudes toward hypnosis. Moderate and low hypnotic ability subjects are likely to profit from hypnosis if methods that temporarily increase baseline hypnotic ability, 
such as theta EEG, frontal electromyographic (EMG) biofeedback, or sensory restriction, are added to hypnotherapy (
1
, 
48
, 
49
, 
65
, 
105
, 
119
).
If there is a need to increase rapport and intensify positive transference reactions, hypnosis may be indicated (
64
, 
87
, 
104
, 
120
). On a specific or temporary basis, 
hypnosis may also amplify imagery, memory, and mood (
90
). All the aforementioned indications should be constrained by professional diagnostic and therapeutic 
judgments regarding the psychodynamics and psychopathology of each clinical case. Attention should also be paid in each case to the patient's specific 
pathophysiology, issues of timing, and perceptions of hypnosis. The clinician should cautiously plan therapeutic suggestions.
The following case study illustrates the use of hypnosis in the psychophysiological psychotherapy of a somatization disorder.

C
ASE
 E
XAMPLES
CASE 1
Jane went to her internist complaining of shortness of breath that occurred mainly during the night, frequent chest pains, and chronic insomnia. She has also rushed 
herself to the emergency room more than 25 times in the last 12 months because she thought that she was having a heart attack. She has had the aforementioned 
symptoms for more than 1 year and denies any premorbid psychiatric or significant medical history. Multiple biomedical tests ordered by her internist and six medical 
specialists (e.g., cardiologists, endocrinologists, neurologists) have produced no evidence of any pathophysiology. Results from multiple psychiatric interviews and 
conventional psychological testing were negative for any psychopathology. Jane was then referred for both evaluation with the high-risk model of threat perception 
and psychophysiologic psychotherapy.
During her initial interview, Jane mentioned that she had dated the same boyfriend for 4 years. She wanted to get married and start a family, but each time she 
suggested this, he offered a different excuse. She loved him, but he had kept her in a holding pattern for 4 years. Jane made it clear that although this was not an 
arrangement she would choose, she was not notably unhappy with it. Most somatizing patients are skeptical of psychological explanations and need to be shown, 
not told, about what bothers them.
On the Harvard test, her hypnotizability was in the high range (11/12). But on all the other high-risk factors—catastrophizing, negative affectivity, Marlowe-Crowne 
scores, major life change, hassles, social support, and coping skills—the patient's scores were in the normal range. These findings explain all the prior negative 
findings for psychopathology from the psychiatric clinical interviews and the standard psychological tests. The patient had no conscious awareness of mental 
distress (e.g., anger, depression). However, hypnotic ability cannot be measured by a psychiatric interview or any conventional psychological test (hypnotic ability is 
statistically orthogonal to all personality test measures except absorption). Highly hypnotizable persons can keep secrets from their minds but not their bodies (
19
). 
A psychophysiologic stress profile (
1
, 
3
, 
16
, 
25
, 
65
) of the patient revealed an abnormal respiratory pattern and an elevated and highly variable heart rate response 
that occurred only during standardized cognitive stress. This abnormal autonomic reactivity was absent under resting baseline conditions.
Uncovering the hypothesized unconscious perceptions or cognitions that were driving the atypical respiration and heart rate responses during psychosocial 
cognitive stress was the next step. While her physiologic responses were monitored, Jane was hypnotized and asked to talk about and visualize several salient 
psychosocial topics (e.g., relationship with parents, boyfriend, or specific close friends; medical evaluations). Only on the topic of her relationship with her boyfriend 
did we observe an amplified autonomic reactivity (episodic inhibition of respiration) and elevated (120 bpm) and variable (55–120 bpm) heart rate that was 
associated with a verbal report of anger and even rage at her boyfriend. She reported during hypnosis feeling choked or strangled in the relationship. After the 
termination of the boyfriend topic, her physiology abruptly returned to normal. She had total spontaneous amnesia to both her autonomic nervous system (ANS) 
reactions and her specific emotional reactions to her boyfriend.
When I told Jane that her relationship with her boyfriend was perhaps distressing her more than she realized, she was incredulous and burst out laughing. The next 
step was to show her, on the monitoring instruments, the ANS changes produced by thoughts, memories, and images of her boyfriend when she was not hypnotized. 
The topic of her boyfriend reliably elicited ANS abnormalities, but to a lesser degree during waking psychotherapy than during hypnosis. She began to recognize 
during psychotherapy the extent to which she felt frustrated by, trapped by, and angry at her boyfriend. Within a few weeks, her clinical symptoms reduced in both 
intensity and frequency, and she began to explore alternative social and dating relationships. She was also able, in a few weeks, to phase off all the psychotropic 
and sleep medications she had used to cope with the sympathetic activation that was driven by her unconscious rage at her boyfriend.
All cases are not this simple. Many somatizing patients are addicted to narcotic, sleep, or psychotropic medications or have had multiple unsuccessful surgeries. They 
are angry, demoralized, skeptical, and bitter, and they continue to press for a strictly medical solution to their exclusive somatic symptoms. The difficult part is finding 
the unconscious factors maintaining the somatic stress response and showing , not just telling, the patient how these stressors drive somatic symptoms. The electronic 
instruments used in psychophysiologic psychotherapy track the biologic correlates of unconscious, threatening psychological events (
3
, 
17
, 
18
, 
25
, 
46
). In amplifying 
these biologic correlates so that they become recognizable to the patient, these instruments operate as truth detectors rather than lie detectors.