Hypnotherapy

An Exploratory Casebook

Milton H. Erickson

and

Ernest L. Rossi

With a Foreword by Sidney Rosen

IRVINGTON PUBLISHERS, Inc., New York

Halsted Press Division of

JOHN WILEY Sons, Inc.

New York London Toronto Sydney

The following copyrighted material is reprinted by permission:

Erickson, M. H. An introduction to the study and application of hypnosis for pain control. In J. Lassner (Ed.), Hypnosis and Psychosomatic Medicine: Proceedings of the

International Congress for Hypnosis and Psychosomatic Medicine. Springer Verlag, 1967. Reprinted in English and French in the Journal of the College of General Practice of Canada, 1967, and in French in Cahiers d' Anesthesiologie, 1966, 14, 189-202. Copyright © 1966, 1967.

All rights reserved. No part of this book may be reproduced in any manner whatever, including information storage or retrieval, in whole or in part (except for brief quotations in critical articles or reviews), without written permission from the publisher. For information, write to Irvington Publishers, Inc., 551 Fifth Avenue, New York, New York 10017.

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A division of JOHN WILEY SONS, Inc., New York

Library of Congress Cataloging in Publication Data

Erickson, Milton H. Hypnotherapy, an exploratory casebook.

Includes bibliographical references.

1. Hypnotism - Therapeutic use. I. Rossi, Ernest Lawrence, joint author. II. Title. RC495.E719 615.8512 78-23839 ISBN 0-470-26595-7

Printed in The United States of America

Foreword

Preface

Chapter 1. The Utilization Approach to Hypnotherapy

1. Preparation

2. Therapeutic Trance

3. Ratification of Therapeutic Change Summary Exercises

Chapter 2. The Indirect Forms of Suggestion

1. Direct and Indirect Suggestion

2. The Interspersal Approach

a) Indirect Associative Focusing

b) Indirect Ideodynamic Focusing

3. Truisms Utilizing Ideodynamic Processes

a) Ideomotor Processes

b) Ideosensory Processes

c) Ideoaffective Processes

d) Ideocognitive Processes

4. Truisms Utilizing Time

5. Not Knowing, Not Doing

6. Open-Ended Suggestions

7. Covering All Possibilities of a Class of Responses

8. Questions That Facilitate New Response Possibilities

a) Questions to Focus Associations

b) Questions in Trance Induction

c) Questions Facilitating Therapeutic Responsiveness

9. Compound Suggestions

a) The Yes Set and Reinforcement

b) Contingent Suggestions and Associational Networks

c) Apposition of Opposites

d) The Negative

e) Shock, Surprise, and Creative Moments

10. Implication and the Implied Directive a) The Implied Directive

11. Binds and Double Binds

a) Binds Modeled on Avoidance-Avoidance and Approach-Approach Conflicts

b) The Conscious-Unconscious Double Bind

c) The Double Dissociation Double Bind

12. Multiple Levels of Meaning and Communication: The Evolution of Consciousness in Jokes, Puns, Metaphor, and Symbol Exercises

Chapter 3. The Utilization Approach: Trance Induction and Suggestion

1. Accepting and Utilizing the Patient's Manifest Behavior

2. Utilizing Emergency Situations

3. Utilizing the Patient's Inner Realities

4. Utilizing the Patient's Resistances

5. Utilizing the Patient's Negative Affects and Confusion

6. Utilizing the Patient's Symptoms Exercises

Chapter 4. Posthypnotic Suggestion

1. Associating Posthypnotic Suggestions with Behavioral Inevitabilities

2. Serial Posthypnotic Suggestions

3. Unconscious Conditioning as Posthypnotic Suggestion

4. Initiated Expectations Resolved Posthypnotically

5. Surprise As a Posthypnotic Suggestion Exercises

Chapter 5. Altering Sensory-Perceptual Functioning: The Problem of Pain and Comfort

Case 1. Conversational Approach to Altering Sensory-Perceptual Functioning: Phantom Limb Pain and Tinnitus

Case 2. Shock and Surprise for Altering Sensory-Perceptual Functioning: Intractable Back Pain

Case 3. Shifting Frames of Reference for Anesthesia and Analgesia

Case 4. Utilizing the Patient's Own Personality and Abilities for Pain Relief

Selected Shorter Cases: Exercises for Analysis

Chapter 6. Symptom Resolution

Case 5. A General Approach to Symptomatic Behavior

Session One:

Part One. Preparation and Initial Trance Work

Part Two. Therapeutic Trance as Intense Inner Work

Part Three. Evaluation and Ratification of Therapeutic Change

Session Two: Insight and Working Through Related Problems

Case 6. Demonstrating Psychosomatic Asthma with Shock to Facilitate Symptom Resolution and Insight

Case 7. Symptom Resolution with Catharsis Facilitating Personality Maturation: An Authoritarian Approach

Case 8. Sexual Dysfunction: Somnambulistic Training in a Rapid Hypnotherapeutic Approach

Part One. Facilitating Somnambulistic Behavior

Part Two. A Rapid Hypnotherapeutic Approach Utilizing . Therapeutic Symbolism with Hand Levitation

Case 9. Anorexia Nervosa Selected Shorter Cases. Exercises for Analysis

Chapter 7. Memory Revivication

Case 10. Resolving a Traumatic Experience

Part One. Somnambulistic Training, Autohypnosis, and Hypnotic Anesthesia

Part Two. Reorganizing Traumatic Life Experience and Memory Revivication

Chapter 8. Emotional Coping

Case 11. Resolving Affect and Phobia with New Frames of Reference

Part One. Displacing a Phobic Symptom

Part Two. Resolving an Early-Life Trauma at the Source of a Phobia

Part Three. Facilitating Learning: Developing New Frames of Reference

Selected Shorter Cases: Exercises for Analysis

Chapter 9. Facilitating Potentials: Transforming Identity

Case 12. Utilizing Spontaneous Trance: An Exploration

Integrating Left and Right Hemispheric Activity

Session 1: Spontaneous Trance and its Utilization: Symbolic Healing

Session 2: Part One. Facilitating Self-Exploration

Part Two. Automatic Handwriting and Dissociation

Case 13. Hypnotherapy in Organic Spinal Cord Damage: New Identity Resolving Suicidal Depression

Case 14. Psychological Shock and Surprise to Transform Identity

Case 15. Experiential Life Review in the Transformation of Identity

Chapter 10. Creating Identity: Beyond Utilization Theory?

Case 16. The February Man

References

Foreword

Speak to the wall so the door may hear - Sufi saying.

Everyone who knows Milton Erickson is aware that he rarely does anything without a purpose. In fact, his goal-directedness may be the most important characteristic of his life and work.

Why is it, then, that prior to writing Hypnotic Realities with Ernest Rossi (Irvington, 1976) he had avoided presenting his work in book form? Why did he choose Ernest Rossi to coauthor that book and the present one? And, finally, I could not help but wonder, Why did he ask me to write this foreword?

Erickson has, after all, published almost 150 articles over a fifty-year period, but only two relatively minor books - Time Distortion in Hypnosis, written in 1954 with L. S. Cooper, and The Practical Applications of Medical and Dental Hypnosis, in 1961 with S. Hershman, MD and I. I. Sector, DDS. It is easy to understand that in his seventies he may well be eager to leave a legacy, a definitive summing up, a final opportunity for others to really understand and perhaps emulate him.

Rossi is an excellent choice as a coauthor. He is an experienced clinician who has trained with many giants in psychiatry - Franz Alexander, amongst others. He is a Jungian training analyst. He is a prolific author and has devoted the major part of his time over the past six years to painstaking observation, recording and discussion of Erickson's work.

Again, Why me? I am also a training analyst, but with a different group - the American Institute of Psychoanalysis (Karen Horney). I have been a practicing psychiatrist for almost thirty years. For almost fifteen years I have also done a great deal of work with disabled patients. I have been involved with hypnosis for over thirty-five years, since I first heard about Milton Erickson, who was then living in Eloise, Michigan.

Both Rossi and I have broad, but differing, clinical and theoretical backgrounds. Neither of us has worked primarily with hypnosis. Therefore, neither of us has a vested interest in promoting some hypnotic theories of our own. We are genuinely devoted to the goal of presenting Erickson's theories and ideas, not only to practitioners of hypnosis, but to the community of psychotherapists and psychoanalysts which has had little familiarity with hypnosis. Towards this end, Rossi assumes the posture of a rather naive student acting on behalf of the rest of us.

Margaret Mead, who also counts herself as one of his students, writes of the originality of Milton Erickson in the issue of The American Journal of Clinical Hypnosis dedicated to him on his seventy-fifth birthday (Mead, M. The Originality of Milton Erickson, AJCH, Vol. 20, No. 1, July 1977, pp. 4-5). She comments that she has been interested in his originality ever since she first met him in the summer of 1940, expanding on this idea by stating, It can be firmly said that Milton Erickson never solved a problem in an old way if he can think of a new way - and he usually can. She feels, however, that his unquenchable, burning originality was a barrier to the transmission of much of what he knew and that inquiring students would become bemused with the extraordinary and unexpected quality of each different demonstration, lost between trying to imitate the intricate, idiosyncratic response and the underlying principles which he was illuminating. In Hypnotic Realities and in this book, Ernest Rossi takes some large steps towards elucidating these underlying principles. He does this most directly by organizing and extracting them from Erickson's case material. Even more helpfully, though, he encourages Erickson to spell out some of these principles.

Students who study this volume carefully, as I did, will find that the authors have done the best job to date in clarifying Erickson's ideas on the nature of hypnosis and hypnotic therapy, on techniques of hypnotic induction, on ways of inducing therapeutic change, and of validating this change. In the process they have also revealed a great deal of helpful data about Erickson's philosophy of life and therapy. Many therapists, both psychoanalytic and others, will find his approaches compatible with their own and far removed from their preconceptions about hypnosis. As the authors point out, Hypnosis does not change the person nor does it alter past experiential life. It serves to permit him to learn more about himself and to express himself more adequately. . . . Therapeutic trance helps people side-step their own learned limitations so that they can more fully explore and utilize their potentials.

Those who read Erickson's generous offering of fascinating case histories, and then attempt to emulate him, will undoubtedly find that they do not achieve results that are at all comparable to his. They may then give up, deciding that Erickson's approach is one that is unique for him. They may note that Erickson has several handicaps that have always set him apart from others, and that may certainly permit him to have a unique way of viewing and responding. He was born with color deficient vision, tone deafness, dyslexia, and lacking a sense of rhythm. He suffered two serious attacks of crippling poliomyelitis. He has been wheelchair bound for many years from the effects of the neurological damage, supplemented by arthritis and myositis. Some will not be content with the rationalization that Erickson is a therapeutic or inimitable genius. And they will find that with the help of clarifiers and facilitators, such as Ernest Rossi, there is much in his way of working that can be learned, taught and utilized by others.

Erickson himself has advised, in Hypnotic Realities (page 258), In working at a problem of difficulty, you try to make an interesting design in the handling of it. That way you have an answer to the difficult problem. Become interested in the design and don't notice the back-breaking labor. In dealing with the difficult problem of analyzing and teaching Erickson's approaches, Rossi's designs can be most helpful. Whether each reader will choose to accept Rossi's suggestion that he practice the exercises recommended in this book, is an individual matter; in my experience, it has been worthwhile to practice some of them. In fact, by deliberately and planfully applying some of Erickson's approaches as underlined by Rossi, I found that I have been able to help patients experience deeper states of trance and be more open to changing as an apparent consequence of this. I found that setting up therapeutic double binds, giving indirect posthypnotic suggestions, using questions to facilitate therapeutic responsiveness, and building up compound suggestions have been particularly helpful. Erickson and Rossi's repeated emphasis on what they call the utilization approach is certainly justified. In this book they give many vivid and useful examples of accepting and utilizing the patient's manifest behavior, utilizing the patient's inner realities, utilizing the patient's resistances, and utilizing the patient's negative affect and symptoms. Erickson's creative use of jokes, puns, metaphors and symbols has been analyzed by others, notably Haley and Bandler and Grinder, but the examples and discussion in this book add a great deal to our understanding.

At times, Erickson will work with a patient in a light trance, in what he calls a common everyday trance, or no trance at all. He does not limit himself to short-term therapy. This is illustrated in his painstaking work over a nine-month period with Pietro, the flutist with the swollen lip, described in one of the dramatic case outlines in this book. His expertise, however, in working with patients in the deepest trances, often with amnesia for the therapeutic work, has always interested observers. The question of whether or not inducing deeper trances, and giving directions or suggestions indirectly rather than directly, leads to more profound or lasting clinical results is a researchable one. It has certainly been my experience that if one does not believe in, or value, deeper trances and does not strive for them, one is not likely to see them very often. My experience has also been that the achievement of deeper trances, often including phenomena such as dissociation, time distortion, amnesia, and age-regression, does lead to quicker and apparently more profound changes in patients' symptoms and attitudes.

Erickson emphasizes the value of helping patients to work in the mode of what he would call the unconscious. He values the wisdom of the unconscious. In fact, he often goes to great lengths to keep the therapeutic work from being examined and potentially destroyed by the patient's conscious mind and by the patient's learned and limited sets. His methods of doing this are more explicitly outlined in this book than in any other writings available to date.

It is true that he tends not to distinguish between induction of trance or hypnotic techniques and therapeutic techniques or maneuvers. He feels that it is a waste of time for the therapist to use meaningless, repetitious phrases in the induction of trance as this time might be more usefully employed injecting therapeutic suggestions or in preparing the patient for change. As Rossi has pointed out, both the therapy and trance, induction involve, in the early stages, a depotentiation of the patient's usual and limited mental sets. Erickson is never content with simply inducing a trance, but is always concerned with some therapeutic role.

He points out the limited effectiveness of direct suggestion, although he is certainly aware that hypnotic techniques, using direct suggestion, will frequently enhance the effectiveness of behavior modification approaches such as desensitization and cognitive retraining. He notes that Direct suggestion . . . does not evoke the re-association and reorganization of ideas, understandings and memories so essential for an actual cure . . . Effective results in hypnotic psychotherapy . . . derive only from the patient's activities. The therapist merely stimulates the patient into activity, often not knowing what that activity may be. And then he guides the patient and exercises clinical judgment in determining the amount of work to be done to achieve the desired results (Erickson, 1948). From this comment, and from reading the case histories in this volume and in other publications, it should be apparent that Erickson demands and evokes much less doctrinal compliance than do most therapists.

It is obvious that clinical judgment comes only as the result of many years of intensive study of dynamics, pathology and health, and from actually working with patients.

The judgment of the therapist will also be influenced by his own philosophy and goals in life. Erickson's own philosophy is manifested by his emphasis on concepts such as growth and delight and joy . To this he adds, Life isn't something you can give an answer to today. You should enjoy the process of waiting, the process of becoming what you are. There is nothing more delightful than planting flower seeds and not knowing what kinds of flowers are going to come up. My own experience in this regard is illustrated by my having visited him in 1970, spending a four-hour session with him, and leaving with the feeling that I had spent this time mostly in listening to stories about his family and patients. I did not see him again until the summer of 1977. Then, at 5:00 a.m. in a Phoenix motel, while I was reviewing some tapes of Erickson at work, some very important insights became vividly evident to me. They were obviously related to work begun during our session in 1970 and to self analysis I had done in the intervening seven years. Later that morning when I excitedly mentioned these insights to Erickson, he, typically, simply smiled and did not attempt to elaborate on them in any way.

When we read some of the writings on other forms of therapy, such as family therapy or Gestalt therapy, we are struck by how much they have been influenced by Erickson. This is no accident as many of the early therapists in these schools began working with hypnosis or even with Erickson himself. I hope that Rossi will trace some of these influences in his future writings. I have alluded to some of them in my article, Recent Experiences with Encounter Gestalt and Hypnotic Techniques (Rosen, S. Am J. Psychoanalysis, Vol. 32, No. 1, 1972, pp. 90-105).

In conjunction with Erickson and Rossi's first volume Hypnotic Realities, Hypnotherapy: An Exploratory Casebook should serve as a firm basis for courses in Ericksonian therapy or Ericksonian hypnosis. These courses may be supplemented by other books, including those written by J. Haley and by Bandler and Grinder. In addition, we are now fortunate to have available a bibliography of the 147 articles written by Erickson himself (see Gravitz, M.A. and Gravitz, R. F., Complete Bibliography 1929-1977,'' American Journal of Clinical Hypnosis, 1977, 20, 84-94).

Rossi has told me that in working with Erickson he has always been struck by the fact that Erickson seems to be atheoretical. I have noted that this applies to Erickson's openness but certainly not to his emphasis on growth or his humanistic or socially oriented views. Rossi and others are constantly rediscovering the fact that Erickson always works towards goals - those of his patients', not his own. This may not seem to be such a revolutionary idea today when it is the avowed intention of almost all therapists, but perhaps many of us are limited in our capacity to carry out this intent. It is significant that both intent and practice are most successfully coordinated and realized in the work of this man who is probably the world's master in clinical hypnosis, and yet hypnosis is still associated by almost everyone with manipulation and suggestion - a typical Ericksonian paradox. The master manipulator allows and stimulates the greatest freedom!

Sidney Rosen, MD

New York

Preface

The present work is the second in a series of volumes by the authors that began with the publication of Hypnotic Realities (Irvington, 1976). Like that first volume, the present work is essentially the record of the senior author's efforts to train the junior author in the field of clinical hypnotherapy. As such, the present work is not of an academic or scholarly nature but rather a practical study of some of the attitudes, orientations, and skills required of the modern hypnotherapist.

In the first chapter we outline the utilization approach to hypnotherapy as the basic orientation to our work. In the second chapter we essay a more systematic presentation of the indirect forms of suggestion, which were originally selected out of the case presentations of our first volume. We now believe that the utilization approach and the indirect forms of suggestion are the essence of the senior author's therapeutic innovations over the past fifty years and account for much of his unique skill as a hypnotherapist.

In Chapter Three we illustrate how the utilization approach and the indirect forms of suggestion can be integrated to facilitate the induction of therapeutic trance in a manner that simultaneously orients the patient toward therapeutic change. In our fourth chapter we illustrate the approaches to posthypnotic suggestion that the senior author has found most effective in day-to-day clinical practice.

These first four chapters outline some of the basic principles of the senior author's approach. We hope this presentation will provide other clinicians with a broad and practical perspective of the senior author's work and serve as a source of hypotheses about the nature of therapeutic trance that will be tested with more controlled experimental studies by researchers.

At the end of each of these first four chapters we have suggested a number of exercises to facilitate learning the orientation, attitudes, and skills required of anyone who wants to put some of this material into actual practice. A simple reading and understanding of the material is not enough. An extensive effort to acquire new habits of observation and interpersonal interaction are required. All the suggested exercises have been put into practice as we have sought to hone our own skills and teach others.

Each of the remaining six chapters presents case studies illustrating and further exploring the senior author's clinical work with patients. Six of these cases (cases 1,5,8,10,11, and 12) are major studies like those in our first volume, Hypnotic Realities, where we transcribed tape recordings of the senior author's actual words and patterns of interaction with patients. The recording equipment for these studies was provided by a research grant from the American Society of Clinical Hypnosis - Education and Research Foundation. In our commentaries on these sessions we have presented our current understanding of the dynamics of the hypnotherapeutic process and discussed a number of issues such as the facilitation of the creative process and the functions of the left and right hemispheres.

Most of the other shorter cases were drawn from the senior author's file of unpublished records of his work in private practice, some of them from long-unopened folders containing yellowed pages more than a quarter of a century old. These cases were all reviewed and re-edited with fresh commentaries and provide an appropriate perspective on the spontaneous creativity and daring required of the hypnotherapist in clinical practice. In addition, we have skimmed through many tape recordings of the senior author's lectures and workshops at the meetings of the American Society of Clinical Hypnosis. Some of these were already typed and partially edited by Florence Sharp, Ph.D., and other members of the Society. Most of these appear under the heading Selected Shorter Cases: Exercises for Analysis. Many of them have been repeated and published so often (Haley, 1973) that they appear anecdotal, as part of the folklore of hypnosis in the past half-century. They can serve as marvelous exercises for analysis, however. At the end of each such case we have placed in italics some of the principles we feel were involved. The reader may enjoy finding others.

It is our impression that the clinical practice of hypnotherapy is currently emerging from a period of relative quiescence into an exciting time of new discoveries and fascinating possibilities. Those who know the history of hypnosis are already familiar with this cyclic pattern of excitement and quiescence that is so characteristic of the field. Some historians of science now believe this cyclic pattern is characteristic of all branches of science and art: The excitement comes with periods of new discovery, the quiescence comes as these are assimilated. As the junior author gradually put this volume together, he frequently had a subjective sense of new discovery. But was it new only for him, or would it be new for others as well? We must rely upon you, our reader, to make an independent assessment of the matter and perhaps carry the work a step further.

Milton H. Erickson, M.D. Ernest L. Rossi, Ph.D.

Acknowledgments

This work can be recognized as a truly community effort, with many more individuals contributing to it than we can acknowledge by name. First among these are our patients, who frequently recognized and cooperated with the exploratory nature of our work with them. Their spontaneous creativity is truly the basis of all innovative therapeutic work: We simply report what they learned to do with the hope that their success may be a useful guide for others.

Many of the teachers and participants in the seminars and workshops of the American Society of Clinical Hypnosis have provided a continual series of insights, illustrations, and comments that have found their way into this work. Prominent among these are Leo Alexander, Ester Bartlett, Franz Baumann, Neil D. Capua, David Cheek, Sheldon Cohen, Jerry Day, T. E. A. Von Dedenroth, Roxanne and Christie Erickson, Fredericka Freytag, Melvin Gravitz, Frederick Hanley, H. Clagett Harding, Maurice McDowell, Susan Mirow, Marion Moore, Robert Pearson, Bertha Rodger, Florence Sharp, Kay Thompson, Paul Van Dyke, M. Erik Wright.

To Robert Pearson we owe a special acknowledgment for having first suggested the basic format of this work, for his continual encouragement during its gestation, and for his critical reading of our final draft. Ruth Ingham and Margaret Ryan have contributed significant editing skills that finally enabled our work to reach the press.

Finally, we wish to acknowledge the following publishers who have generously permitted the republication of five of the papers in this volume: American Society of Clinical Hypnosis, Journal Press, W. B. Saunders Company, and Springer Verlag.

CHAPTER 1

The Utilization Approach to Hypnotherapy

We view hypnotherapy as a process whereby we help people utilize their own mental associations, memories, and life potentials to achieve their own therapeutic goals. Hypnotic suggestion can facilitate the utilization of abilities and potentials that already exist within a person but that remain unused or underdeveloped because of a lack of training or understanding. The hypnotherapist carefully explores a patient's individuality to ascertain what life learnings, experiences, and mental skills are available to deal with the problem. The therapist then facilitates an approach to trance experience wherein the patient may utilize these uniquely personal internal responses to achieve therapeutic goals.

Our approach may be viewed as a three-stage process: (1) a period of preparation during which the therapist explores the patients repertory of life experiences and facilitates constructive frames of reference to orient the patient toward therapeutic change; (2) an activation and utilization of the patient's own mental skills during a period of therapeutic trance; (3) a careful recognition, evaluation, and ratification of the therapeutic change that takes place. In this first chapter we will introduce some of the factors contributing to the successful experience of each of these three stages. In the chapters that follow we will illustrate and discuss them in greater detail.

1. Preparation

The initial phase of hypnotherapeutic work consists of a careful period of observation and preparation. Initially the most important factor in any therapeutic interview is to establish a sound rapport - that is, a positive feeling of understanding and mutual regard between therapist and patient. Through this rapport therapist and patient together create a new therapeutic frame of reference that will serve as the growth medium in which the patient's therapeutic responses will develop. The rapport is the means by which therapist and patient secure each others' attention. Both develop a yes set, or acceptance of each other. The therapist presumably has a well developed ability to observe and relate; the patient is learning to observe and achieve a state of response attentiveness , that state of extreme attentiveness in responding to the nuances of communication presented by the therapist.

In the initial interview the therapist gathers the relevant facts regarding the patient's problems and the repertory of life experiences and learnings that will be utilized for therapeutic purposes. Patients have problems because of learned limitations. They are caught in mental sets, frames of reference, and belief systems that do not permit them to explore and utilize their own abilities to best advantage. Human beings are still in the process of learning to use their potentials. The therapeutic transaction ideally creates a new phenomenal world in which patients can explore their potentials, freed to some extent from their learned limitations. As we shall later see, therapeutic trance is a period during which patients are able to break out of their limited frameworks and belief systems so they can experience other patterns of functioning within themselves. These other patterns are usually response potentials that have been learned from previous life experience but, for one reason or another, remain unavailable to the patient. The therapist can explore patients' personal histories, character, and emotional dynamics, their field of work, interests, hobbies, and so on to assess the range of life experiences and response abilities that may be available for achieving therapeutic goals. Most of the cases in this book will illustrate this process.

As the therapist explores the patient's world and facilitates rapport, it is almost inevitable that new frames of reference and belief systems are created. This usually happens whenever people meet and interact closely. In hypnotherapy this spontaneous opening and shifting of mental frameworks and belief systems is carefully studied, facilitated, and utilized. The therapist is in a constant process of evaluating what limitations are at the source of the patient's problem and what new horizons can be opened to help the patient outgrow those limitations. In the preparatory phase of hypnotherapeutic work mental frameworks are facilitated in a manner that will enable the patient to respond to the suggestions that will be received later during trance. Suggestions made during trance frequently function like keys turning the tumblers of a patient's associative processes within the locks of certain mental frameworks that have already been established. A number of workers (Weitzenhoffer, 1957, Schneck, 1970, 1975) have described how what is said before trance is formally induced can enhance hypnotic suggestion. We agree and emphasize that effective trance work is usually preceded by a preparatory phase during which we help patients create an optimal attitude and belief system for therapeutic responses.

A singularly important aspect of this optimal attitude is expectancy. Patients' expectations of therapeutic change permits them to suspend the learned limitations and negative life experiences that are at the source of their problems. A suspension of disbelief and an extraordinarily high expectation of cure has been used to account for the miraculous healing sometimes achieved within a religious belief system. As will be seen in our overall analysis of the dynamics of therapeutic trance in the following section, such seemingly miraculous healing can be understood as a special manifestation of the more general process we utilize to facilitate therapeutic responses in hypnotherapy.

2. Therapeutic Trance

Therapeutic trance is a period during which the limitations of one's usual frames of reference and beliefs are temporarily altered so one can be receptive to other patterns of association and modes of mental functioning that are conducive to problem-solving. We view the dynamics of trance induction and utilization as a very personal experience wherein the therapist helps patients to find their own individual ways. Trance induction is not a standardized process that can be applied in the same way to everyone. There is no method or technique that always works with everyone or even with the same person on different occasions. Because of this we speak of approaches to trance experience. We thereby emphasize that we have many means of facilitating, guiding, or teaching how one might be led to experience the state of receptivity that we call therapeutic trance. However, we have no universal method for effecting the same uniform trance state in everyone. Most people with problems can be guided to experience their own unique variety of therapeutic trance when they understand that it may be useful. The art of the hypnotherapist is in helping patients reach an understanding that will help them give up some of the limitations of their common everyday world view so that they can achieve a state of receptivity to the new and creative within themselves.

For didactic purposes we have conceptualized the dynamics of trance induction and suggestion as a five-stage process, outlined in Figure 1.

While we may use this paradigm as a convenient framework for analyzing many of the hypnotherapeutic approaches we will illustrate in this volume, it must be understood that the individual manifestations of the process will be just as unique and various as are the natures of the people experiencing it. We will now outline our understanding of these five stages.

Figure 1: A five-stage paradigm of the dynamics of trance induction and suggestion (from Erickson and Rossi, 1976.)


1 . Fixation of Attention	via	Utilizing the patient's beliefs and behavior for focusing attention on inner realities.
2. Depotentiating Habitual Frameworks and Belief Systems	via	Distraction, shock, surprise, doubt, confusion, dissociation, or any other process that interrupts the patient's habitual frameworks.
3. Unconscious Search	via	Implications, questions, puns, and other indirect forms of hypnotic suggestion.
4. Unconscious Process	via	Activation of personal associations and mental mechanisms by all the above.
5. Hypnotic Response	via	An expression of behavioral potentials that are experienced as taking place autonomously.

Fixation of Attention

The fixation of attention has been the classical approach for initiating therapeutic trance, or hypnosis. The therapist would ask the patient to gaze at a spot or candle flame, a bright light, a revolving mirror, the therapist's eyes, gestures, or whatever. As experience accumulated it became evident that the point of fixation could be anything that held the patient's attention. Further, the point of fixation need not be external; it is even more effective to focus attention on the patient's own body and inner experience. Thus approaches such as hand levitation and body relaxation were developed. Encouraging the patient to focus on sensations or internal imagery led attention inward even more effectively. Many of these approaches have become standardized and are well described in reference works on hypnosis (Weitzenhoffer, 1957; Hartland, 1966; Haley, 1967).

The beginner in hypnotherapy may well study these standardized approaches and closely follow some of them to initiate trance in a formalized manner. They are often highly impressive to the patient and very effective in inducing trance. Student therapists will be in error, however, if they attempt to utilize only one approach as the universal method and thereby blind themselves to the unique motivations and manifestations of trance development in each person. The therapist who carefully studies the process of attention in everyday life as well as in the consulting room will soon come to recognize that an interesting story or a fascinating fact or fantasy can fixate attention just as effectively as a formal induction. Anything that fascinates and holds or absorbs a person's attention could be described as hypnotic. We have the concept of the common everyday trance for those periods in everyday life when we are so absorbed or preoccupied with one matter or another that we momentarily lose track of our outer environment.

The most effective means of focusing and fixing attention in clinical practice is to recognize and acknowledge the patient's current experience. When the therapist correctly labels the patient's ongoing hereand-now experience, the patient is usually immediately grateful and open to whatever else the therapist may have to say. Acknowledging the patient's current reality thus opens a yes set for whatever suggestions the therapist may wish to introduce. This is the basis of the utilization approach to trance induction, wherein therapists gain their patients' attention by focusing on their current behavior and experiences (Erickson, 1958,1959). Illustrations of this utilization approach to trance induction will be presented in our third chapter.

Depotentiating Habitual Frameworks and Belief Systems

In our view one of the most useful psychological effects of fixating attention is that it tends to depotentiate patients' habitual mental sets and common everyday frames of reference. Their belief systems are more or less interrupted and suspended for a moment or two. Consciousness has been distracted. During that momentary suspension latent patterns of association and sensory-perceptual experience have an opportunity to assert themselves in a manner that can initiate the altered state of consciousness that has been described as trance or hypnosis.

There are many means of depotentiating habitual frames of reference. Any experience of shock or surprise momentarily fixates attention and interrupts the previous pattern of association. Any experience of the unrealistic, the unusual, or the fantastic provides an opportunity for altered modes of apprehension. The authors have described how confusion, doubt, dissociation, and disequilibrium are all means of depotentiating patients' learned limitations so that they may become open and available for new means of experiencing and learning, which are the essence of therapeutic trance (Erickson, Rossi, and Rossi, 1976). The interruption and suspension of our common everyday belief system has been described by the junior author as a creative moment (Rossi, 1972a):

But what is a creative moment? Such moments have been celebrated as the exciting hunch by scientific workers and inspiration by people in the arts (Barron, 1969). A creative moment occurs when a habitual pattern of association is interrupted; there may be a spontaneous lapse or relaxation of one's habitual associative process; there may be a psychic shock, an overwhelming sensory or emotional experience; a psychedelic drug, a toxic condition or sensory deprivation may serve as the catalyst; yoga, Zen, spiritual and meditative exercises may likewise interrupt our habitual associations and introduce a momentary void in awareness. In that fraction of a second when the habitual contents of awareness are knocked out there is a chance for pure awareness, the pure light of the void (Evans-Wentz, 1960) to shine through. This fraction of a second may be experienced as a mystic state, satori, a peak experience or an altered state of consciousness (Tart, 1969). It may be experienced as a moment of fascination or falling in love when the gap in one's awareness is filled by the new that suddenly intrudes itself.

The creative moment is thus a gap in one's habitual pattern of awareness. Bartlett (1958) has described how the genesis of original thinking can be understood as the filling in of mental gaps. The new that appears in creative moments is thus the basic unit of original thought and insight as well as personality change. Experiencing a creative moment may be the phenomenological correlate of a critical change in the molecular structure of proteins within the brain associated with learning (Gaito, 1972; Rossi, 1973b), or the creation of new cell assemblies and phase sequences (Hebb, 1963).

The relation between psychological shock and creative moments is apparent: a psychic shock interrupts a person's habitual associations so that something new may appear. Ideally psychological shock sets up the conditions for a creative moment when a new insight, attitude, or behavior change may take place in the subject. Erickson (1948) has also described hypnotic trance itself as a special psychological state which effects a similar break in the patient's conscious and habitual associations so that creative learning can take place.

In everyday life one is continually confronted with difficult and puzzling situations that mildly shock and interrupt one's usual way of thinking. Ideally these problem situations will initiate a creative moment of reflection that may provide an opportunity for something new to emerge. Psychological problems develop when people do not permit the naturally changing circumstances of life to interrupt their old and no longer useful patterns of association and experience so that new solutions and attitudes may emerge.

Unconscious Search and Unconscious Process

In everyday life there are many approaches to fixing attention, depotentiating habitual associations, and thereby initiating an unconscious search for a new experience or solution to a problem. In a difficult situation, for example, one may make a joke or use a pun to interrupt and reorganize the situation from a different point of view. One may use allusions or implications to intrude another way of understanding the same situation. Like metaphor and analogy (Jaynes, 1976) these are all means of momentarily arresting attention and requesting a search - essentially a search on an unconscious level - to come up with a new association or frame of reference. These are all opportunities for creative moments in everyday life wherein a necessary reorganization of one's experience takes place.

In therapeutic trance we utilize similar means of initiating a search on an unconscious level. These are what the senior author has described as the indirect forms of suggestion (Erickson and Rossi, 1976; Erickson, Rossi, and Rossi, 1976). In essence, an indirect suggestion initiates an unconscious search and facilitates unconscious processes within patients so that they are usually somewhat surprised by their own responses. The indirect forms of suggestion help patients bypass their learned limitations so they are able to accomplish a lot more than they are usually able to. The indirect forms of suggestion are facilitators of mental associations and unconscious processes. In the next chapter we will outline our current understanding of a variety of these indirect forms of suggestion.

The Hypnotic Response

The hypnotic response is the natural outcome of the unconscious search and processes initiated by the therapist. Because it is mediated primarily by unconscious processes within the patient, the hypnotic response appears to occur automatically or autonomously; it appears to take place all by itself in a manner that may seem alien or dissociated from the person's usual mode of responding on a voluntary level. Most patients typically experience a mild sense of pleasant surprise when they find themselves responding in this automatic and involuntary manner. That sense of surprise, in fact, can generally be taken as an indication of the genuinely autonomous nature of their response.

Hypnotic responses need not be initiated by the therapist, however. Most of the classical hypnotic phenomena, in fact, were discovered quite by accident as natural manifestations of human behavior that occurred spontaneously in trance without any suggestion whatsoever. Classical hypnotic phenomena such as catalepsy, anesthesia, amnesia, hallucinations, age regression, and time distortion are all spontaneous trance phenomena that were a source of amazement and bewilderment to early investigators. It was when they later attempted to induce trance and study trance phenomena systematically that these investigators found that they could suggest the various hypnotic phenomena. Once they found it possible to do this, they began to use suggestibility itself as a criterion of the validity and depth of trance experience.

When the next step was taken to utilize trance experience as a form of therapy, hypnotic suggestibility was emphasized even more as the essential factor for successful work. An unfortunate side effect of this emphasis on suggestibility was in the purported power of hypnotists to control behavior with suggestion. By this time our conception of hypnotic phenomena had moved very far indeed from their original discovery as natural and spontaneous manifestations of the mind. Hypnosis acquired the connotations of manipulation and control. The exploitation of naturally occurring trance phenomena as a demonstration of power, prestige, influence, and control (as it has been used in stage hypnosis) was a most unfortunate turn in the history of hypnosis.

In an effort to correct such misconceptions the senior author (Erickson, 1948) described the merits of direct and indirect suggestion in hypnotherapy as follows:

The next consideration concerns the general role of suggestion in hypnosis. Too often, the unwarranted and unsound assumption is made that, since a trance state is induced and maintained by suggestion, and since hypnotic manifestations can be elicited by suggestion, whatever develops from hypnosis must necessarily and completely be a result and primary expression of suggestion. Contrary to such misconceptions, the hypnotized person remains the same person. Only his behavior is altered by the trance state, but even so, that altered behavior derives from the life experience of the patient and not from the therapist. At the most, the therapist can influence only the manner of self-expression. The induction and maintenance of a trance serve to provide a special psychological state in which the patient can reassociate and reorganize his inner psychological complexities and utilize his own capacities in a manner concordant with his own experiential life. Hypnosis does not change the person, nor does it alter his past experiential life. It serves to permit him to learn more about himself and to express himself more adequately.

Direct suggestion is based primarily, if unwittingly, upon the assumption that whatever develops in hypnosis derives from the suggestions given. It implies that the therapist has the miraculous power of effecting therapeutic changes in the patient, and disregards the fact that therapy results from an inner resynthesis of the patient's behavior achieved by the patient himself. It is true that direct suggestion can effect an alteration in the patient's behavior and result in a symptomatic cure, at least temporarily. However, such a cure is simply a response to the suggestion and does not entail that reassociation and reorganization of ideas, understandings and memories so essential for an actual cure. It is this experience of reassociating and reorganizing his own experiential life that eventuates in a cure, not the manifestation of responsive behavior which can, at best, satisfy only the observer.

For example, anesthesia of the hand may be suggested directly and a seemingly adequate response may be elicited. However, if the patient has not spontaneously interpreted the command to include a realization of the need for inner reorganization, that anesthesia will fail to meet clinical tests and will be a pseudo-anesthesia.

An effective anesthesia is better induced, for example, by initiating a train of mental activity within the patient himself by suggesting that he recall the feeling of numbness experienced after a local anesthetic, or after a leg or arm went to sleep, and then suggesting that he can now experience a similar feeling in his hand. By such an indirect suggestion the patient is enabled to go through those difficult inner processes of disorganizing, reorganizing, reassociating and projecting inner real experience to meet the requirements of the suggestion. Thus, the induced anesthesia becomes a part of his experiential life, instead of a simple, superficial response.

The same principles hold true in psychotherapy. The chronic alcoholic can be induced by direct suggestion to correct his habits temporarily, but not until he goes through the inner process of reassociating and reorganizing his experiential life can effective results occur.

In other words, hypnotic psychotherapy is a learning process for the patient, a procedure of reeducation. Effective results in hypnotic psychotherapy, or hypnotherapy, derive only from the patient's activities. The therapist merely stimulates the patient into activity, often not knowing what that activity may be, and then he guides the patient and exercises clinical judgment in determining the amount of work to be done to achieve the desired results. How to guide and to judge constitute the therapist's problem while the patient's task is that of learning through his own efforts to understand his experiential life in a new way. Such reeducation is, of course, necessarily in terms of the patient's life experiences, his understandings, memories, attitudes and ideas, and it cannot be in terms of the therapist's ideas and opinions.

In our work, therefore, we prefer to emphasize how therapeutic trance helps people sidestep their own learned limitations so that they can more fully explore and utilize their potentials. The hypnotherapist makes many approaches to altered states of functioning available to the patient. Most patients really cannot direct themselves consciously in trance experience because such direction can come only from their previously learned habits of functioning which are inhibiting the full utilization of their potentials. Patients must therefore learn to allow their own unconscious response potentials to become manifest during trance. The therapist, too, must depend upon the patient's unconscious as a source of creativity for problem-solving. The therapist helps the patient find access to this creativity via that altered state we call therapeutic trance. Therapeutic trance can thus be understood as a free period of psychological exploration wherein therapist and patient cooperate in the search for those hypnotic responses that will lead to therapeutic change. We will now turn our attention to the evaluation and facilitation of that change.

3. Ratification of Therapeutic Change

The recognition and evaluation of altered patterns of functioning facilitated by therapeutic trance is one of the most subtle and important tasks of the therapist. Many patients readily recognize and admit changes that they have experienced. Others with less introspective ability need the therapist's help in evaluating the changes that have taken place. A recognition and appreciation of the trance work is necessary, lest the patient's old negative attitudes disrupt and destroy the new therapeutic responses that are still in a fragile state of development.

The Recognition and Ratification of Trance

Different individuals experience trance in different ways. The therapist's task is to recognize these individual patterns and when necessary point them out to patients to help verify or ratify their altered state of trance. Consciousness does not always recognize its own altered states. How often do we not recognize that we are actually dreaming? It is usually only after the fact that we recognize we were in a state of reverie or daydreaming. The inexperienced user of alcohol and psychedelic drugs must also learn to recognize and then go with the altered state in order to enhance and fully experience its effects. Since therapeutic trance is actually only a variation of the common everyday trance or reverie that everyone is familiar with but does not necessarily recognize as an altered state, some patients will not believe they have been affected in any way. For these patients, in particular, it is important to ratify trance as an altered state. Without this proof the patient's negative attitudes and beliefs can frequently undo the value of the hypnotic suggestion and abort the therapeutic process that has been initiated.

Because of this we will list in Table 1 some of the common indicators of trance experience which we have previously discussed and illustrated in some detail (Erickson, Rossi, and Rossi, 1976). Because trance experience is highly individualized, patients will manifest these indicators in varying combinations as well as in different degrees.


	TABLE 1
	SOME COMMON INDICATORS OF TRANCE EXPERIENCE
	Autonomous Ideation and Inner	Respiration
	Experience	Swallowing
		Startle reflex
	Balanced Tonicity (Catalepsy)
	Body Immobility	Objective and Impersonal Ideation
	Body Reorientation After Trance	Psychosomatic Responses
	Changed Voice Quality	Pupillary Changes
	Comfort, Relaxation	Response Attentiveness
	Economy of Movement	Sensory, Muscular Body Changes
		(Paresthesias)
	Expectancy
		Slowing Pulse
	Eye Changes and Closure
		Spontaneous Hypnotic Phenomena
	Facial Features Smooth Relaxed	Amnesia
		Anesthesia
	Feeling Distanced or Dissociated	Body Illusions
		Catalepsy
	Feeling Good After Trance	Regression
		Time Distortion
	Literalism	etc.
	Loss or Retardation of Reflexes	Time Lag in Motor and Conceptual
	Blinking	Behavior

Most of these indicators will be illustrated as they appear in the cases of this book.

We look upon the spontaneous development of hypnotic phenomena such as age regression, anesthesia, catalepsy, and so on as more genuine indicators of trance than when these same phenomena are suggested. When they are directly suggested, we run into the difficulties imposed by the patient's conscious attitudes and belief system. When they come about spontaneously, they are the natural result of the dissociation or reorganization of the patient's usual frames of reference and general reality orientation which is characteristic of trance.

Certain investigators have selected some of these spontaneous phenomena as defining characteristics of the fundamental nature of trance. Meares (1957) and Shor (1959), for example, have taken regression as a fundamental aspect of trance. From our point of view, however, regression per se is not a fundamental characteristic of trance, although it is often present as an epiphenomenon of the early stage of trance development, when patients are learning to give up their usual frames of reference and modes of functioning. In this first stage of learning to experience an altered state, many uncontrolled things happen, including spontaneous age regression, paresthesias, anesthesias, illusions of body distortion, psychosomatic responses, time distortion, and so on. Once patients learn to stablize these unwanted side reactions, they can then allow their unconscious minds to function freely in interacting with the therapist's suggestions without some of the limitations of their usual frames of reference.

Ideomotor and Ideosensory Signaling

Since much hypnotherapeutic work does not require a dramatic experience of classical hypnotic phenomena, it is even more important that the therapist learn to recognize the minimal manifestations of trance as alterations in a patient's sensory-perceptual, emotional, and cognitive functioning. A valuable means of evaluating these changes is in the use of ideomotor and ideosensory signaling (Erickson, 1961; Cheek and Le Cron, 1968). An experience of trance as an altered state can be ratified by requesting any one of a variety of ideomotor responses as follows:

If you have experienced some moments of trance in our work today, your right hand (or one of your fingers) can lift all by itself.

If you have been in trance today without even realizing it, your head will nod yes (or your eyes will close) all by itself.

The existence of a therapeutic change can be signaled in a similar manner.

If your unconscious no longer needs to have you experience (whatever symptom), your head will nod.

Your unconscious can review the reasons for that problem, and when it has given your conscious mind its source in a manner that is comfortable for you to discuss, your right index finger can lift all by itself.

Some subjects experience ideosensory responses more easily than other subjects. They may thus experience a feeling of lightness, heaviness, coolness, or prickliness in the designated part of the body.

In requesting such responses we are presumably allowing the patient's unconscious to respond in a manner that is experienced as involuntary by the patient. This involuntary or autonomous aspect of the movement or feeling is an indication that it comes from a response system that is somewhat dissociated from the patient's habitual pattern of voluntary or intentional response. The patient and therapist thus have indication that something has happened independently of the patient's conscious will. That something may be trance or whatever therapeutic response was desired.

An uncritical view of ideomotor and ideosensory signaling takes such responses to be the true voice of the unconscious. At this stage of our understanding we prefer to view them as only another response system that must be checked and crossed-validated just as any other verbal or nonverbal response system. We prefer to evoke ideomotor responses in such a manner that the patient's conscious mind may not witness them (for example, having eyes closed or averted when a finger or hand signal is given). It is very difficult, however, to establish that the conscious mind is unaware of what response is given and that the response is in fact given independently of conscious intention. Some patients feel that the ideomotor or ideosensory response is entirely on an involuntary level. Others feel they must help it or at least know ahead of time what it is to be.

A second major use of ideomotor and ideosensory signaling is to help patients restructure their belief system. Doubts about therapeutic change may persist even after an extended period of exploring and dealing with a problem in trance. These doubts can often be relieved when the patient believes in ideomotor or ideosensory responses as an independent index of the validity of therapeutic work. The therapist may proceed, for example, with suggestions as follows:

If your unconscious acknowledges that a process of therapeutic change has been initiated, your head can nod.

When you know you need no longer be bothered by that problem, your index finger can lift, or get warm [or whatever].

In such usage there is value, of course, in having the patient's conscious mind recognize the positive response. The more autonomous or involuntary the ideomotor or ideosensory response, the more convincing it is to the patient.

At the present time we have no way of distinguishing when an ideomotor or ideosensory response is (1) a reliable and valid index of something happening in the unconscious (out of the patient's immediate range of awareness), or (2) simply a means of restructuring a conscious belief system. A great deal of carefully controlled experimental work needs to be done in this area. It is still a matter of clinical judgment to determine which process, or the degree to which both processes, are operating in any individual situation.

Summary

Our utilization approach to hypnotherapy emphasizes that therapeutic trance is a means by which we help patients learn to use their mental skills and potentials to achieve their own therapeutic goals. While our approach is patient-centered and highly dependent on the momentary needs of the individual, there are three basic phases that can be outlined and discussed for didactic purposes: Preparation, Therapeutic Trance, and Ratification of Therapeutic Change.

The goal of the initial preparatory period is to establish an optimal frame of reference to orient the patient toward therapeutic change. This is facilitated by the following factors, which were discussed in this chapter and which will be illustrated in the cases of this book.

Rapport

Response Attentiveness

Assessing Abilities to Be Utilized

Facilitating Therapeutic Frames of Reference

Creating Expectancy

Therapeutic trance is a period during which the limitations of one's habitual frames of reference are temporarily altered so that one can be receptive to more adequate modes of functioning. While the experience of trance is highly variable, the overall dynamics of therapeutic trance and suggestion could be outlined as a five-stage process: (1) Fixation of attention; (2) depotentiating habitual frameworks; (3) unconscious search; (4) unconscious processes; (5) therapeutic response.

The utilization approach and the indirect forms of suggestion are the two major means of facilitating these overall dynamics of therapeutic trance and suggestion. The utilization approach emphasizes the continual involvement of each patient's unique repertory of abilities and potentials, while the indirect forms of suggestion are the means by which the therapist facilitates these involvements.

We believe that the induction and maintenance of therapeutic trance provides a special psychological state in which patients can reassociate and reorganize their inner experience so that therapy results from an inner resynthesis of their own behavior.

Ratifying the process of therapeutic change is an integral part of our approach to hypnotherapy. This frequently involves a special effort to help patients recognize and validate their altered state. The therapist must develop special skills in learning to recognize minimal manifestations of altered functioning in sensory-perceptual, emotional, and cognitive processes. Ideomotor and ideosensory signaling are of special use as an index of therapeutic change as well as a means of facilitating an alteration of the patient's belief system.

Exercises

1. New observational skills are the first stage in the training of the hypnotherapist. One needs to learn to recognize the momentary variations in another's mentation. These skills can be developed by training oneself to carefully observe the mental states of people in everyday life as well as in the consulting room. There are at least four levels, ranging from the most obvious to the more subtle.

1. Role relations

2. Frames of reference

3. Common everyday trance behaviors

4. Response attentiveness

1. Role relations: Carefully note the degree to which individuals in all walks of life are caught within roles, and the degrees of flexibility they have in breaking out of their roles to relate to you as a unique person. For example, to what degree are the clerks at the supermarket identified with their roles? Notice the nuances of voice and body posture that indicate their role behavior. Does their tone and manner imply that they think of themselves as an authority to manipulate you, or are they seeking to find out something about you and what you really need? Explore the same questions with police, officials of all sorts, nurses, bus drivers, teachers, etc.

2. Frames of reference: To the above study of 'role relations add an inquiry into the dominant frames of reference that are guiding your subject's behavior. Is the bus or taxicab driver more dominated by a safety fame of reference? Which of the store clerks is more concerned with securing his present job and which is obviously bucking for a promotion? Is the doctor more obviously operating within a financial or therapeutic frame of reference?

3. Common everyday trance behavior: Table 1 can be a guide as to what to look for in evaluating a person's everyday trance behavior. Even in ordinary conversation one can take careful note of those momentary pauses when the other person is quietly looking off into the distance or staring at something, as he or she apparently reflects inward. One can ignore and actually ruin these precious moments when the other is engaged in inner search and unconscious processes by talking too much and thereby distracting the person. How much better simply to remain quiet oneself and carefully observe the individual manifestations of the other's everyday trance behavior. Notice especially whether the person's eye blink slows down or stops altogether. Do the eyes actually close for a moment? Does the body not remain perfectly immobile, perhaps even with limbs apparently cataleptic, fixed in mid-gesture?

Watching for these moments and pauses is especially important in psychotherapy. The authors will themselves sometimes freeze in mid-sentence when they observe the patient going off into such inward focus. We feel what we are saying is probably less important than allowing the patient to have that inward moment. Sometimes we can facilitate the inner search by simply saying things such as:

That's right, continue just as you are.

Follow that now.

Interesting isn't it?

Perhaps you can tell me some of that later.

After a while patients become accustomed to this unusual tolerance and reinforcement of their inner moments; the pauses grow longer and become what we would call therapeutic trance. The patients then experience increasing relaxation and comfort and may prefer to respond with ideomotor signals as they give increasing recognition to their trance state.

4. Response Attentiveness: This is the most interesting and useful of the trance indicators. The junior author can recall that lucky day when a series of three patients seen individually on successive hours just happened to manifest a similar wide-eyed look of expectancy, staring fixedly into his eyes. They also had a similar funny little smile (or giggle) of wistfulness and mild confusion. That was it! Suddenly he recognized what the senior author had been trying to teach him for the past five years: Response attentiveness! The patients may not have realized themselves just how much they were looking to the junior author for direction at that moment. That was the moment to introduce a therapeutic suggestion or frame of reference! That was the moment to introduce trance either directly or indirectly! The junior author can recall the same slight feeling of discomfort with each patient at that moment. The patient's naked look of expectancy bespoke a kind of openness and vulnerability that is surprising and a bit disconcerting when it is suddenly encountered. In everyday situations we tend to look away and distract ourselves from such delicate moments. At most we allow ourselves to enjoy them briefly with children or during loving encounters. In therapy such creative moments are the precious openers of the yes set and positive transference. Hypnotherapists allow themselves to be open to these moments and perhaps to be equally vulnerable as they offer some tentative therapeutic suggestions. More detailed exercises on the recognition and utilization of response attentiveness will be presented at the end of Chapter Three.

CHAPTER 2

The Indirect Forms of Suggestion

1. Direct and Indirect Suggestion

A direct suggestion makes an appeal to the conscious mind and succeeds in initiating behavior when we are in agreement with the suggestion and have the capacity actually to carry it out in a voluntary manner. If someone suggests, Please close the window, I will close it if I have the physical capacity to do so, and if I agree that it's a good suggestion. If the conscious mind had a similar capacity to carry out all manner of psychological suggestions in an agreeable and voluntary manner, then psychotherapy would be a simple matter indeed. The therapist would need only suggest that the patient give up such and such a phobia or unhappiness and that would be the end of the matter.

Obviously this does not happen. Psychological problems exist precisely because the conscious mind does not know how to initiate psychological experience and behavior change to the degree that one would like. In many such situations there is some capacity for desired patterns of behavior, but they can only be carried out with the help of an unconscious process that takes place on an involuntary level. We can make a conscious effort to remember a forgotten name, for example, but if we cannot do so, we cease trying after a few moments of futile effort. Five minutes later the name may pop up spontaneously within our minds. What has happened? Obviously a search was initiated on a conscious level, but it could only be completed by an unconscious process that continued on its own even after consciousness abandoned its effort. Sternberg (1975) has reviewed experimental data supporting the view that an unconscious search continues at the rate of approximately thirty items per second even after the conscious mind has gone on to other matters.

The indirect forms of suggestion are approaches to initiating and facilitating such searches on an unconscious level. When it is found that consciousness is unable to carry out a direct suggestion, we may then make a therapeutic effort to initiate an unconscious search for a solution by indirect suggestion. The naive view of direct suggestion which emphasizes control maintains that the patient passively does whatever the therapist asks. In our use of indirect suggestion, however, we realize that suggested behavior is actually a subjective response synthesized within the patient. It is a subjective response that utilizes the patient's unique repertory of life experiences and learning. It is not what the therapist says but what the patient does with what is said that is the essence of suggestion. In hypnotherapy the words of the therapist evoke a complex series of internal responses within the patient; these internal responses are the basis of suggestion. Indirect suggestion does not tell the patient what to do; rather, it explores and facilitates what the patient's response system can do on an autonomous level without really making a conscious effort to direct itself.

The indirect forms of suggestion are semantic environments that facilitate the experience of new response possibilities. They automatically evoke unconscious searches and processes within us independent of our conscious will.

In this chapter we shall discuss a number of indirect forms of suggestion that have been found to be of practical value in facilitating hypnotic responsiveness. Most of these indirect forms are in common usage in everyday life. Indeed, this is where the senior author usually recognized their value as he sought more effective means of facilitating hypnotic work.

Because we have already discussed most of these indirect forms from a theoretical point of view (Erickson and Rossi, 1976; Erickson, Rossi, and Rossi, 1976), our emphasis in this chapter will be on their therapeutic applications. It will be seen that many of these indirect forms are closely related to each other, that several can be used in the same phrase or sentence, and that it is sometimes difficult to distinguish one from another. Because of this, it may be of value for the reader to recognize that an attitude or approach is being presented with this material rather than a'' technique'' that is designed to achieve definite and predictable (though limited) results. The indirect forms of suggestion are most useful for exploring potentialities and facilitating a patient's natural response tendencies rather than imposing control over behavior.

2. The Interspersal Approach

The senior author has described the interspersal approach (Erickson, 1966; Erickson and Rossi, 1976) along with nonrepetition as his most important contributions to the practice of suggestion [In a conversation with Anisley Mears, Gordon Ambrose, and others on the evening when the senior author, at the age of seventy-four, was awarded the Benjamin Franklin gold medal for his innovative contributions to hypnosis at the 7th International Congress of Hypnosis on July 2, 1976.]. In the older, more traditional forms of direct suggestion the hypnotherapist usually droned on and on, repeating the same suggestion over and over. The effort was seemingly directed to programming or deeply imprinting the mind with one fixed idea. With the advent of modern psychodynamic psychology, however, we recognize that the mind is in a continual state of growth and change; creative behavior is in a continual process of development. While direct programming can obviously influence behavior (e.g., Coueism, advertising), it does not help us explore and facilitate a patient's unique potentials. The interspersal approach, on the other hand, is a suitable means of presenting suggestions in a manner that enables the patient's own unconscious to utilize them in its own unique way.

The interspersal approach can operate on many levels. We can within a single sentence intersperse a single word that facilitates the patient's associations:

You can describe those feelings as freely as you wish.

The interspersed word freely automatically associates a positive valence of freedom with feelings patients may have suppressed. It can thereby help patients to free feelings that they really want to reveal. Each patient's individuality is still respected, however, because free choice is admitted. The senior author (Erickson, 1966) has illustrated how an entire therapeutic session can be conducted by interspersing words and concepts suggestive of comfort, utilizing the patient's own frames of reference so that pain relief is achieved without the formal induction of trance. Case 1 of this volume will give another clear illustration of this approach. In the following sections we will discuss and illustrate indirect associative focusing and indirect ideodynamic focusing as two aspects of the interspersal approach.

2a. Indirect Associative Focusing

A basic form of indirect suggestion is to raise a relevant topic without directing it in any obvious manner to the patient. The senior author likes to point out that the easiest way to help patients talk about their mothers is to talk about your own mother or mothers in general. A natural indirect associative process is thereby set in motion within patients that brings up apparently spontaneous associations about their mothers. Since we do not directly ask about a patient's mother, the usual limitations of conscious sets and habitual mental frameworks (including psychological defenses) that such a direct question might evoke are bypassed. Bandler and Grinder (1975) have described this process as a transderivational phenomenon - a basic linguistic process whereby subject and object are automatically interchanged at a deep, (unconscious), structural level.

In therapy we can use a process of indirect associative focusing to help a patient recognize a problem. The senior author, for example, will frequently intersperse remarks or tell a number of stories and anecdotes in seemingly casual conversation. Even when his stories appear unrelated, however, they all have a common denominator or common focused association which he hypothesizes to be a relevant aspect of the patient's problem. Patients may wonder why the therapist is making such interesting but apparently nonrelevant conversation during the therapy hour. If the common, focused association is in fact a relevant aspect of their problem, however, patients will frequently find themselves talking about it in a surprisingly revelatory manner. If the therapist guessed wrong, nothing is lost. The patient will simply not talk about the focused association because there is no particular recognition and contribution within the patient's own associative processes to raise it to the verbal level.

A major value of this interspersal approach is that therapists can to some degree avoid imposing their own theoretical views and preoccupations upon their patients. If the focused association is of value to patients, their own unconscious processes of search and evaluation will permit them to recognize it as an aspect of their problem and utilize it in their own way to find their own solutions. Examples of this process of indirect associative focusing to help patients recognize and resolve psychodynamic problems will be presented in a number of case illustrations of this volume (e.g., particularly Case 5, a general approach to symptomatic behavior).

2b. Indirect Ideodynamic Focusing

One of the earliest theories of hypnotic responsiveness was formulated by Bernheim (1895), who described it as a peculiar aptitude for transforming the idea received into an act. He believed, for example, that in the hypnotic experience of catalepsy there was ' 'an exaltation of the idea-motor reflex excitability, which effects the unconscious transformation of the thought into movement, unknown to the will. In the hypnotic experience of sensory hallucinations he theorized that the memory of sensation [is] resuscitated along with exultation of the ideo-sensorial reflex excitability, which effects the unconscious transformation of the thought into sensation, or into a sensory image.'' This view of ideodynamic responsiveness (that ideas can be transformed into an actual experience of movements, sensations, perceptions, emotions, and so on, independently of conscious intentionality) is still tenable today. Our utilization theory of hypnotic suggestion emphasizes that suggestion is a process of evoking and utilizing a patient's own mental processes in ways that are outside his usual range of ego control (Erickson and Rossi, 1976).

Ideodynamic processes can be evoked with an interspersal approach utilizing indirect associative focusing as described in the previous section. When the senior author addressed professional groups about hypnotic phenomena, for example, he frequently interspersed interesting case histories and told stories about hand levitation or hallucinatory sensations. These vivid illustrations initiated a natural process of ideomotor and ideosensory responsiveness within the listeners without their being aware of it. When he then asked for volunteers from the audience for a demonstration of hypnotic behavior, they were primed for responsiveness by ideodynamic processes that were already taking place within them in an involuntary manner on an unconscious level. These unrecognized ideodynamic responses can frequently be measured by electronic instrumentation (Prokasy and Raskin, 1973).

In a similar manner, when confronted with a resistant subject we can surround him with one or more good hypnotic subjects to whom we direct our hypnotic suggestions. A process of indirect ideodynamic responsiveness takes place automatically within the resistant subject as he listens to the suggestions and observes the responses of others. He is soon surprised at how the hypnotic atmosphere effects him so that he becomes much more responsive than before.

Many clear illustrations of this process of interspersing indirect ideodynamic suggestion will be found in the cases of this book. In our first case, for example, the senior author talks about his friend John, who had phantom limb pain in his foot just like the patient's: John was marvelous. And I discussed with him the importance of having nice feelings in your wooden foot, your wooden knee. . . . The importance of having good feelings in the wooden foot, the wooden knee, the wooden leg. Feeling it to be warm. Cool. Rested . . . you can have phantom pleasure.

In the context of a number of anecdotes and stories about how others have learned to experience phantom pleasure instead of pain, interspersed indirect ideodynamic suggestions such as the above begin automatically to initiate unconscious searches and processes that will lead to the amelioration of phantom pain even without the formal induction of trance.

3. Truisms Utilizing Ideodynamic Processes

The basic unit of ideodynamic focusing is the truism: a simple statement of fact about behavior that the patient has experienced so often that it cannot be denied. In most of our case illustrations it will be found that the senior author frequently talks about certain psychophysiological processes or mental mechanisms as if he were simply describing objective facts to the patient. Actually these verbal descriptions can function as indirect suggestions when they trip off ideodynamic responses from associations and learned patterns that already exist within patients as a repository of their life experience. The generalized reality orientation (Shor, 1959) usually maintains these subjective responses in appropriate check when we are engaged in ordinary conversation. When attention is fixed and focused in trance so that some of the limitations of the patient's habitual mental sets are depotentiated, however, the following truisms may actually trip off a literal and concrete experience of the suggested behavior, which is printed in italics.

3a. Ideomotor Processes

Most people can experience one hand as being lighter than another.

Everyone has had the experience of nodding their head yes or shaking it no even without realizing it.

When we are tired, our eyes begin to blink slowly and sometimes close without our quite realizing it.

Sometimes as we relax or go to sleep, a muscle will twitch so that our arm or leg makes a slight involuntary movement (Overlade, 1976).

3b. Ideosensory Processes

You already know how to experience pleasant sensations like the warmth of the sun on your skin.

Most people enjoy the refreshing coolness of a light breeze.

Some people can imagine their favorite food so well they can actually taste it.

The salt and smell of a light ocean breeze is pleasant to most people.

3c. Ideoaffective Processes

Some people blush easily when they recognize certain feelings about themselves.

Its easy to feel anger and resentment when we are made to feel foolish. We usually frown when we have memories that are all too painful to

remember.

Most of us try to avoid thoughts and memories that bring tears, yet they frequently deal with the most important things.

We have all enjoyed noticing someone smile at a private thought and we frequently find ourselves smiling at their smile.

In formulating such ideoaffective suggestions it is helpful to include a behavioral marker (blush, frown, tears, smile) whenever possible, to provide some possible feedback to the therapist about what the patient is receiving and acting upon.

3d. Ideocognitive Processes

We know that when you are asleep your unconscious can dream. You can easily forget that dream when you awaken.

You can sometimes remember one important part of that dream that interests you.

We can sometimes know a name and have it on the tip of our tongue and yet not be able to say the name.

4. Truisms Utilizing Time

In hypnotherapeutic work truisms utilizing time are very important because there is frequently a time lag in the execution of hypnotic responses. The stages of unconscious search and processes leading to hypnotic responses require varying lengths of time in different patients. It is usually best to permit the patient's own unconscious to determine the appropriate amount of time required for any response.

Sooner or later your hand is going to lift (eyes close, or whatever).

Your headache (or whatever) can now leave as soon as your system is ready for it to leave.

Your symptom can now disappear as soon as your unconscious knows you can handle (such and such) problem in a more constructive manner.

5. Not Knowing, Not Doing

While truisms are an excellent means of introducing suggestions in a positive manner that the conscious mind can accept, valid hypnotic experience involves the utilization of unconscious processes. A basic aspect of therapeutic trance is to arrange circumstances so that constructive mental processes are experienced in taking place by themselves without the patient making any effort to drive or direct them. When one is relaxed, as is typical of most trance experiences, the parasympathetic system physiologically predisposes one not to do rather than to make any active effort of doing. Similarly when we are relaxed and the unconscious takes over, we usually feel comfortable and do not know how the unconscious carries out its activities. Not knowing and not doing are synonymous with the unconscious or autonomous responsiveness that is the essence of trance experience. An attitude of not knowing and not doing is therefore of great value in facilitating hypnotic responsiveness. This is particularly true during the initial stages of trance induction, where the following suggestions may be appropriate.

You don't have to talk or move or make any sort of effort. You don't even have to hold your eyes open.

You don't have to bother trying to listen to me because your unconscious can do that and respond all by itself.

People can sleep and not know they are asleep.

They can dream and not remember that dream.

You don't know just when those eyelids will close all by themselves.

You may not know just which hand will lift first.

These examples clearly illustrate how different our indirect hypnotic forms are from the direct approach, which typically begins, Now pay close attention to my voice and do exactly what I say. The direct approach focuses conscious attention and tends to activate conscious cooperation by the patient. This can be of value in initiating some types of responsive behavior in good hypnotic subjects, but for the average patient it may activate conscious processes to the point where unconscious processes are inhibited rather than enhanced.

Not knowing and not doing are of particular value in trance work when we wish to evoke the patient's own individuality in seeking the best modality of therapeutic response.

You don't really know just how your unconscious will help you resolve that problem. But your conscious mind can be receptive to the answer when it does come.

Your conscious mind surely has many questions, but it does not really know just when the unconscious will let you give up that undesirable habit. You don't know if it will be sooner or later. You don't know if it will be all at once or slowly, by degrees. Yet you can learn to respect your own natural way of doing things.

6. Open-Ended Suggestions

Therapists as well as patients do not always know what is the best avenue for constructive processes to express themselves. Human predispositions and potentialities are so complex that we may even consider it presumptuous to assume that anyone could possibly know ahead of time just what is the most creative approach to the new that continually overtakes us. Indeed, one view of maladjustment is that we do in fact attempt to impose old views and solutions into changed life circumstances where they are no longer appropriate (Rossi, 1972). The open-ended suggestion is a means of dealing with this problem. Open-ended suggestions permit us to explore and utilize whatever response possibilities are most available to the patient. It is of value on the level of conscious choice as well as unconscious determinism. When patients are awake and consciously directing their own behavior, the open-ended suggestion permits self-determination. When patients are in trance, the open-ended suggestion permits the unconscious to select the most appropriate means of carrying out a therapeutic response.

As we have already seen, not knowing and not doing lead naturally to open-ended suggestions. The following are further illustrations.

We all have potentials we are unaware of, and we usually don't know how they will be expressed.

Your mind can review more feelings, memories, and thoughts related to that problem, but you don't know yet which will be most useful for solving the problem you are coping with.

You can find yourself ranging into the past, the present, or the future as your unconscious selects the most appropriate means of dealing with that.

He doesn't know what he is learning, but he is learning. And it isn't right for me to tell him, You learn this or you learn that! Let him learn whatever he wishes, in whatever order he wishes.

While giving a great deal of apparent freedom to explore and express the patient's own individuality, such open-ended suggestions carry a strong implication that a therapeutic response will be forthcoming.

7. Covering All Possibilities of a Class of Responses

While open-ended suggestions permit the widest possible latitude for the expression of a therapeutic response, suggestions covering all possibilities of a class of responses are of more value when the therapist wishes to focus the patient's responsiveness in a particular direction. In initiating trance, for example, the following might be appropriate.

Soon you will find a finger or a thumb moving a bit, perhaps by itself. It can move up or down, to the side or press down. It can be slow or quick or perhaps not move at all. The really important thing is to sense fully whatever feelings develop.

All possibilities of finger movement have been covered, including the possibility of not moving at all. The suggestion is thus fail-safe. The patient is successful no matter what response develops. The therapist is simply exploring the patient's initial responsiveness while initiating trance by focusing attention.

Exactly the same approach can be used when the patient has experienced therapeutic trance and is ready to deal with a problem.

Soon you will find the weight problem being dealt with by eating more or less of the right foods you can enjoy. You may first gain weight or lose it or remain the same for a while as you learn the really important things about yourself.

In both of these illustrations we can observe how we are distracting the patient's consciousness from the important area of responsiveness with an interesting idea in the end (in italics), so that the unconscious can have more opportunity to determine which of the response possibilities (not in italics) will be expressed. This is in keeping with the classical notion of hypnosis as the simultaneous focusing and distraction of attention.

8. Questions That Facilitate New Response Possibilities

Recent research (Steinberg, 1975) indicates that the human brain, when questioned, continues an exhaustive search throughout its entire memory system on an unconscious level even after it has found an answer that is apparently satisfying on a conscious level. This unconscious search and activation of mental processes on an autonomous level is the essence of our indirect approach, wherein we seek to utilize a patient's unrecognized potentials to evoke hypnotic phenomena and therapeutic responses.

This process of an unconscious search and an autonomous processing of information is evident in many phenomena of everyday life. According to one folk saying, The morning is wiser than the evening. After we have slept on a problem, we find the solution comes more easily in the morning. Evidently an unconscious search and problem-solving process has been taking place while the consciousness was at rest. There is evidence that dreaming can be an experimental theater of the mind, where questions can be answered and new life possibilities synthesized (Ross, 1971-1973).

The Socratic method of education, whereby a teacher asks the student a series of pointed questions, is a classical illustration of using questions as initiators of mental processes. We can wonder, indeed, if consciousness could have evolved to its current level without the development and utilization of questions as a provocative syntactical form which facilitate internal processes of inquiry. In this section we will illustrate how questions can focus associations as well as suggest and reinforce new response possibilities.

8a. Questions to Focus Associations

An interesting illustration of how questions can focus different aspects of inner experience comes from research on the subjective reports of hypnotic subjects (Barber, Dalai, and Calverley, 1968). When asked, Did you experience the hypnotic state as basically similar to the waking state? most subjects (83 percent) reported affirmatively. On the other hand, when asked, Did you experience the hypnotic state as basically different from the waking state? 72 percent responded affirmatively. We could take these apparently contradictory responses as indications of the unreliability of the subjects' reports about the hypnotic experience. From another point of view, however, we can understand how such questions focused the subjects on different aspects of their experiences. The first question focused their attention on the similarities between the waking and hypnotic states; the second focused attention on the differences. Both questions could initiate valid responses about different aspects of the subjects' inner experiences; no contradiction need be implied.

In hypnotherapy it is often of value to help patients discriminate between different aspects of their inner lives or to find the common denominator in apparently different experiences. Carefully formulated questions such as the above can facilitate this process.

8b. Questions in Trance Induction

Questions are of particular value as indirect forms of suggestion when they cannot be answered by the conscious mind. Such questions activate unconscious processes and initiate autonomous responses which are the essence of trance behavior. The following are illustrations of how a series of questions may be used to initiate and deepen trance by two different approaches to induction - eye fixation and hand levitation. In each illustration the first few questions may be answered by responsive behavior that is guided by conscious choice. The next few questions may be answered by either conscious intentionality or unconscious choice. The last few can only be answered on an unconscious or autonomous level of responsiveness. These series of questions cannot be used in a fixed and rigid manner, but must always incorporate and utilize the patient's ongoing behavior. It is understood that patients need not respond in a conventional verbal manner to these questions, but only with the responsive behavior suggested. Patients usually do not recognize that a very important but subtle shift is taking place. They are no longer verbally interacting in a social manner with their typical defenses. Rather, they are focused intensely within themselves wondering about how they will respond. This implies that a dissociation is taking place between their conscious thinking (with its sense of control) and their apparently autonomous responses to the therapist's questions. The apparently autonomous nature of their behavioral responses is usually acknowledged as hypnotic . With that the stage is set for further autonomous and unconsciously determined therapeutic responses.

Eye Fixation

1. 1. Would you like to find a spot you can look at comfortably?

2. 2. As you continue looking at that spot for a while, do your eyelids want to blink?

3. 3. Will those lids begin to blink together or separately?

4. 4. Slowly or quickly?

5. 5. Will they close all at once or flutter all by themselves first?

6. 6. Will those eyes close more and more as you get more and more comfortable?

7. 7. That's fine. Can those eyes now remain closed as your comfort deepens like when you go to sleep?

8. 8. Can that comfort continue more and more so that you'd rather not even try to open your eyes?

9. 9. Or would you rather try and find you cannot?

10. 10. And how soon will you forget about them altogether because your unconscious wants to dream? (Therapist can observe slight eyeball movements as the patient's closed eyes follow changes on the inner dream scene.)

This series begins with a question that requires conscious choice and volition on the part of the patient and ends with a question that can only be carried out by unconscious processes. An important feature of this approach is that it is fail-safe in the sense that any failure to respond can be accepted as a valid and meaningful response to a question. Another important feature is that each question suggests an observable response that gives the therapist important information about how well the patient is following suggestions. These observable responses are also associated with important internal aspects of trance experience and can be used as indicators of them.

If there is a failure to respond adequately, the therapist can go on with a few other questions at the same level until responsive behavior is again manifest, or the therapist can question patients about their inner experience to explore any unusual response patterns or difficulties they may have. It is not uncommon for some patients, for example, to open their eyes occasionally even after it is suggested that they will remain closed. This seems to be an automatic checking device that some patients use without even being aware of it. It does not interfere with therapeutic trance work. The question format thus gives each patient's own individuality an opportunity to respond in a therapeutically constructive manner. These features are also found in the hand-levitation approach, which we will now illustrate.

Hand Levitation

1. 1. Can you feel comfortable resting your hands gently on your thighs? [As therapist demonstrates] That's right, without letting them touch each other.

2. 2. Can you let those hands rest ever so lightly so that the fingertips just barely touch your thighs?

3. 3. That's right. As they rest ever so light, do you notice how they tend to lift up a bit all by themselves with each breath you take?

4. 4. Do they begin to lift even more lightly and easily by themselves as the rest of your body relaxes more and more?

5. 5. As that goes on, does one hand or the other or maybe both continue lifting even more?

6. 6. And does that hand stay up and continue lifting higher and higher, bit by bit, all by itself? Does the other hand want to catch up with it, or will the other hand relax in your lap?

7. 7. That's right. And does that hand continue lifting with these slight little jerking movements, or does the lifting get smoother and smoother as the hand continues upward toward your face?

8. 8. Does it move more quickly or slowly as it approaches your face with deepening comfort? Does it need to pause a bit before it finally touches your face so you'll know you are going into a trance? And it won't touch until your unconscious is really ready to let you go deeper, will it?

9. 9. And will your body automatically take a deeper breath when that hand touches your face as you really relax and experience yourself going deeper?

10. 10. That's right. And will you even bother to notice the deepening comfortable feeling when that hand slowly returns to your lap all by itself? And will your unconscious be in a dream by the time that hand comes to rest?

8c. Questions Facilitating Therapeutic Responsiveness

Questions can be combined with not knowing and with open-ended suggestions to facilitate a variety of patterns of responsiveness.

And what will be the effective means of losing weight? Will it be because you simply forget to eat and have little patience with heavy meals because they prevent you from doing more interesting things? Will certain foods that put on weight no longer appeal to you for whatever reasons? Will you discover the enjoyment of new foods and new ways of preparing them and eating so that you'll be surprised that you did lose weight because you really didn't miss anything?

The last question in this series is an illustration of how compound questions can be built up with and and so to facilitate whatever tendency is most natural for the patient.

The ambiguity and suggestive effect of compound questions has long been recognized in jurisprudence. The use of compound questions by attorneys is therefore forbidden during their cross-examination of a witness. In a hotly contested case a judge or an opposing attorney can often be heard objecting to the compounds by which an unscrupulous attorney may befuddle and perhaps ensnare an unwary witness. In our therapeutic use of compound questions their very ambiguity is of value in depotentiating the patient's learned limitations so new possibilities may be experienced.

We will now turn to a more detailed examination of compound suggestions.

9. Compound Suggestions

We have already seen in many of our previous illustrations how two or more suggestions can be combined to support each other. In this section we shall take a closer look at a variety of compound suggestions that have been found to be of value in hypnotherapeutic work. At the simplest level a compound suggestion is made up of two statements joined together with a grammatical conjunction or with a slight pause that places them in close association. Traditional grammar has classified conjunctions broadly as coordinating and subordinating. The coordinating conjunctions and, but, and or join statements that are logically coordinated or equal in rank, while subordinating conjunctions such as though, if, so, as, after, because, since, and until join one expression to another that is its adjunct or subordinate. The linguistic joining and separating expressions obviously have correspondences with similar processes in mathematics and logic as well as with the psychological processes of mental association and dissociation that are of essence in hypnotherapy. George Boole (1815-1864), one of the originators of symbolic logic, felt that he was formulating the laws of thought with his equations. We know today, however, that while logic, natural language, and mental processes share some intriguing interfaces, there is no system of complete correspondence between them. While a system of logic or mathematics can be completely defined, natural language and mental processes are perpetually in a state of creative flux. There is in principle no fixed formula or system of logic or language that can completely determine or control mental processes. We would be deluding ourselves, therefore, if we sought a completely deterministic means of manipulating mental processes and controlling behavior with our indirect forms of suggestion. We can use them to explore and facilitate response potentials within the patient, however. In this section we will illustrate five classes of compound suggestion that have been of particular use in hypnotherapy: (a) the yes set and reinforcement, (b) contingency, (c) apposition of opposites, (d) the negative, and (e) shock, surprise, and creative moments. Other forms of indirect suggestion such as implication, binds, and double binds are so complex that we will discuss them in separate sections.

9a. The Yes Set and Reinforcement

A basic form of compound statement widely used in daily life is the simple association of a certain and obviously good notion with the suggestion of a desirable possibility.

It's such a beautiful day, let's go swimming.

It's a holiday, so why shouldn't I do what I want?

You have done well and can continue.

In each of the above an initially positive association ( beautiful day, holiday, done well ) introduces a yes set that facilitates the acceptance of the suggestion that follows. We saw earlier how truisms are another means of opening a yes set to facilitate suggestion.

When the truism or positive and motivating association follows the suggestion, we have a means of reinforcing it. Thus:

Let's go swimming, it's such a beautiful day.

9b. Contingent Suggestions and Associational Networks

A useful form of compound statement occurs when we tie a suggestion to an ongoing or inevitable pattern of behavior. A hypnotic suggestion that may be difficult for a patient is easier when it is associated with behavior that is familiar. The hypnotic suggestion hitchhikes onto the natural and spontaneous responses that are well within the patient's normal repertory. The contingent suggestion is italicized in the following examples.

With each breath you take you can become aware of the natural rhythms of your body and feelings of comfort that develop.

As you continue sitting there, you will find yourself becoming more relaxed and comfortable.

As your hand lowers, you'll find yourself going comfortably back in time to the source of that problem.

As you mentally review the source of that problem your unconscious can develop some tentative ways of dealing with it.

And when your conscious mind recognizes a plausible and worthwhile solution, your finger can lift automatically.

When you feel ready to talk about it, you'll find yourself awakening feeling refreshed and alert, with an appreciation of the good work you've been able to do.

As can be seen from the last four examples, contingent suggestions can be tied together into associational networks that create a system of mutual support and momentum for initiating and carrying out a therapeutic pattern of responses. From the broadest point of view a whole therapy session - indeed, an entire course of therapy - can be conceived as a series of contingent responses wherein each successful therapeutic step evolves from all that came before. Haley (1974) has presented a number of the senior author's clinical cases that illustrate this process.

9c. Apposition of Opposites

Another indirect form of compound suggestion is what we may describe as the balance or apposition of opposites. A balance between opponent systems is a basic biological process that is built into the structure of our nervous system (Kinsbourne, 1974). Most biological systems can be conceptualized as a homeostatic balance of processes that prevents the overall system from straying outside the relatively narrow range required for optimal functioning. To account for some of the phenomena of hypnosis, it has been proposed that there are alternatives in various opponent systems, such as the sympathetic and parasympathetic system, the left and right cerebral hemispheres, cortical versus subcortical processes, the first and second signaling system (Platonov, 1959).

This balancing or apposition of opponent processes is also evident on the psychological and social levels. There is tension and relaxation, motivation and inhibition, conscious and unconscious, eros and logos, thesis and antithesis. An awareness and understanding of the dynamics of such opponent processes is of greatest significance in any form of psychotherapy. In this section we can provide only a few illustrations of how we can balance opponent processes by means of verbal suggestion. In the process of hypnotic induction, for example, we have the following:

As that fist gets tighter and tense, the rest of your body relaxes. As your right hand lifts, your left hand lowers.

As that arm feels lighter and lifts, your eyelids can feel heavier and lower until they are closed.

Similar suggestions can be formulated for virtually any of the opponent processes in the sensory, perceptual, affective, and cognitive realms.

As your forehead gets cooler, your hands can get warmer.

As your jaw becomes more and more numb and insensitive, notice how your left hand becomes more and more sensitive.

You can experience all your feelings about something that occurred at age X without being able to remember just what caused those feelings.

When you next open your eyes you will have an unusually clear memory of all that, but without the feelings you had then.

As you review that, you can now experience an appropriate balance of thinking and feeling about the whole thing.

As can be seen from the last three examples, a process of dissociation can be utilized to first help the patient very thoroughly experience both sides of an opponent system before they are brought together at a more adequate level of integration.

9d. The Negative

Closely associated with the apposition of opposites is the senior author's emphasis on the importance of discharging the negativity or resistance that builds up whenever a patient is following a series of suggestions. In everyday life we can recognize how people who are negative or resistant usually have a history of feeling they were imposed upon too much. Because of this they now want to have it their way! They resist being overdirected and very often do the opposite of what they believe others want them to do. This oppositional tendency, of course, is actually a healthy compensation for their early histories. Nature apparently wants us to be individuals, and many believe that the history of man's cultural and psychological development has been an effort to achieve ever-more-encompassing degrees of free, unfettered, and genuine self-expression.

In experimental research psychologists have developed the concept of reactive inhibition to account for similar behavioral phenomena (Woodworth and Schlosberg, 1954). After repeating some task (running a maze, solving certain problems of a similar nature) the subject, whether rat or man, appears less and less willing to go on, and more easily accepts alternative pathways and other patterns of behavior. This inhibition apparently has an adaptive function in blocking previous behavior in favor of the expression of new responses that can lead to new possibilities.

In his practical work with patients, the senior author has explored various means of coping with and actually utilizing this inhibitory or oppositional tendency. He believes that the simple expression of a negative by the therapist can often serve as a lightning rod to automatically discharge any minor inhibition and resistance that has been building up within the patient. Thus he will use such phrases as the following:

And you can, can you not? You can try, can't you? You can't stop it, can you? You will, won't you? You do, don't you? Why not let that happen?

Research has demonstrated another value in this close juxtaposition of the positive and the negative. It has been found that it is 30 percent more difficult to comprehend a negative than a positive (Donaldson, 1959). Thus the use of negatives can introduce confusion that tends to depotentiate a patient's limited conscious set so that inner work can be done.

The use of the negative is also related to another indirect form - not knowing and not doing. This use of the negative can be very usefully and casually introduced in contingent suggestions, such as the following that utilize the connective until.

You don't have to go into trance until you are really ready.

You won't take a really deep breath until that hand touches your face.

You won't really know just how comfortable you can be in trance until that arm slowly lowers all the way down to rest on your lap.

And you really don't have to do [therapeutic response] until [Inevitable behavior in patient's near future].

You won't do it until your unconscious is ready.

The latter use of the negative is actually a form of the conscious-unconscious double bind we will discuss in a later section.

9e. Shock, Surprise, and Creative Moments

A most interesting form of compound suggestion is illustrated when a shock surprises patients' habitual mental frameworks so their usual conscious sets are depotentiated and there is a momentary gap in their awareness, which can then be filled with an appropriate suggestion (Rossi, 1973; Erickson and Rossi, 1976). The shock opens the possibility of a creative moment during which the patient's unconscious is engaged in an inner search for an answer or conception that can reestablish psychic equilibrium. If the patient's own unconscious processes do not provide the answer, the therapist has an opportunity to introduce a suggestion that may have the same effect.

Shock and surprise can sometimes precipitate autonomic reactions that are normally not under voluntary control. At a delicate moment in a conversation one sometimes blushes in an uncontrolled manner when unconscious emotional processes are touched upon. If a person is not blushing during such an unguarded moment, one can frequently precipitate a blushing response by simply asking, Why are you blushing? This question - as an indirect form of suggestion administered during the delicate (potentially creative) moment when the listener's habitual mental frameworks are in nascent flux - evokes the suggested autonomic processes easily.

In everyday life a loud noise may startle us so that we freeze, momentarily inhibiting all body movement; we are thrown into a momentary trance as the unconscious races for a means of comprehending what is happening. The answer may flash that it was only a car backfiring, and we relax. But if in that precise moment someone yells the suggestion, bomb! we almost certainly will flinch, look around in panic, or fall to the ground to protect ourselves. Daily life is filled with less dramatic examples of unexpected shocks that startle and surprise and perhaps lead to a double-take, where we have to look back or go over that again to comprehend what is really going on. We could theorize that foul language is actually a form of shock that has developed in most cultures to startle the listeners so they will be more available to what is being said and be more readily influenced by it.

If people have problems because of learned limitations, it can be therapeutic to momentarily depotentiate those limitations with some form of psychological shock. They can then reevaluate their situation via the automatic process of unconscious search that is initiated within them. In this case the process of shock, surprise, and creative moments is open-ended; the patient's own unconscious processes provide whatever reorganization or solution that emerges. If nothing satisfactory comes forth, the therapist may then add suggestions as further stimuli during the momentary gap, in hope that they may catalyze a therapeutic response.

Momentary shock can be generated in therapeutic dialogue by interspersing shock words, taboo concepts, and emotions. Words like sex, secrets, and whispering momentarily fix attention, and the listener is more receptive. A momentary pause after the shock allows an inner search to take place. It can be followed by reassurance or an appropriate suggestion.

Your sex life

[Pause]

just what you need to know and understand about it.

Secretly what you want

[Pause]

is most important to you.

You may get divorced

[Pause]

unless you both really learn to get what you need in the relationship.

In each of these examples the shock in italics initiates an inner search that can lead to the expression of an important response during the pause. The therapist learns to recognize and evaluate the nonverbal body reactions to such psychological shock. If there are indications that the patient has become preoccupied with the inner search, the therapist simply remains quiet until the patient comes forth with whatever material has been stimulated. If there are no indications of material coming from the patient, the therapist ends the pause with a reassurance or suggestion, as illustrated above. The most effective initiators of shock utilize the patient's own frames of reference, taboos, and needs for a break out of the old so that a creative reorganization can take place. Illustrations of this process have been published elsewhere (Rossi, 1973b), and detailed clinical examples will be found in a number of the cases in this volume.

10. Implication and the Implied Directive

Implication is a basic linguistic-psychological form that provides us with the clearest model of the dynamics of indirect suggestion. Most psychotherapists agree that it is not what the therapist says that is important but what the patient hears. That is, the words of the therapist only function as stimuli that set off many personal trains of association within the patient. It is these personal trains of association within the patient that actually function as a major vehicle for the therapeutic process. This process can be disrupted when the therapist's innocent remarks have unfortunate implications for the patient, but it can be greatly facilitated when the therapist's words carry implications that evoke latent potentials within the patient.

A great deal of communication in daily life as well as in therapy is carried out by implication in a manner that is, for the most part, not consciously planned or even recognized by the participants. We witness this in everyday life when a housewife, for example, bangs her pots a bit louder when she is displeased with her husband but may hum softly to herself when she is pleased. She may not recognize what she is doing, and her husband may not always know quite how he is getting the message, but he feels it at some level. Body language and gesture (Birdwhistell, 1952, 1971; Scheflen, 1974) are nonverbal modes of communication that usually function via implications. In such implication the message is not stated directly but is evoked by a progress of inner search and inference. This inner search engages the patient's own unconscious processes so that the response that emerges is as much a function of the patient as it is of the therapist. Like all the other indirect forms of suggestion, our psychological use of implication ideally evokes and facilitates the patient's own processes of creativity.

On the simplest level implication is formed verbally by the If. . . then phrase.

If you sit down then you can go into trance.

Now if you uncross your legs and place your hands comfortably on your lap, then you will be ready to enter trance.

Patients who follow such suggestions by actually sitting down, uncrossing their legs, and placing their hands in their lap are also accepting, perhaps without quite realizing it, the implication that they will go into trance.

What is the value of such implication? Ideally such implications bypass consciousness and automatically evoke the desired unconscious processes that will facilitate trance induction in a way that the conscious mind could not because it does not know how. We can prepare ourselves to go to sleep, but the conscious mind cannot make it happen. Thus if we directly order a naive patient, Sit down and go into trance [The reader will note that even this apparently direct suggestion actually contains an indirect hypnotic form: a compound contingent suggestion where and go into trance is contingent on Sit down . For some particularly apt or experienced subjects, therefore, this statement could facilitate an effective induction.] he or she may well sit down while politely protesting, But I've never gone into trance, and I'm afraid I don't know how. Since the essence of hypnotic suggestion is that responses are carried out on an autonomous or unconscious level, it is usually futile to expect the conscious mind to carry them out via direct suggestion. When direct suggestions are successful, they usually involve preparation for hypnotic work in the same sense that brushing one's teeth and lying in bed are conscious, preparatory acts that set the stage for going to sleep, which is then mediated by unconscious processes. With implication and all the other indirect forms of suggestion, we are presuming to do something more: We are making an effort to evoke and facilitate the actual unconscious processes that will create the desired response.

As we reflect upon the process of implication, we gradually become aware that everything we say has implications. Even the most general conversation can be analyzed as a study in implication - how the words of one speaker can evoke all sorts of associations in the listener. In everyday life as well as in hypnotherapy it is often the implications that are more potent as suggestions than what is being said directly. In a public conversation the participants are frequently inhibited, and respond with associations that are nothing more than cliches. In a more personal interaction, such as hypnotherapy, the participants have license to respond with their more intimate or idiosyncratic associations. In such personal interactions we are sometimes surprised at what associations and feelings we experience. When our conscious mind is surprised in this manner, the therapy has been successful in facilitating an expression of our individuality that we were not previously aware of. We could say that potentials have been released or new dimensions of insight and consciousness have been synthesized.

The following are examples of the use of implication for deepening patients' involvement with their own inner realities during trance.

Your own memories, images, and feelings are now more important to you in this state.

While giving an apparently direct suggestion about memories, images, and feelings, this statement also carries the important implication that trance is different from the ordinary awake state, and in this state everything else is irrelevant (outside noises, the time of day, the office setting, etc.).

We are usually not aware of the moment when we fall asleep and sometimes are not even aware that we slept.

This statement has obvious implications for a lack of awareness about the significant aspects of trance, a lack that can further depotentiate the limiting sets of consciousness. This implication is emphasized in the following monologue, which structures a frame of reference in which automatic and unconscious behavior can be facilitated.

Now you know you do many things all day long without being aware of them. Your heart just beats along without any help or conscious direction from you. Just as you usually breathe without being aware of it. And even when you walk, your legs seem to move by themselves and take you wherever you want to go. And your hands do most of the things you want them to do without your saying Now hands do this, now hands do that. Your hands work automatically for you, and you usually don't have to pay attention to them. Even when you speak, you do it automatically, you don't have to be consciously aware of how to pronounce each word. You can speak without even knowing it. You know how to do it automatically without even thinking about it. Also, when you see or hear things or when you touch or feel things, they work automatically without you having to be conscious of them. They work by themselves and you don't have to pay attention. They just take care of themselves without your having to be bothered about them.

10a. The Implied Directive

A special form of implication that is closely associated with contingency suggestions is what we have termed the implied directive (Erickson and Rossi, 1976). The implied directive is an indirect form of suggestion that is in common usage in clinical hypnosis (Cheek and LeCron, 1968) even though it has not yet received detailed psychological analysis. Like the other indirect forms of suggestion, its use has evolved out of a recognition of its value in everyday life. The implied directive has three recognizable parts:

1. 1. a time-binding introduction;

2. 2. the implied suggestion that takes place within the patient;

3. 3. behavioral response that signals when the implied suggestion has been accomplished.

Thus, as soon as

1. 1. the time-binding introduction

your unconscious has reached the source of that problem,

2. 2. the implied suggestion initiating an unconscious search taking place within the patient

your finger can lift.

3. 3. the behavioral response that signals when the implied suggestion has been accomplished.

As can be seen from this illustration, the implied directive is an indirect form of suggestion that initiates inner search and unconscious processes and then lets us know when a therapeutic response has been accomplished. It is of particular value when we need to initiate and facilitate an extensive process of inner exploration and when we are attempting to unravel the dynamics of symptom formation.

Other indirect forms of suggestion that are particularly useful for initiating an unconscious search in hypnosis are implied directives such as the following:

When you have found a feeling of relaxation and comfort, your eyes close all by themselves.

In this example the patient must obviously make a search on an unconscious level that will ideally initiate parasympathetic responses that can be experienced as comfort and relaxation. Eye closure is a response naturally associated with such internal comfort and thus serves as an ideal signal that the internal process has taken place.

As that comfort deepens, your conscious mind can relax while your unconscious reviews the nature of the problem. And when a relevant and interesting thought reaches your conscious mind, your eyes will open as you carefully consider it.

This example builds upon the first and initiates another unconscious search for a general exploratory approach to a problem.

As can be seen from these examples, an unconscious search initiates an unconscious process that actually solves the problem that the conscious mind could not handle. These unconscious processes are the essence of creativity and problem-solving in everyday life as well as in therapy. Hypnotherapy, in particular, depends upon the successful utilization of such unconscious processes to facilitate a therapeutic response. Cheek and LeCron (1968) have given extensive illustrations of how a series of questions in the form of implied directives can be used for both the exploration and resolution of symptoms.

11. Binds and Double Binds

Pyschological binds and double binds have been explored by a number of authors (Haley, 1963; Watzlawicketal., 1967, 1974;Erickson and Rossi, 1975) for their use in therapeutic situations. The concept of binds appears to have a fascinating potential that extends our quest for new therapeutic approaches into the areas of linguistics, logic, semantics, epistemology, and the philosophy of science. Since they are the vanguard of new patterns of our therapeutic consciousness, our understanding of them is as yet very incomplete. We are not always sure what binds and double binds are, or how we can best formulate and use them. Most of our knowledge about them comes from clinical studies and theoretical formulations (Bateson, 1972) with very little controlled experimental research that exactly specifies their parameters.

Because of this, we will use the terms bind and double bind only in a very special and limited sense to describe certain forms of suggestion that offer patients an opportunity for therapeutic responses. A bind offers a patient a free, conscious choice between two or more alternatives. Whichever choice is made, however, leads the patient in a therapeutic direction. A double bind, by contrast, offers possibilities of behavior that are outside the patient's usual range of conscious choice and voluntary control. The double bind arises out of the possibility of communicating on more than one level. In daily life we frequently say something verbally while commenting on it extraverbally. We may say, Let's go to the movies. We can say it with innumerable variations of tone and intent, however, that can have many implications. These variations are all comments or metacommunications on our primary verbal message about going to the movies. As we shall see in the following sections, binds and double binds are very much a function of who is receiving the message. What is a bind or double bind for one person may not be for another. As is the case with all the other indirect forms of suggestion, binds and double binds utilize the patient's unique repertory of associations and patterns of long learning. Most binds and double blinds cannot be applied in a mechanical or rote fashion. Therapists must understand something about how their messages are going to be received in order to make it effective.

11a. Binds Modeled on Avoidance-Avoidance and Approach-Approach Conflicts

Psychological binds are life situations in which we experience a constriction in our behavior. Typically we are caught in circumstances that allow us only unpleasant alternatives of response. We are caught between the devil and the deep blue sea. We thus experience an avoidance-avoidance conflict; we have to make a choice even though we would like to avoid all the alternatives. In such circumstances we usually choose the lesser of the two evils.

Psychological binds can also be constructed on the model of an approach-approach conflict. In this case one is in the bind of having to choose only one of a number of desirable courses of action and excluding all the other desirable possibilities. In common parlance, You can't have your cake and eat it too.

Since we have all had innumerable experiences of such binds, the avoidance-avoidance and approach-approach conflicts usually exist as established processes governing our behavior. As we study patients, we learn to recognize how some are governed more by avoidance-avoidance conflicts while others, perhaps more fortunate (but not necessarily so), appear to be perpetually juggling approach-approach alternatives. The clinical art of utilizing these models of conflict is to recognize which tendency is dominant within a particular patient and then structure binds that offer only therapeutic alternatives of response. When we do not know which tendency is more predominant, we can offer general binds that are applicable to anyone, such as the following.

Would you like to enter trance now or later? Would you like to enter trance sitting or lying down? Would you like to go into a light, medium, or deep trance?

The patient has free, conscious choice in responding to any of the alternatives offered above. As soon as a choice is made, however, the patient is bound to enter trance. As can be seen from these examples, the question format is particularly well suited for offering binds. When using it with ideomotor signaling, we can frequently formulate an associational network of structured inquiry that can rapidly unravel the dynamics of a problem and resolve it. Cheek and LeCron (1968) have pioneered such lines of structured inquiry for many psychological and psychosomatic conditions.

An example of the therapeutic use of an avoidance-avoidance bind to resolve a symptom of insomnia was the case of a meticulous elderly gentleman who took pride in doing all his own housework - except that he hated to wax floors. After an appraisal of his personality, the senior author told the gentleman that there was an obvious solution to the insomnia problem, but he might not like it. The gentleman politely insisted that he would do whatever was necessary to be able to sleep. The senior author continued to demur, while permitting the gentleman to commit himself further by giving a number of examples of how persistent he was in dealing with difficult problems once he determined he would. He insisted that his word was his bond, and he was used to dealing with unpleasant matters. This clearly confirmed that this man of admirable character was, indeed, well practiced in working through avoidance-avoidance conflicts. His determination in the face of such conflicts was utilized in structuring a therapeutic avoidance-avoidance bind. He was told that if he was not asleep within fifteen minutes of going to bed, he had to get up and wax floors until he felt he could sleep. If he was still not asleep within fifteen minutes, he had to get up again and so continue this procedure until he was asleep. The gentleman later reported that he had well-waxed floors and slept remarkably well.

We may call this situation a therapeutic avoidance-avoidance bind because the gentleman was presented with negative alternatives over which he had conscious, voluntary choice. He could choose between the negative alternatives of insomnia or waxing floors. As we study this example a bit further, however, it begins to reveal aspects of a double bind. We could conceptualize the gentleman's characterological structure, which enabled him to persist in the face of difficulties, as well as his word was his bond'' as metalevels that bound him automatically to his therapeutic task. These metalevels of his character were utilized in a manner that was outside his normal range of conscious choice and control.

This example illustrates the difficulties in any exact formulation or understanding of the operation of the bind and double bind in actual clinical practice. In general, however, we can say that the more we involve the patients' own associations and learned patterns of response, the more they are likely to experience a bind, double bind, or triple bind as an effective agent in behavior change that is experienced as taking place on an autonomous (unconscious, hypnotic) level.

11b. The Conscious-Unconscious Double Bind

Some of the most fascinating and useful double binds are those that deal with the interface between conscious and unconscious processes (Erickson, 1964; Erickson and Rossi, 1975). These double binds all rest upon the fact that while we cannot control our unconscious, we can receive a message consciously that can initiate unconscious processes. The conscious-unconscious double bind is designed to bypass the limitations of our conscious understanding and abilities so that behavior can be mediated by the hidden potentials that exist on a more autonomous or unconscious level. Any response to the following, for example, requires that the patient experience an inner focus and search that initiates unconscious processes in ways that are usually beyond conscious control.

If your unconscious wants you to enter trance, your right hand will lift all by itself. Otherwise your left hand will lift.

Whether one gets a yes (right hand) or no (left hand) response to this suggestion, one has begun to induce trance, since any truly autonomous response (lifting either hand) implies that a trance exists. If the patient simply sits quietly, and no hand response is evident after a few minutes, the therapist can introduce a further double bind with the following addition.

Since you've been sitting quietly and there is yet no hand response, you can wonder if your unconscious would prefer not to make any effort at all as you go into trance. It may be more comfortable not to have to move or talk or even bother trying to keep your eyes open.

At this point the patient's eyes may close and trance become manifest. The eyes may remain open with a passive stare, and there will be continuing body immobility suggestive of the development of trance. If the patient is experiencing difficulty, on the other hand, there will be an uneasy shifting of the body, facial movements, and finally some talk about the problem.

The conscious-unconscious double bind in association with questions, implications, not knowing - not doing, and ideomotor signaling is thus an excellent means of initiating trance and exploring a patient's patterns of response.

In therapy the conscious-unconscious double bind has innumerable uses, all based on its ability to mobilize unconscious processes. The use of the negative as described earlier is very useful here.

You don't have to listen to me because your unconscious is here and can hear what it needs to, to respond in just the right way.

And it really doesn't matter what your conscious mind does because your unconscious can find the right means of coping with that pain [or whatever].

You've said you don't know how to solve that problem. You are uncertain and confused. Your conscious mind really doesn't know what to do. And yet we know that the unconscious does have access to many memories and images and experiences that it can make available to you in ways that can be most surprising for solving that problem. You don't know what all your possibilities are yet. Your unconscious can work on them all by itself. And how will you know when it has been solved? Will the solution come in a dream you will remember, or will you forget the dream but find that the problem is gradually resolving itself in a way that your conscious mind cannot understand? Will the resolution come quickly while wide-awake or in a quiet moment of reflection or daydreaming? Will you be at work or at play, shopping or driving your car, when you finally realize it? You really don't know, but you certainly can be happy when the solution does come.

In these examples it can be seen how the conscious-unconscious double bind in association with questions and open-ended suggestions can facilitate whatever responses are most suitable for the patient's individuality. All the major cases of this volume illustrate how this form of double bind can be applied to a variety of problems and situations. In all such situations we are depotentiating the patient's conscious, habitual, and presumably more limited patterns in favor of unconscious processes and potentials. If we are willing to identify these unconscious processes with the activity of the nondominant cerebral hemisphere (usually the right - Galin, 1974; Hoppe, 1977) and conscious self-direction and rational processes with the dominant cerebral hemisphere (usually the left), we could say that the conscious-unconscious double bind tends to depotentiate the limitations of the dominant hemisphere and thereby possibly facilitate the potentials of the nondominant. This is particularly the case with the double dissociation double bind, to which we will now turn our attention.

11c. The Double Dissociation Double Bind

Traditionally the concept of dissociation has been used as an explanation of hypnosis. Hypnotic or autonomous behavior takes place outside the patient's immediate range of consciousness and is therefore dissociated from the conscious mind. The senior author has evolved many subtle and indirect means of facilitating dissociations that appear to utilize many entirely normal but alternate pathways of behavior that lead to the same end. All roads lead to Rome is a cliche that expresses the intense obviousness and, therefore, usefulness of this approach. Precisely because alternate pathways to the same response are very obviously true and respectful of the patient's individuality, suggestions that utilize them are very acceptable.

The double dissociation double bind was discovered by the authors (Erickson, Rossi, and Rossi, 1976) when we analyzed the following.

You can as a person awaken, but you do not need to awaken as a body.

[Pause]

You can awaken when your body awakens but without a recognition of your body.

In the first half of this suggestion awakening as a person is dissociated from awakening as a body. In the second half awakening as a person and as a body are dissociated from a recognition of the body. Suggestions that embody such dissociations facilitate hypnotic behavior while also exploring each individual's unique response abilities. The double dissociation double blind tends to confuse a patient's conscious mind and thus depotentiate his habitual sets, biases, and learned limitations. This sets the stage for unconscious searches and processes that may mediate creative behavior. The following examples suggest the range of its application.

You can dream you're awake even though you're in trance.

[Pause]

Or you can act as if you're in trance even while awake.

You can find your hand lifting without knowing where it is going.

[Pause]

Or you may sense where it is going even though you're not really directing it.

You can make an abstract drawing without knowing what it is.

[Pause]

You can later find some meaning in it even though it does not seem related to you personally.

You can speak in trance even though you don't always recognize the meaning of your words.

[Pause]

Or you can remain silent as your head very slowly nods yes or shakes no all by itself in response to my questions.

As can be seen from these examples, the double dissociation double bind is often a potpourri of all sorts of indirect forms of suggestion: implications, contingencies, negatives, open-ended suggestions, apparently covering all possibilities of a class of responses, not knowing, not doing, and so on. Their common denominator is the facilitation of dissociations that tend to depotentiate a patient's habitual conscious sets so that more involuntary levels of response can be expressed. The authors (Erickson, Rossi, and Rossi, 1976) have discussed how this form of the double bind may be related to the neuropsychological concepts formulated by Luria (1973).

A detailed study and assessment of the patient's response to carefully formulated double dissociation double binds can be of great use in planning further hypnotic work. Consider the following, which can provide either an initiation into somnambulistic training or at least a validation of trance.

Now, in a moment your eyes will open but you don't need to awaken. [Pause]

Or you can awaken when your eyes open, but without remembering what happened when they were closed.

This double dissociation double bind has a definite marker indicating that the suggestion has been received and is being acted upon: the eyes opening. When the eyes open, the therapist notes whether (1) there is a simultaneous movement of the body, indicating that the patient is awakening or (2) the patient remains immobile, indicating that trance is continuing. If the patient's body remains immobile when the eyes open, the patient will have a complete memory of all trance events, since that trance continues. The therapist can assess this condition by questioning and then requesting an ideomotor response so the patient's unconscious can firmly validate that a trance is still present (e.g., If you are still in trance your yes finger can lift, your head can slowly nod yes, and so on). An affirmative ideomotor response, indicating that the patient continues to experience trance even with eyes open, is a strong indication that the patient has entered the first stages of somnambulistic training: Patients in this state can in general act as if they are awake, yet they continue to follow suggestions as if they were in a deep trance. The therapist then simply continues this somnambulistic training by proffering further suggestions to deepen their involvement and extend their range of hypnotic responsiveness (automatic talking and writing, visual and auditory hallucinations, and so on).

If, on the other hand, such patients move and speak as if they were perfectly awake when their eyes open, they are apparently acting on the second alternative, and we would assess the validity of the trance by determining the presence of an amnesia for trance events. But what if a patient awakes and there is no amnesia? Does this mean that trance was not experienced? Possibly. More likely, however, such patients will recall only one or two things of such particular significance for them during trance that they attracted conscious attention and so are recalled easily after trance. There will tend to be an amnesia for many other trance events; however, another possibility is that amnesia may be a particularly difficult response for such patients. They may have experienced a genuine trance but for some reason cannot experience the response of amnesia. To assess this possibility the therapist reintroduces trance and then, after another double dissociation double bind, uses another modality as an indication of trance. In the following, for example, body movement (or an inhibiting verbal response) is used as a trance indication instead of amnesia.

Now, in a moment your eyes will open, but you don't need to awaken.

Or you can awaken when your eyes open, but you won't feel like moving your arms for a few minutes [or won't feel like speaking for a few minutes].

Patients who accept the second alternative and awaken can validate the trance by not moving their arms (or speaking) for a few minutes. It is wise to offer trance indicators in this permissive manner. ( You won't feel like moving your arms ) rather than as a challenge ( You won't be able to move your arms ), because the challenge is often taken as an affront by our modern consciousness that takes such hubris in its apparent independence and power.

12. Multiple Levels of Meaning and Communication: The Evolution of Consciousness in Jokes, Puns, Metaphor, and Symbol.

Our five-stage paradigm of the dynamics of trance induction and utilization (Figure 1) illustrates some of the essential processes in what we may call multiple levels of meaning and communication (Erickson and Rossi, 1976). Most literary devices are actually means of initiating unconscious searches and processes to evoke multiple levels of meaning. This is a most interesting and significant aspect of the economy of mental dynamics and the evolution of consciousness. Freud has discussed the antithetical meaning of primal words (Freud, 1910) and the relation of jokes and puns to the unconscious (Freud, 1905). Jokes are of particular value in our approach because they help patients break through their too-limited mental sets and thus initiate unconscious searches for other and perhaps new levels of meaning. Jung has discussed the concept of the symbol not as a simple sign of one thing for another, but rather as the best representation of something that is still in the process of becoming conscious (Jung, 1956). The significant factor in all these conceptions is the idea of the evolution of consciousness. If patients have problems because of learned limitations, then it is clear that therapeutic processes can be initiated by helping them develop behavioral potentials and new patterns of consciousness that bypass those limitations.

From this point of view we can understand how metaphor and analogy can be something more than artistic devices: They can evoke new patterns and dimensions of consciousness. The very derivation of the word metaphor (meta, beyond, over ; pherin, to bring, bear ) suggests how new meaning developed within the unconscious is brought over to consciousness by means of metaphor. The traditional definition of metaphor is that it is a word or phrase that literally denotes one thing but by analogy suggests another (e.g., a ship plows the sea; a volley of oaths). In our psychological usage, however, such traditionally literary devices as metaphor, analogy, and simile are understood as means of facilitating the development of insight or new consciousness in the therapeutic transaction. They are essentially stimuli that initiate unconscious searches and processes leading to the creation of new meaning and dimensions of consciousness. Recently Jaynes (1976) has integrated a broad range of data from the fields of psychology, linguistics, neuropsychology, and anthropology which affirmed the hypothesis that metaphor and analogy generate new levels of consciousness.

The senior author has pioneered the use of such approaches to facilitate therapeutic processes in hypnotherapy. His gradual development of the interspersal approach has been the most significant factor in his learning to cultivate multiple levels of meaning and communication as well as enhance the evolution of consciousness. Deterministic as well as nondeterministic processes are both in evidence here. In many of the cases in this book the senior author uses these approaches to facilitate the awareness of certain dynamics that he feels to be at the core of the patient's problems. He uses multiple levels of communication in a highly deterministic way to help the patient recognize certain definite dynamics. In most of these cases, however, the patients also learn entirely new things that neither they nor the senior author could have predicted. It is the nondeterministic aspect of these approaches that is most exciting in facilitating the evolution of consciousness. Jung has formulated these dynamics in what he calls the transcendent function: the integration of conscious and unconscious contents in a manner that facilitates the evolution of new patterns of awareness (Jung, 1960). We presume that many of the practical approaches illustrated by the cases in this volume are actually means of facilitating the evolution of such new patterns of awareness.

Exercises

1. We have previously presented a number of exercises to facilitate the acquisition of skill with most of the indirect forms of suggestion discussed in this chapter (Erickson, Rossi, and Rossi, 1976). So multifaceted are the possibilities of the indirect approaches, however, that one can feel overwhelmed to the point where one does not attempt a systematic beginning in practicing their use. Because of this we strongly suggest that the reader learn to use only a few at a time. The interspersal approach, together with all forms of questions and truisms, for example, can be utilized in any therapeutic interview even without the formal induction of trance. It is highly instructive simply to observe the development of ayes set when these approaches are used with the patient's own vocabulary and frames of reference. At this level our approach might appear similar to the nondirective, client-centered approach of Rogers (1951).

2. Even without the formal induction of trance one can explore the effectiveness of ideodynamic process in an open-ended manner with the patient simply by maintaining an attitude of expectancy about what can be experienced. It is instructive to note how after a period of five to twenty minutes of such exercises with the eyes closed most subjects will stretch, yawn, and reorient to their bodies when they open their eyes to end the inner work - as if they had been asleep or in trance. Perhaps they have been (Erickson, 1964). We really have no independent criterion for assessing whether they were or not.

3. The next stage of competence probably involves the planned use of the varieties of compound suggestions. The therapist needs time and patience to carefully write out ahead of time patterns of contingency suggestions and associational networks. The use of shock, surprise, and creative moments can involve a careful study and retrospective analysis of how these phenomena operate spontaneously in everyday life.

4. The use of implications can be facilitated by a careful study of tape recordings of one's therapy sessions. What are the conscious and unconscious implications of both the therapist's and the patient's remarks? After a period of such study one gradually develops more of a consciousness of the implications of words just as one is uttering them. One is then in a position to begin the planned use of implications as a therapeutic approach. The multiple levels of meaning via jokes, puns, and metaphor now became more easily available.

5. The therapeutic binds and double binds discussed in this chapter are fairly simple to learn, and they provide an almost infinite range of possibilities for exploring psychodynamics and facilitation of hypnotic responsiveness. The therapist newly interested in this area can spend many enjoyable hours formulating plausible conscious-unconscious and double dissociation double binds that apparently cover all possibilities of response, just as others might spend their time on crossword puzzles. To test one out in clinical practice is a fail-safe procedure, since at worst the patient will probably ignore it and nothing will happen at all. Other forms of the double bind discussed by Watzlawick et al. (1967), Haley (1963, 1973), and the authors (Erickson and Rossi, 1975) still only come to the junior author by happy accident. We are here in the vanguard of our understanding of understanding. Controlled experimental studies as well as interesting clinical examples very much need to be published.

6. The indirect forms of suggestion may make a contribution to the current intriguing debate about writing a computer program to do psychotherapy (Weizenbaum, 1976; Nichols, 1978). Readers with the appropriate experience might explore the possibility that a computer programmed with these hypnotic forms could generate new combinations of suggestions uniquely suitable for specific symptom complexes, personality problems, and altered states of consciousness.

CHAPTER 3

The Utilization Approach: Trance Induction and Suggestion

The senior author (Erickson, 1958, 1959) has distinguished between the formalized ritualistic procedures of trance induction, where the same method is applied mechanically to everyone, and the naturalistic approach, wherein the patient's unique personality and behavior are utilized to facilitate trance. In this utilization approach the patient's attention is fixed on some important aspect of his own personality and behavior in a manner that leads to the inner focus that we define as therapeutic trance. The patient's habitual conscious sets are more or less depotentiated, and unconscious searches and processes are initiated to facilitate a therapeutic response. In this chapter we will illustrate this utilization approach to trance induction and suggestion with a variety of examples from clinical practice. We will analyze some of the typical approaches to preparing patients for trance experience along with the actual induction and ratification of the trance. In these examples we will focus on how an interaction of the utilization approach and the indirect forms of suggestion can facilitate a therapeutic outcome in virtually any situation in which the therapist and patient find themselves.

1. Accepting and Utilizing the Patients' Manifest Behavior

The initial step in the utilization approach, as in most other forms of psychotherapy, is to accept the patients' manifest behavior and to acknowledge their personal frames of reference. This openness and acceptance of the patients' worlds facilitate a corresponding openness and acceptance of the therapist by the patients. The following examples taken from the senior author's unpublished and published records (Erickson 1958, 1959) illustrate how the rapport can develop and rapidly lead to an experience of therapeutic trance.

The development of a trance state is an intrapsychic phenomenon, dependent upon internal processes, and the activity of the hypnotist serves only to create a favorable situation. As an analogy, an incubator supplies a favorable environment for the hatching of eggs, but the actual hatching derives from the development of life processes within the egg.

In trance induction, the inexperienced hypnotist often tries to direct or bend the subject's behavior to fit his conception of how the subject should behave. There ought to be a constant minimization of the role of the hypnotist and a constant amplification of the subject's role. An example may be cited of a volunteer subject, used later to teach hypnosis to medical students. After a general discussion of hypnosis, she expressed a willingness to go into a trance immediately. The suggestion was offered that she select the chair and position she felt would be most comfortable. When she had settled herself to her satisfaction, she remarked that she would like to smoke a cigarette. She was immediately given one, and she proceeded to smoke lazily, meditatively watching the smoke drifting upward. Casual conversational remarks were offered about the pleasure of smoking, of watching the curling smoke, the feeling of ease in lifting the cigarette to her mouth, the inner sense of satisfaction of becoming entirely absorbed just in smoking comfortably and without need to attend to any external things. Shortly, casual remarks were made about inhaling and exhaling, these words timed to fit in with her actual breathing. Others were made about the ease with which she could almost automatically lift her cigarette to her mouth and then lower her hand to the arm of the chair. These remarks were also timed to coincide with her actual behavior. Soon, the words inhale, exhale, lift, and lower acquired a conditioning value of which she was unaware because of the seemingly conversational nature of the suggestions. Similarly, casual suggestions were offered in which the words sleep, sleepy, and sleeping were timed to her eyelid behavior.

Before she had finished the cigarette, she had developed a light trance. Then the suggestion was made that she might continue to enjoy smoking as she slept more and more soundly; that the cigarette would be looked after by the hypnotist while she absorbed herself more and more completely in deep sleep; that, as she slept, she would continue to experience the satisfying feelings and sensations of smoking. A satisfactory profound trance resulted and she was given extensive training to teach her to respond in accord with her own unconscious pattern of behavior.

In this example the initial preparation and facilitation of an optimal frame of reference occurred as the subject listened to a general discussion of hypnosis. The senior author, as a teacher, could not help but use indirect associative focusing and ideodynamic focusing in his general talk about hypnosis. As we saw in the previous chapter, all such general discussions automatically initiate ideodynamic processes that can then serve as the foundation for trance experience.

The fact that this subject volunteered is an indication that this initial preparation was particularly effective for her. One of the joys of working with volunteers from such groups is precisely this form of self-recognition of one's readiness for trance.

Her surprising desire to smoke, once she was settled for trance work, might have been experienced as a disconcerting sign of resistance by a less experienced therapist. Indeed, when this same subject was later used by students, who did not accept her wish to smoke, they were not able to induce trance. The senior author immediately accepted her behavior, however, and even gave her a cigarette. This enhanced their rapport as they were now cooperatively engaged together in her smoking. As she proceeded to smoke lazily, meditatively, we can begin to appreciate how her apparently disruptive behavior of smoking may have been an unconsciously determined means of cooperating with the hypnotic process. For this subject smoking led to an inner meditative mood entirely in keeping with trance induction. The senior author recognized and utilized this meditative mood to facilitate trance by fixing her attention even more on her smoking with casual conversational remarks. This casual conversation, of course, provides the senior author with a general context into which he can intersperse suggestions about pleasure, ease, inner sense of satisfaction, and becoming entirely absorbed in smoking ' 'comfortably without need to attend to any external things. These interspersed suggestions tended to depotentiate her habitual waking orientation even further. The process of not knowing and not doing that takes place when we do not have to attend to external things led her to an unconscious search for some new form of direction and orientation.

This new direction was provided by the senior author with his obvious interest in her smoking behavior. He then utilized her smoking behavior for a process of unconscious conditioning; her inhaling, exhaling, lifting and lowering of her hand became conditioned to following his voice and suggestions. This unconscious conditioning was a way of assessing and reinforcing her response attentiveness. Finally the ideodynamic associative value of words like sleep were then associated with her actual eyelid behavior suggestive of sleep (eyelids closing, fluttering, etc.). Even though both therapist and patient fully recognize that therapeutic trance is not sleep, words evoking the idea of sleep tend to evoke associated behaviors (like comfort and not doing) that tend to facilitate trance.

The process of rapport was further enhanced as he took her cigarette and suggested she might continue to enjoy smoking as she slept more and more soundly. A hallucinatory wish fulfillment of something she obviously enjoyed, such as smoking, was made contingent on sleeping more and more soundly. She was given an expectancy of continued satisfying feelings as she went deeper into trance. This sound utilization of her smoking behavior, together with many indirect forms of suggestion that evoked her own associative processes, then led to more extensive trance training.

Our next example is a particularly vivid illustration of how a highly intellectualized frame of reference attending primarily to external things can be gradually shifted to an internal focus that is more suitable for therapeutic trance.

This patient entered the office in a most energetic fashion and declared at once that he did not know if he was hypnotizable. He was willing to go into a trance if it were at all possible, provided the writer would approach the entire matter in an intellectual fashion rather than in a mystical, ritualistic manner. He declared that he needed psychotherapy for a variety of reasons and that he had tried various schools of psychotherapy extensively without benefit. Hypnosis had been attempted on various occasions and had failed miserably because of mysticism and a lack of appreciation for the intellectual approach.

Inquiry revealed that he felt an intelligent approach signified, not a suggestion of ideas, but questioning him concerning his own thinking and feeling in relation to reality. The writer, he declared, should recognize that he was sitting in a chair, that the chair was in front of a desk, and that these constituted absolute facts of reality. As such, they could not be overlooked, forgotten, denied or ignored. In further illustration, he pointed out that he was obviously tense, anxious, and concerned about the tension tremors of his hands, which were resting on the arms of the chair, and that he was also highly distractable, noticing everything about him.

The writer immediately seized upon this last comment as the basis for the initial cooperation with him. He was told, Please proceed with an account of your ideas and understanding, permitting me only enough interruptions to insure that I understand fully and that I follow along with you. For example, you mentioned the chair but obviously you have seen my desk and have been distracted by the objects on it. Please explain fully.

He responded verbosely with a wealth of more or less connected comments about everything in sight. At every slight pause, the writer interjected a word or phrase to direct his attention anew. These interruptions, made with increasing frequency, were as follows: And that paperweight; the filing cabinet; your foot on the rug; the ceiling light; the draperies; your right hand on the arm of the chair; the pictures on the wall; the changing focus of your eyes as you glance about; the interest of the book titles; the tension in your shoulders; the feeling of the chair; the disturbing noises and thoughts; weight of hands and feet; weight of problems, weight of desk; the stationery stand; the records of many patients; the phenomena of life, of illness, of emotion, of physical and mental behavior; the restfulness of relaxation; the need to attend to one's needs; the need to attend to one's tension while looking at the desk or the paperweight or the filing cabinet; the comfort of withdrawal from the environment; fatigue and its development; the unchanging character of the desk; the monotony of the filing cabinet; the need to take a rest; the comfort of closing one's eyes; the relaxing sensation of a deep breath; the delight of learning passively; the capacity for intellectual learning by the unconscious. Various other similar brief interjections were offered, slowly at first and then with increasing frequency.

Initially, these interjections were merely supplementary to the patient's own train of thought and utterances. At first, the effect was simply to stimulate him to further effort. As this response was made, it became possible to utilize his acceptance of stimulation of his behavior by a procedure of pausing and hesitating in the completion of an interjection. This served to effect in him an expectant dependency upon the writer for further and more complete stimulation.

As this procedure was continued, gradually and unnoticeably to the patient his attention was progressively directed to inner subjective experiential matters. It then became possible to use almost directly a simple, progressive relaxation technique of trance induction and to secure a light medium trance.

Throughout therapy, further trance inductions were basically comparable, although the procedure became progressively abbreviated.

The patient's initial statement that he did not know if he was hypnotizable is an important admission of his availability for trance. As we saw in the previous chapter, not knowing and not doing are actually an important condition for trance experience. This highly intellectualized individual is admitting there is a place where he does not know, a place where his habitual sets and frames of reference are not stable - hypnosis is a place where these habitual, and obviously in some way inadequate mental frameworks can be bypassed so that the needed psychotherapy can take place.

The patient then states his conditions for trance experience. The writer (the senior author) must eschew all mystical and ritualistic means and use an intellectual approach. The patient's intellectual orientation is obviously the ability that any sensible therapist would assess as most suitable for utilization.

The patient then describes his distractable state, and the senior author immediately utilizes it as a basis for the initial cooperation with him. He encourages the patient to continue with an account of his ideas to ensure that I understand fully and that I follow along with you. This is an unrecognized interspersed suggestion that means understanding and following are important in therapy. Just as the therapist initially understands and follows the patient, so will the patient soon come to understand and follow the therapist. Rapport, response attentiveness, and an optimal attitude for creating a therapeutic frame of reference are all implied and thereby facilitated by this initial suggestion and acceptance of the patient's behavior.

The senior author's request that the patient explain fully is actually an unrecognized means of focusing and fixing the patient's attention onto a prominent aspect of his own behavior (distracted by objects) that he himself pointed out. Since the patient pointed out this aspect of his own behavior, it must hold some special interest for him and thus can serve as an ideal means of holding his attention. This is a curious situation that may involve a double bind for this particular patient: His distractibility is used to undistract, to focus his attention.

The senior author now gingerly interacts with the patient by redirecting his attention anew at every pause as a means of cooperating with him, and at the same time, enhancing his response attentiveness. By very gradual steps the senior author builds an associative network that leads the patient from the paperweight and filing cabinet to the delight of learning passively and the capacity for intellectual learning by the unconscious. The shift in focus is from the outer to the inner, which is in keeping with trance work. The shift is facilitated by a continuing utilization of the patient's intellectual approach, with the emphasis on learning passively and the unconscious learning. The passivity and unconscious aspects of trance experience are thus associated with the learning that the patient already accepts and knows how to do; it is thus much easier for the patient to accept passivity and the unconscious when it is associated with learning. In this shift from an outer to an inner focus the senior author has a great opportunity to intersperse many forms of indirect associative focusing (e.g., the phenomena of life, of illness, of emotion, of physical and mental behavior ) and indirect ideodynamic focusing (e.g., the restfulness of relaxation . . . the comfort of withdrawal from the environment, fatigue and its development ). This can facilitate trance induction by initiating unconscious searches and processes that could evoke partial aspects of trance experience as well as a review of the patient's problems.

As the therapist continued to utilize the patient's own train of thought and utterances, his response attentiveness was further enhanced and a greater degree of expectant dependency was experienced by the patient as he now began to look to the therapist for further direction into inner subjective experiential matters, where his psychological problems were.

A similar approach was used in the following case, which the reader should now find easy to analyze in terms of the dynamics we have presented.

Essentially the same procedure was employed with a male patient in his early 30' s who entered the office and began pacing the floor. He explained repetitiously that he could not endure relating his problems sitting quietly or lying on a couch. He had repeatedly been discharged by various psychiatrists because they accused him of lack of cooperation. He asked that hypnotherapy be employed, if possible, since his anxieties were almost unendurable and always increased in intensity in a psychiatrist's office making it necessary for him to pace the floor constantly.

Further repetitious explanation of his need to pace the floor was finally successfully interrupted by the question, Are you willing to cooperate with me by continuing to pace the floor, even as you are doing now? His reply was a startled, Willing? Good God, man! I've got to do it if I stay in the office.

Thereupon, he was asked to permit the writer to participate in his pacing by the measure of directing it in part. To this he agreed rather bewilderedly. He was asked to pace back and forth, to turn to the right, to the left, to walk away from the chair, and to walk toward it. At first these instructions were given in a tempo matching his step. Gradually, the tempo of the instructions was slowed and the wording changed to Now turn to the right away from the chair in which you can sit; turn left toward the chair in which you can sit; walk away from the chair in which you can sit; walk toward the chair in which you can sit. etc. With this wording, a foundation was laid for more cooperative behavior.

The tempo was slowed still more and the instructions again varied to include the phrase, the chair which you will soon approach as if to seat yourself comfortably. This in turn was altered to the chair in which you will shortly find yourself sitting comfortably.

His pacing became progressively slower and more and more dependent upon the writer's verbal instructions until direct suggestions could be given that he seat himself in the chair and go deeper and deeper into a profound trance as he related his history.

Approximately 45 minutes were spent in this manner inducing a medium trance that so lessened the patient's tension and anxiety that he could cooperate readily with therapy thereafter.

The value of this type of Utilization Technique lies in its effective demonstration to the patient that he is completely acceptable and that the therapist can deal effectively with him regardless of his behavior. It meets both the patient's presenting needs and it employs as the significant part of the induction procedure the very behavior that dominates the patient.

The senior author's question, Are you willing to cooperate with me by continuing to pace the floor, even as you are doing now? is an unusually fecund example of the use of a number of indirect hypnotic forms in a single sentence. Being a question, it immediately fixes the patient's attention and sends him on an inner search for an appropriate response. It is an excellent compound suggestion that associates an important suggestion about cooperation with his ongoing behavior of pacing the floor. Pacing the floor constantly was the patient's own ability that was rapidly assessed, accepted, and utilized to facilitate ayes set. The question came as a bit of a shock and surprise that depotentiated his dominant mental set about his own resistance and startled him into a strong exclamation of his need to cooperate. Rapport was thus strongly established, and therapy structured as a joint endeavor. With such a strong immediate rapport, a high expectation was set in motion, heightening the patient's response attentiveness to his own internal states as well as to the therapist's further suggestions. By a gradual process of association and unconscious conditioning this response attentiveness was heightened even further, so the patient was finally able to accept suggestions to sit down and go even deeper into himself so that he could relate his history in a state of deep absorption that is described as profound trance.

The beginning therapist who is just learning to integrate the utilization approach with the indirect forms of suggestion may initially feel a bit overwhelmed by these examples, which seem to require such quick wits and a complete command of the material. In practice, however, most patients are desperately searching for help and are very willing to cooperate if they are given an opportunity, as indicated by the following example.

Another subject, a graduate in psychology, experienced great difficulty in going into a deep trance. After several hours of intensive effort, she timidly inquired if she could advise on technique, even though she had no other experience with hypnosis. Her offer was gladly accepted, whereupon she gave counsel: You're talking too fast on that point; you should say that very slowly and emphatically and keep repeating it. Say that very rapidly and wait awhile and then repeat it slowly; and please, pause now and then to let me rest, and please don't split your infinitives. with her aid, a profound, almost stuporous trance was secured in less than thirty minutes. Thereafter, she was employed extensively in a great variety of experimental work and was used to teach others how to induce deep trances.

Acceptance of such help is neither an expression of ignorance nor of incompetence; rather, it is an honest recognition that deep hypnosis is a joint endeavor in which the subject does the work and the hypnotist tries to stimulate the subject to make the necessary effort. It is an acknowledgment that no person can really understand the individual patterns of learning and response of another. While this measure works best with highly intelligent, seriously interested subjects, it is also effective with others. It establishes a feeling of trust, confidence, and active participation in a joint task. Moreover, it serves to dispel misconceptions of the mystical powers of the hypnotist and to indirectly define the respective roles of the subject and the hypnotist.

This acceptance and utilization of the patient's help is the cardinal feature of our approach, which contrasts sharply with the older, authoritarian methods that are still ingrained in the imagination of the laity and the popular press. The earlier, misguided approach that makes trance experience synonymous with passive obedience is, unfortunately, still being promulgated by stage hypnotists. More than a generation ago, however, the senior author illustrated how the patient's cooperation and self-control are of essence in good hypnotic work, as can be seen in the utilization of emergency situations described in the following section.

2. Utilizing Emergency Situations

Emergency situations are invariably trance-inducing. Cheek (Cheek and LeCron, 1968; Cheek, 1959, 1966, 1969, 1974) has illustrated how many iatrogenic problems and neurotic symptoms can be learned by overhearing unfortunate remarks during emergency and stress situations when the patient had lapsed into a spontaneous trance (as a primitive protective response to danger) and was consequently in an unusually heightened state of suggestibility.

The senior author has illustrated how such emergency situations can be utilized to gradually introduce therapeutic suggestions. Two examples with his own children are as follows.

Seven-year-old Allan fell on a broken bottle and severely lacerated his leg. He came rushing into the kitchen crying loudly from pain and fright, shouting, It's bleeding, it's bleeding!

As he entered the kitchen, he seized a towel and began swabbing wildly to wipe up the blood. When he paused in his shouting to catch his breath, he was urgently told, Wipe up that blood; wipe up that blood; use a bath towel; use a bath towel; use a bath towel; a bath towel, not a hand towel, a bath towel. and one was handed to him. He dropped the towel he had already used. He was immediately told urgently and repetitiously, Now wrap it around your leg, wrap it tightly, wrap it tightly.

This he did awkwardly but sufficiently effectively. Thereupon, with continued urgency, he was told, Now hold it tightly, hold it tightly, let's get in the car and go to the doctor's office; hold it tightly.

All the way to the surgeon's office, careful explanation was given him that his injury was really not large enough to warrant as many stitches as his sister had had at the time of her hand injury. However, he was urgently counselled and exhorted that it would be entirely his responsibility to see to it that the surgeon put in as many stitches as possible. All the way there, he was thoroughly coached on how to emphatically demand his full rights.

Without awaiting any inquiry, Allan emphatically told the nurse at the surgeon's office that he wanted 100 stitches. She merely said, This way, sir, right to the surgery. Allan was told, as she was followed, That's just the nurse. The doctor is in the next room. Now don't forget to tell him everything just the way you want it.

As Allan entered the room, he announced to the surgeon. I want 100 stitches. See! Whipping off the towel, he pointed at his leg and declared, Right there, 100 stitches. That's a lot more than Betty Alice had. And don't put them too far apart. And don't get in my way. I want to see. I've got to count them. And I want black thread, so you can see it. Hey, I don't want a bandage. I want stiches!

It was explained to the surgeon that Allan understood well his situation and needed no anesthesia. To Allan, the writer explained that his leg would first have to be washed. Then he was to watch the placing of the sutures carefully to make sure they were not too far apart; he was to count each one carefully and not to make any mistakes in his counting.

Allan counted the sutures and rechecked his counting while the surgeon performed his task in puzzled silence. He demanded that the sutures be placed closer together and complainingly lamented the fact that he would not have as many as his sister. His parting statement was to the effect that, with a little more effort, the surgeon could have given him more sutures.

On the way home, Allan was comforted regarding the paucity of the sutures and adequately complimented on his competence in overseeing the entire procedure so well. It was also suggested that he eat a big dinner and go to sleep right afterwards. Thus his leg could heal faster and he would not have to go to the hospital the way his sister did. Full of zeal, Allan did as suggested.

No mention of pain or anesthesia was made at any time nor were any comforting reassurances offered. Neither was there any formal effort to induce a trance. Instead, various aspects of the total situation were utilized to distract Allan's attention completely away from the painful considerations and to focus it upon values of importance to a seven-year-old boy in order to secure his full, active cooperation and intense participation in dealing with the entire problem adequately.

In situations such as this, the patient experiences a tremendously urgent need to have something done. Recognition of this need, and a readiness to utilize it by doing something in direct relationship to the origin of the need, constitutes a most effective type of suggestion in securing the patient's full cooperation for adequate measures.

Little Roxanna came into the house sobbing, distressed by an inconsequential (but not to her) scratch upon her knee. Adequate therapy was not assurance that the injury was too minor to warrant treatment, nor even the statement that she was mother's brave little girl and that mother would kiss her and the pain would cease and the scratch would heal. Instead, effective therapy was based upon the utilization of the personality need for something to be done in direct relationship to the injury. Hence, a kiss to the right, a kiss to the left and a kiss right on top of the scratch effected for Roxie an instantaneous healing of the wound and the whole incident became a part of her thrilling historical past.

This type of technique based upon the utilization of strong personality needs is effective with children and adults. It can readily be adapted to situations requiring in some way strong, active, intense responses and participation by the patient.

As can be seen from these examples, the hypnotherapist is continually utilizing the patient's own internal frames of reference even in such outer emergency situations. Further illustrations of this all-important use of the patient's inner realities are presented in the next section.

3. Utilizing the Patient's Inner Realities

The utilization of patients' outer manifest behaviors can be generalized to an acceptance and utilization of their inner realities - their thoughts, feelings, and life experiences. The senior author illustrates this in the following.

Another type of utilization technique is the employment of the patient's inner, as opposed to outer, behavior; that is, using his thoughts and understandings as the basis for the induction procedure. This technique has been employed experimentally and also in therapeutic situations where the patient's type of resistances made it advisable. It has also been effectively used on naive subjects. Ordinarily, good intelligence and some degree of sophistication as well as earnestness of purpose are required.

The procedure is relatively simple. The experimental or therapeutic subject is either asked or allowed to express freely his thoughts, understandings, and opinions. He is then encouraged to speculate aloud more and more extensively upon what could be the possible course of his thinking and feeling if he were to develop a trance state. As the patient does this, or even if he merely protests the impossibility of such speculation, his utterances are repeated after him in their essence as if the operator were either earnestly seeking further understanding or confirming his statements. Thus, further comment by the subject is elicited and repeated in turn by the operator. In the more sophisticated subject, there tends to be greater spontaneity; but occasionally the naive, even uneducated subject may prove to be remarkably responsive.

With this technique, the patient's utterances may vary greatly from one instance to another, but the following example is given in sufficient detail to illustrate the method.

This patient, in seeking psychiatric help, declared, I've made no progress at all in three years of psychoanalysis, and the year I spent in hypnotherapy was also a total loss. I didn't even go into a trance. I tried hard enough. I just got nowhere. I've been referred to you and I don't see much sense in it. Probably another failure. I just can't conceive of myself going into a trance. I don't even know what a trance is. These remarks, together with the information received previously from the referring physician, suggested the possibility of employing the woman's own verbalization as the induction procedure.

The writer's utterances are in italics:

You really can't conceive of what a trance is - no, I can't, what is it? - yes, what is it! - a psychological state, I suppose - A psychological state you suppose, what else! - I don't know - you really don't know - no, I don't - you don't, you wonder, you think - think what - yes, what do you think, feel, sense? - (pause) - I don't know - but you can wonder - do you go to sleep? - no, tired, relaxed, sleepy - really tired - so very tired and relaxed, what else? - I'm puzzled - puzzles you, you wonder, you think, you feel, what do you feel? - my eyes - yes, your eyes, how? - they seem blurred - blurred, closing - (pause) - they are closing-closing, breathing deeper - (pause) - tired and relaxed, what else? - (pause) - sleep, tired, relaxed, sleep, breathing deeper - (pause) - what else - I feel funny - funny, so comfortable, really learning - (pause) - learning, yes, learning more and more - (pause) - eyes closed, breathing deeply, relaxed, comfortable, so very comfortable, what else? - (pause) - I don't know - you really don't know, but really learning to go deeper and deeper - (pause) - too tired to talk, just sleep - maybe a word or two - I don't know (spoken laboriously) - breathing deeper and you really don't know, just going deeper, sleeping soundly, more and more soundly, not caring, just learning, continuing ever deeper and deeper and learning more and more with your unconscious mind.

From this point on it was possible to deal with her simply and directly without any special elaborations of suggestions. Subsequent trances were secured through the use of posthypnotic suggestions.

The above is simply a condensation of the type of utterances utilized to induce trance. In general, there is much more repetition, usually only of certain ideas, and these vary from patient to patient. Sometimes this technique proves to be decidedly rapid. Frequently with anxious, fearful patients, it serves to comfort them with a conviction that they are secure, that nothing is being done to them or being imposed upon them, and they feel that they can comfortably be aware of every step of the procedure. Consequently, they are able to give full cooperation which would be difficult to secure if they were to feel that a pattern of behavior was being forcibly imposed upon them.

As can be seen from the above, the patient's experience of not knowing, I don't know what trance is, can be an ideal starting point for initiating trance and the exploration of inner realities. The following is a further illustration of how a patient's life experiences can be used to facilitate trance induction.

A volunteer subject at a lecture before a university group declared, I was hypnotized once several years ago. It was a light trance, not very satisfactory, and while I would like to cooperate with you, I'm quite certain that I can't be hypnotized. Do you recall the physical setting of that trance? Oh yes, it was in the psychology laboratory of the university I was then attending. Could you, as you sit here, recall and describe to me the physical setting of that trance situation?

He agreeably proceeded to describe in detail the laboratory room in which he had been lightly hypnotized, including a description of the chair in which he had sat, and a description of the professor who had induced the trance. This was followed by a comparable response to the writer's request that he describe in as orderly and as comprehensive a fashion as possible his recollection of the actual suggestions given him at that time and the responses he made to them.

Slowly, thoughtfully, the subject described an eye closure technique with suggestions of relaxation, fatigue, and sleep. As he progressed in verbalizing his recollections, his eyes slowly closed, his body relaxed, his speech became slower and more hesitant; he required increasingly more prompting until it became evident that he was in a trance state. Thereupon, he was asked to state where he was and who was present: He named the previous university and the former professor. Immediately, he was asked to listen carefully to what the writer had to say also, and he was then employed to demonstrate the phenomena of the deep trance.

The junior author has found that questions focusing on memories can be a reliable means of assessing the patient's availability for trance and frequently a fine means of facilitating the actual induction of trance. When one woman was asked about her earliest memory, for example, she first responded with one that was long familiar to her. When she was encouraged to explore further, she paused for a few moments, manifesting that inner focus we call the common everyday trance, and then quietly remarked how she seemed to be looking up at a bright light, with nothing else in focus. A moment later her left leg began levitating, while the rest of her body remained immobile but noticeably relaxed. She then reported that she felt a scream building up in her throat. With that she suddenly shook her head, shuffled her body, and obviously reoriented to the awake state. In her inner search for an earlier memory she had spontaneously fallen into a trance and momentarily experienced a genuine age regression to infancy, when her visual field and her body were apparently not entirely under voluntary control, and she felt herself about to cry as an infant might. That frightened her, so she spontaneously reoriented to the awake state.

Although we do not often get responses as dramatic as this, we frequently find that questions focusing patients on an inner review of their lives and activities facilitate that inner search and the unconscious processes in a manner that leads to a recognizably therapeutic trance.

4. Utilizing the Patient's Resistances

The unfortunate dominance-submission view of hypnosis is probably the basis of much of the so-called resistance to hypnosis. Because of this the senior author developed many utilization approaches and indirect forms of suggestion to cope with this resistance. His approach is essentially the same as that outlined in the earlier section, where he first recognizes and accepts the patient's manifest behavior as a foundation for establishing rapport, and then gradually focuses the patient inward.

Many times, the apparently active resistance encountered in subjects is no more than an unconscious measure of testing the hypnotist's willingness to meet them halfway instead of trying to force them to act entirely in accord with his ideas. Thus, one subject, who had been worked with unsuccessfully by several hypnotists, volunteered to act as a demonstration subject. When her offer was accepted, she seated herself on the chair facing the audience in a stiffly upright, challenging position. This apparently unpropitious behavior was met by a casual, conversational remark to the audience that hypnosis was not necessarily dependent upon complete relaxation or automatism, but that hypnosis could be induced in a willing subject if the hypnotist was willing to fully accept the subject's behavior. The subject responded to this by rising and asking if she could be hypnotized standing up. Her inquiry was countered by the suggestion, Why not demonstrate that it can be? A series of suggestions resulted in the rapid development of a deep trance. Inquiries by the audience revealed that she had read extensively on hypnosis and objected strenuously to the frequently encountered misconception of the hypnotized person as a passively responsive automaton, incapable of self-expression. She explained further that it should be made clear that spontaneous behavior was fully as feasible as responsive activity and that utilization of hypnosis could be effected by recognition of this fact.

It should be noted that the reply, Why not demonstrate that it can be? constituted an absolute acceptance of her behavior, committed her fully to the experience of being hypnotized, and ensured her full cooperation in achieving her own purposes as well as those of the hypnotist.

Throughout the demonstration, she frequently offered suggestions to the author about what he might next ask her to demonstrate, sometimes actually altering the suggested task. At other times, she was completely passive in her responses.

Again we see how an apparently simple question with a negative - Why not demonstrate that it can be? - immediately accepts and utilizes the patient's resistance, while initiating her into an inner search that evokes partially conscious and partially unconscious processes leading to hypnotic responses. We can see that her so-called resistance is really not a resistance so much as it is a perfectly reasonable reaction against the erroneous dominance-submission view of hypnosis.

We believe that most so-called resistances have some reasonable basis within the patient's own frame of reference. Resistance is usually an expression of the patient's individuality! The therapist's task is to understand, accept, and utilize that individuality to help patients bypass their learned limitations to achieve their own goals. This example is a particularly clear illustration of how a patient is really in control, while the therapist is simply a provider of useful stimuli and frames of reference that help a patient experience and express new potentialities. We see how it can be perfectly appropriate for the patient to reject or modify the therapist's suggestions in order to more adequately meet the patient's needs.

In the following example the senior author makes extensive use of the indirect forms of suggestion to utilize the patient's resistance in order to facilitate trance and hypnotic responsiveness. It is an unusually clear illustration of that curious blend of both leading and following the patient that is so characteristic of the senior author's approach.

One often reads in the literature about subject resistance and the techniques employed to circumvent or overcome it. In the author's experience, the most satisfactory procedure is that of accepting and utilizing the resistance as well as any other type of behavior, since properly used they can all favor the development of hypnosis. This can be done by wording suggestions in such a fashion that a positive or a negative response, or an absence of response, are all defined as responsive behavior. For example, a resistive subject who is not receptive to suggestions for hand levitation can be told, Shortly your right hand, or it may be your left hand, will begin to lift up, or it may press down, or it may not move at all, but we will wait to see just what happens. Maybe the thumb will be first, or you may feel something happening in your little finger, but the really important thing is not whether your hand lifts up or presses down or just remains still; rather, it is your ability to sense fully whatever feelings may develop in your hand.

With such wording absence of motion, lifting up, and pressing down are all covered, and any of the possibilities constitutes responsive behavior. Thus a situation is created in which the subject can express his resistance in a constructive, cooperative fashion; manifestation of resistance by a subject is best utilized by developing a situation in which resistance serves a purpose. Hypnosis cannot be resisted if there is no hypnosis attempted. The hypnotist, recognizing this, should so develop the situation that any opportunity to manifest resistance becomes contingent upon hypnotic responses with a localization of all resistance upon irrelevant possibilities. The subject whose resistance is manifested by failure to levitate his hand can be given suggestions that his right hand will levitate, his left hand will not. To resist successfully, contrary behavior must be manifested. The result is that the subject finds himself responding to suggestion, but to his own satisfaction. In the scores of instances where this measure has been employed, less than a half dozen subjects realized that a situation had been created in which their ambivalence had been resolved. One writer on hypnosis naively employed a similar procedure in which he asked subjects to resist going into a trance in an effort to demonstrate that they could not resist hypnotic suggestion. The subjects cooperatively and willingly proved that they could readily accept suggestions to prove that they could not. The study was published in entire innocence of its actual meaning.

Whatever the behavior offered by the subject, it should be accepted and utilized to develop further responsive behavior. Any attempt to correct or alter the subject's behavior, or to force him to do things he is not interested in, militates against trance induction and certainly against deep trance experience. The very fact that a subject volunteers to be hypnotized and then offers resistance indicates an ambivalence which, when recognized, can be utilized to serve successfully the purposes of both the subject and the hypnotist. Such recognition of and concession to the needs of the subject and the utilization of his behavior do not constitute, as some authors have declared, an unorthodox technique based upon clinical intuition; instead, such an approach constitutes a simple recognition of existing conditions, based upon full respect for the subject as a uniquely functioning personality.

The reader will recognize the use of many indirect forms of suggestion such as covering all possibilities of a class of responses, contingency suggestions, and double binds in the above. These approaches are integrated by the senior author in the following example of a more comprehensive approach that can be adapted to practically any situation.

Another comparable Utilization Technique has been employed experimentally and clinically on both naive and experienced subjects. It has been used as a means of circumventing resistances, as a method of initial trance induction, and as a trance reinduction procedure. It is a technique based upon an immediate and direct elicitation of meaningful but unconsciously executed behavior which is separate and apart from consciously directed activity except that of interested attention. The procedure is as follows:

Depending upon the subject's educational background, a suitable casual explanation is given relating general concepts of the conscious and of the unconscious or subconscious minds. Similarly, a casual though carefully instructive explanation is given of ideomotor activity with a citing of familiar examples, including hand levitation.

Then, with utter simplicity, the subject is told to sit quietly, to rest his hands palm down on his thighs, and to listen carefully to a question that will be asked. This question, it is explained, can be answered only by his unconscious mind, not by his conscious mind. He can, it is added, offer a conscious reply, but such a reply will be only a conscious statement and not an actual reply to the question. As for the question itself, it can be any of several pertinent questions, and it is of no particular significance to the person. Its only purpose is to give the unconscious mind an opportunity to manifest itself in the answer given. The further explanation is offered that the answer to the question asked the unconscious mind will be an ideomotor response of one or the other hand lifting upward, that of the left signifying no, and that of the right signifying yes.

The question is then presented: Does your unconscious mind think that you can go into a trance? Further collaboration is offered: Consciously you cannot know what your unconscious mind thinks or knows. But your unconscious mind can let your conscious mind discover what it thinks or understands by the simple process of causing a levitation of either the right or the left hand. Thus your unconscious mind can communicate in a visibly recognizable way with your conscious mind. Now just watch your hands and see what the answer is. Neither you nor I know what your unconscious mind thinks, but as you see one or the other of your hands lifting, you will know.

If there is much delay, additional suggestions can be given: One of your hands is lifting. Try to notice the slightest movement, try to feel and to see it, to enjoy the sensation of its lifting and be pleased to learn what your unconscious thinks.

Regardless of which hand levitates, a trance state frequently of the somnambulistic type supervenes simultaneously. Usually, it is advisable to utilize, rather than to test, the trance immediately since the subject tends to arouse promptly. This is often best done by remarking simply and casually. It is very pleasing to discover that your unconscious can communicate with your conscious mind in this way. There are many other things that your unconscious can learn to do. For example, now that it has learned that it can develop a trance state and to do so remarkably well, it can learn various trance phenomena. For instance, you might be interested in - . The needs of the situation can then be met.

This technique centers around the utilization of the subject's interest in his own unconscious activity. A yes or no situation is outlined concerning thinking, with action contingent upon that thinking and constituting an overt unconscious communication, a manifestation basic to, and an integral part of a hypnotic trance. In other words, it is necessary for the subject to go into a trance in order to discover the answer to the question.

Experienced subjects approached with this technique have recognized the situation immediately: How interesting! No matter which answer you give, you have to go into a trance first.

Willing subjects disclose their unaffected interest from the beginning. Resistant subjects manifest their attitudes by difficulty in understanding the preliminary explanations, by asking repeatedly for instructions, and then by an anticipation of hand levitation by lifting the left hand voluntarily. Those subjects who object to trance induction in this manner tend to awaken at the first effort to test or to utilize the trance. Most of them, however, will readily go back into the trance when told, And you can go into a trance just as easily and quickly as your unconscious answered that question just by continuing to watch as your unconscious mind continues to move your hand up toward your face. As your hand moves up, your eyes will close, and you will go into a deep trance. In nearly all instances, the subject then develops a trance state.

An essential component of this technique is an attitude of utter expectancy, casualness, and simplicity on the part of the operator, which places the responsibility for any developments entirely upon the subjects.

The senior author begins by carefully assessing the patient's background and then uses concepts that fit the patient's frames of reference. He uses a process of indirect associative focusing as he discusses the concepts of the conscious and unconscious to lay a foundation for his later use of the conscious-unconscious double bind. Patients' expectations are then heightened as they are asked to prepare for a question that initiates an inner search for unconscious processes that will lead to an ideomotor or ideosensory response. There is an emphasis on the pleasure of learning and a continual utilization of each patient's areas of interest. The conscious-unconscious double bind is structured so that any response made is contingent on the development of trance. This first successful experience with ideomotor activity is then generalized into a recognizable trance induction with an implied directive , As your hand moves up, your eyes will close, and you will go into a deep trance.

An example that dramatically illustrates how trance behavior can be manifest, even when the patient resists the idea of being in a trance, was recorded during a workshop of the American Society of Clinical Hypnosis in 1960. The senior author was giving a talk on the dynamics of hypnosis. During such a talk there is ample opportunity to intersperse many ideodynamic suggestions that cannot help but activate the described ideodynamic process at least partially within most members of the audience. After giving a demonstration of hand levitation, he describes the following occurrence:

One of the subjects felt very, very strongly that she was not a good subject. As I observed that intensely rapt attention (response attentiveness) she was giving me, however, I could feel very strongly that she was a good subject. So I asked her to 'Give your unconscious mind the privilege of manifesting in some way that you are a good hypnotic subject but that you will not consciously recognize it. At the same time you can continue to function well at the conscious level. I might add that the manifestation might be obvious to the audience but not to you.' Even as she continued to focus closely on me and not the audience or anything else, she said, Tm not a good subject, and I don't believe you can convince me.

At this point I was utilizing her resistance to let her think she was awake and not in a somnambulistic trance. But the very intensity of her absorption in watching my every move and following everything I said was a clue to her somnambulistic condition.

I asked her again if I could put her into a trance, but she shook her head 'no,' she wouldn't cooperate. At that moment her left hand began levitating, but she did not see it because she was looking over toward me on the right.

She laughed and joked with the doctors in the audience and said she did not like to feel she was being uncooperative, but she did feel she couldn't go into a trance. Remember, I told her to function very well at the conscious level and very well at the unconscious level. And there she was talking to me and talking to the audience in this fashion. I indicated to one of the doctors in the audience that he should come up and pinch her levitated left hand. He found that she had a total anesthesia in that left hand, that she was willing to swear to the group that she was wide awake and that she couldn't possibly be in a trance. The doctor then came around and pinched her right hand, and she said, 'Ouch, that hurts! Naturally I would feel a pinch.' She was pinched again on the left hand but did not feel it.

What I wanted to demonstrate to the doctors there, and what I want to stress to you, is the separation of functioning that goes on all the time in the human body, separation at an intellectual level, separation at an emotional level, separation at a sensory level, just as you have forgotten the shoes on your feet at this moment and the glasses on your face.

This dramatic example illustrates the importance of the hypnotherapist's learning to recognize that state of rapt response attentiveness when the patient is, for all practical purposes, already in a trance state fixated on the therapist, no matter what may be said to the contrary. When the senior author observes this state of intense absorption on himself, he offers patients one or more forms of indirect suggestion that provides them with an opportunity for a hypnotic response. In this case he used a form of the conscious-unconscious double bind that enabled her unconscious to select a hypnotic manifestation (hand levitating that she had already been primed for by watching others), while allowing her conscious mind to keep its usual patterns of functioning. She was thus able to keep her resistance while manifesting good hypnotic responsiveness.

The following is another illustration wherein trance was induced even under the most resistant conditions, where the subject was a professional actor attempting to simulate hypnosis. Unknown to the senior author, at a lecture demonstration before a medical group, one of the subjects was a trained actor. He watched the other subjects carefully and then, in accord with previous secret arrangements with several people in the audience, he simulated hypnosis and demonstrated anesthesia, negative and positive auditory and visual hallucinations, and developed uncontrollable sneezing upon hallucinating goldenrod in bloom, at the request of one of the conspirators, relayed through the senior author. However, the senior author noted that the actor's manifestation of catalepsy was faulty, and his time relationships were wrong. Minor startle reflexes were noted, too, and the subject was observed to be controlling the involuntary tendency to turn his head toward the author when addressed from the side. Accordingly, he was asked to demonstrate hand levitation in response to carefully given suggestions. The actor did not show the usual time lag in response to suggestions of a sudden little jerk or quiver. This served to convince the senior author that he was being hoaxed.

Accordingly, the subject was furnished with pencil and paper and instructed to do automatic writing and to do this automatic writing in the correct style of true automatic writing. The actor had never witnessed automatic writing; however, as he began writing, suggestions were offered of writing slowly and better and better, writing automatically the sentence, 'This is a beautiful day in June.' The word this'' was repeated four times with strong intonations to fixate consciousness on it, while the rest of the sentence was said more softly and swiftly, so that it would tend to be missed by consciousness and fall into the unconscious. The word this was written in his ordinary script, but the rest of the sentence was written in the characteristic script of automatic writing. The actor subject was now beginning to experience some genuine trance behavior without realizing it. As he finished writing, the paper and pencil were removed from his sight and he was asked to awaken with an amnesia for trance events. He roused immediately and was asked to discuss hypnosis for the audience. With great satisfaction he proceeded to expose the hoax perpetrated upon the senior author to the amazement of the audience in general and the glee of the conspirators. The subject talked freely of what he had done and demonstrated his ability to sneeze at will.

After he had recounted everything except the automatic writing, this was shown to him and he was asked what he thought of it. He read the sentence aloud, stated that it was just a simple statement with no particular relevancy. Asked about the script, he observed that it appeared to be somewhat labored and juvenile. It soon became apparent to everyone that he had a total amnesia for the writing, that he was genuinely curious about the writing and why he was being questioned about it. When his amnesia had been adequately demonstrated, he was asked to duplicate that writing exactly, He agreed readily, but as he took the pencil and set it to the paper, it was at once obvious that he had developed a trance state again (repeating trance behavior tends by association to reinduce trance). After he had written the sentence this second time, he was aroused with instructions for an amnesia for trance events. As he aroused, he resumed his mockery of the author for being so easily deceived. Again he was shown the writing. He recognized that he had seen the one sentence a few moments ago, but there was a second sentence that he had not seen before.

He was allowed to retain the amnesia for a week. In the meantime those physicians who had arranged for the hoax sought out the senior author and related the whole plan to deceive him and to determine if hypnotic phenomena could be deliberately and successfully imitated. They also stated that they had tried to convince the actor that he had done the automatic writing but had failed in their efforts. They added that they had arranged for the actor to meet the senior author again so that the hypnotic amnesia could be removed.

Their request was met to their satisfaction and to the amazement of the actor, who summarized the entire matter by the simple statement, Well, it is obvious to me now that the best way to fake hypnosis is to go into a trance.

5. Utilizing the Patient's Negative Affects and Confusion

Most therapists are wary of a patient's negative affects, doubts, and confusion. Negative affects are usually seen as something that must be circumvented. The following is an illustration by the senior author of how negative affects can be utilized to induce trance and to facilitate therapeutic change.

A patient's misunderstandings, doubts, and uncertainties may also be utilized as the technique of induction. Exemplifying this approach are the instances of two patients, both college-trained women, one in her late 30's, the other in her early 40's. One patient expressed extreme doubt and uncertainty about the validity of hypnotic phenomena as applied to herself, but explained that her desperate need for help compelled her to try hypnosis as a remotely possible means of therapy.

The other declared her conviction that hypnosis and physiological sleep were identical and that she could not possibly go into a trance without first developing physiological sleep. This, she explained, would preclude therapy; yet she felt that hypnosis offered the only possible, however questionable, means of psychotherapy for her, provided that the hypnotherapy was so conducted as to preclude physiological sleep. That this was possible, she disbelieved completely.

Efforts at explanation were futile and served only to increase the anxiety and tension of both patients. Therefore an approach utilizing their misapprehensions was used. The technique, except for the emphasis employed, was essentially the same for both patients. Each patient was instructed that deep hypnosis would be induced. They were to cooperate in going into a deep trance by assessing, appraising, evaluating, and examining the validity and genuineness of each item of reality and each item of subjective experience that was mentioned. In so doing, the women were to feel under obligation to discredit and reject anything that seemed at all uncertain or questionable. For the one, emphasis was placed primarily upon subjective sensations and reactions with an interspersed commentary upon reality objects. For the other, attentiveness to reality objects as proof of wakefulness was emphasized with an interspersing of suggestions for subjective responses. In this manner, there was effected for each a progressive narrowing of the field of awareness and a corresponding increase in a dependence upon and a responsiveness to the writer. It became possible to induce in each a somnambulistic trance by employing a simple eye closure progressive relaxation technique slightly paraphrased to meet the special needs of each of the two patients.

The following sample of utterances, in which the emphasis is approximately evenly divided between subjective aspects and reality objects, is offered to illustrate the actual verbalization employed.

As you sit comfortably in that chair, you can feel the weight of your arms resting on the arms of the chair. And your eyes are open and you can see the desk and there is only the ordinary blinking of the eyelids, which you may or may not notice, just as one may notice the feeling of the shoes on one's feet and then again forget about it. And you really know that you can see the bookcase and you can wonder if your unconscious has noted any particular book title. But now again you can note the feeling of the shoes on your feet as they rest on the floor, and at the same time you can become aware of the lowering of your eyelids as you direct your gaze upon the floor. And your arms are still resting their weight on the arms of the chair, and all these things are real and you can be attentive to them and sense them. And if you look at your wrist and then look at the corner of the room, perhaps you can feel or sense the change in your visual focus. Perhaps you can remember when, as a child, you may have played with the experience of looking at an object as if it were far off and then close by. And as associated memories of your childhood pass through your mind, they can range from simple memories to tired feelings because memories are real. They are things, even though abstract, as real as the chair and the desk, and the tired feeling that comes from sitting without moving, and for which one can compensate by relaxing the muscles and sensing the weight of the body, just as one can feel so vividly the weariness of the eyelids as fatigue and relaxation develop more and more. And all that has been said is real and your attention to it is real and you can feel and sense more and more as you give your attention to your hand or to your foot or the desk or your breathing or to the memory of the feeling of comfort some time when you closed your eyes to rest your gaze. And you know that dreams are real, that one sees chairs and trees and people and hears and feels various things in dreams and that visual and auditory images are as real as chairs and desks and bookcases that become visual images. In this way, with increasing frequency, the writer's utterances became simple, direct suggestions for subjective responses.

This technique of utilizing doubts and misunderstandings has been used with other patients and with experimental subjects. It is well suited to the use of hand levitation as a final development, since ideomotor activity within the visual range offers opportunity for excellent objective and subjective realities.

The above is an excellent illustration of the interspersal approach to introduce patients to their own subjective responses gradually and in a manner that focuses attention inward for trance. Associating their inner realities with outer objects, through which they could validate their experiences; enabled them to accept the former to a greater and greater degree. The senior author then uses a series of open-ended suggestions in a very general discussion of sensations, feelings, memories, dreams, and visual images as a means of indirect associative and ideodynamic focusing to deepen their involvement with whatever subjective realities were most available to them. The utilization of doubt and misunderstanding in the example serves as an introduction to a more general understanding of negative affects as indicators of personality change.

The experience of anxiety, confusion, doubt, uncertainty, and depression is characteristic of most patients involved in a process of growth and personality change (Rossi, 1967, 1968, 1971, 1972a, 1972b, 1973; Erickson, Rossi, and Rossi, 1976). Thus while the patient is uncomfortable with these manifestations, the therapist can recognize in them the hopeful indications of a much-needed process of personality transformation that is taking place within the patient. We could even conceptualize that the typical states of depression and uncertainty with which most people enter therapy are actually spontaneous manifestations of the second and third stages (depotentiating habitual conscious sets and unconscious search) of our general paradigm of trance induction and suggestion. They are entirely normal and necessary stages in the natural process of personality growth and transformation (Rossi, 1972a). Depression and uncertainty only take pathological forms when a problem is so overwhelming that one cannot work through these uncomfortable affects on one's own. In helping patients cope with these states we can again recognize how hypnotherapy can be understood as a facilitator of natural processes inherent in psychological growth.

6. Utilizing the Patient's Symptoms

Since the patient's symptom is usually a major focus of attention, we can sometimes utilize it to facilitate trance induction and rapidly resolve the problem. With this approach we are again utilizing each patient's inner realities - dominant frames of reference and fixed belief - to induce trance and facilitate therapy. Unusually elegant examples of this approach are the following, drawn from the senior author's work in teaching dentists:

A man in his thirties became interested in hypnosis and volunteered to act as a subject for some experimental studies at a university. In the first hypnotic session he discovered that he was an excellent hypnotic subject, but lost his interest in any further experimental studies.

Several years later he decided to have hypnosis employed by his dentist, since he needed extensive dental work and feared greatly the possibility of pain.

He entered a trance state for his dentist readily, developed an excellent anesthesia of the hand upon suggestion, but failed to be able to transfer this anesthesia or even an analgesia to his mouth in any degree. Instead, he seemed to become even more sensitive orally. Efforts to develop oral anesthesia or analgesia directly also failed.

Further but unsuccessful efforts were painstakingly made by the dentist and a colleague to teach this patient by various techniques how to develop anesthesia or analgesia. He could respond in this way only in parts of the body other than the mouth. He was then brought to this writer as a special problem.

A trance state was induced readily and the patient was casually reminded of his wish for comfort in the dental chair. Thereupon, he was instructed to be attentive to the instructions given him and to execute them fully.

Suggestions were then given him that his left hand would become exceedingly sensitive to all stimuli, in fact painfully so. This hyperesthetic state would continue until he received instructions to the contrary. Throughout its duration, however, adequate care would be exercised to protect his hand from painful contacts.

The patient made a full and adequate response to these suggestions. In addition to the hyperesthesia of the hand, and entirely without any suggestion to that effect, he spontaneously developed an anesthesia of his mouth, permitting full dental work with no other anesthetic agent.

Even in subsequent efforts anesthesia or analgesia could not be induced directly or purposely except as a part of the hyperesthesia-anesthesia pattern peculiar to that patient. However, this is not a single instance of this type of behavior. Other comparable cases have been encountered from time to time.

Apparently, psychologically, the patient's fixed understanding was that the dental work must absolutely be associated with hyper-sensitivity. When this rigid understanding was met, dental anesthesia could be achieved in a fashion analogous to the relaxation of one muscle permitting the contraction of another.

Hypnosis had been attempted repeatedly and unsuccessfully on a dentist's wife by her husband and several of his colleagues. Each time, she stated, she became absolutely scared stiff, so I just couldn't move and then I'd start crying. I just couldn't do anything they asked. I couldn't relax, I couldn't do hand levitation. I couldn't shut my eyes; all I could do was be scared silly and cry.

A naturalistic approach employing synergism was utilized. A general summary of her situation was offered to her in the following words:

You wish to have hypnosis utilized in connection with your dental work. Your husband and his colleagues wish the same, but each time hypnosis was attempted, you have failed to go into a trance. You got scared stiff and you cried. It would really be enough just to get stiff without crying. Now you want me to treat you psychiatrically, if necessary, but I don't believe it is. Instead, I will just put you in a trance so that you can have hypnosis for your dentistry.

She replied, But I'll just get scared stiff and cry.

She was answered with, No, you will first get stiff. That is the first thing to do and do it now. Just get more and more stiff, your arms, your legs, your body, your neck - completely stiff - even stiffer than you were with your husband.

Now close your eyes and let the lids get stiff, so stiff that you can't open them.

Her responses were most adequate.

Now the next thing you have to do is to get scared silly and then to cry. Of course, you don't want to do this, but you have to because you learned to, but don't do it just yet.

It would be so much easier to take a deep breath and relax all over and to sleep deeply.

Why don't you try this, instead of going on to getting scared silly and crying?

Her response to this alternative suggestion was immediate and remarkably good.

The next suggestion was, Of course you can continue to sleep deeper and deeper in the trance state and be relaxed and comfortable. But any time you wish, you can start to get scared stiff and silly and to cry. But maybe now that you know how to do so, you will just keep on being comfortable in the trance so that any dental or medical work you need can be done comfortably for you.

A simple posthypnotic suggestion to enable the induction of future trances was then given.

In both of these examples the therapist accepts the patient's dominant frame of reference (hypersensitivity in the first case and scared stiff in the second) and then utilizes it to introduce and facilitate therapeutic responses. He encourages the patients to do what they already know they can do and then displaces, transforms, or adds to it something they need to do. He uses questions, contingent suggestions, and associational networks to carry the patients from their well-rehearsed but maladaptive behaviors to the desired therapeutic responses. Other instructive examples that illustrate how this approach rapidly achieves therapeutic goals are as follows.

Another type of case in which this same general approach was utilized concerns a bride of a week, who desired a consummation of her marriage but developed a state of extreme panic with her legs in the scissors position at every attempt or offer of an attempt.

She entered the office with her husband, haltingly gave her story, and explained that something had to be done, since she was being threatened with an annulment. Her husband confirmed her story and added other descriptive details.

The technique used was essentially the same as that utilized in a half dozen similar instances.

She was asked if she were willing to have any reasonable procedure employed to correct her problem. Her answer was, Yes, anything except that I mustn't be touched, because I just go crazy if I'm touched. This statement her husband corroborated.

She was instructed that hypnosis would be employed. She consented hesitantly, but again demanded that no effort be made to touch her.

She was told that her husband would sit continuously in the chair on the other side of the office and that the writer would also sit beside her husband. She, however, was personally to move her chair to the far side of the room, to sit down there and watch her husband continuously. Should either he or the writer at any time leave their chairs, she was to leave the room immediately, since she was sitting next to the office door.

Then she was to sprawl out in her chair, leaning far back with her legs extended, her feet crossed, and all the muscles fully tensed. She was to look at her husband fixedly until all she could see would be him, with just a view of the writer out of the corner of her eye. Her arms were to be crossed in front of her and her fists were to be tightly clenched.

Obediently she began this task. As she did so, she was told to sleep deeper and deeper, seeing nothing but her husband and the writer. As she slept more and more deeply, she would become scared and panicky, unable to move or to do anything except to watch both and to sleep more and more deeply in the trance, in direct proportion to her panic state.

This panic state, she was instructed, would deepen her trance, and at the same time hold her rigidly immobile in the chair.

Then gradually, she was told, she would begin to feel her husband touching her intimately, caressingly, even though she would continue to see him still on the other side of the room. She was asked if she were willing to experience such sensations and she was informed that her existing body rigidity would relax just sufficiently to permit her to nod or to shake her head in reply, and that an honest answer was to be given slowly and thoughtfully.

Slowly she nodded her head affirmatively.

She was asked to note that both her husband and the writer were turning their heads away from her, because she would now begin to feel a progressively more intimate caressing of her body by her husband, until finally she felt entirely pleased, happy and relaxed.

Approximately five minutes later she addressed the writer,

Please don't look around. I'm so embarrassed. May we go home now, because I'm all right?

She was dismissed from the office and her husband was instructed to take her home and passively await developments.

Two hours later a joint telephone call was received explaining simply, Everything is all right.

A check-up telephone call a week later disclosed all to be well. Approximately 15 months later they brought their first-born in with greatest of pride.

Another example is that of an enuretic eight-year-old boy, half carried, half dragged into the office by his parents. They had previously solicited the aid of the neighbors on his behalf, and he had been prayed for publicly in church. Now he was being brought to a crazy doctor as the last resort with a promise of a hotel dinner, to be provided following the interview.

His resentment and hostility toward all were fully apparent.

The approach was made by declaring You're mad and you're going to keep right on being mad, and you think there isn't a thing you can do about it, but there is. You don't like to see a 'crazy doctor,' but you are here and.you would like to do something, but you don't know what. Your parents brought you here, made you come. Well, you can make them get out of the office. In fact, we both can - come on, let's tell them to go on out. At this point the parents were unobtrusively given a dismissal signal, to which they readily responded, to the boy's immediate, almost startled, satisfaction.

The writer then continued, But you're still mad and so am I, because they ordered me to cure your bedwetting. But they can't give me orders like they give you. But before we fix them for that - with a slow, elaborate, attention-compelling, pointing gesture - look at those puppies right there. I like the brown one best, but I suppose you like the black-and-white one, because its front paws are white. If you are very careful, you can pet mine, too. I like puppies, don't you?

Here the child, taken completely by surprise, readily developed a somnambulistic trance, walked over, and went through the motions of petting two puppies, one more than the other. When finally he looked up at the writer, the statement was made to him, I'm glad you're not mad at me any more and I don't think that you or I have to tell your parents anything. In fact, maybe it would serve them just right for the way they brought you here if you waited until the school year was almost over. But one thing is certain. You can just bet that after you've had a dry bed for a month, they will get you a puppy just about like little Spotty there, even if you never say a word to them about it. They've just got to. Now close your eyes, take a deep breath, sleep deeply, and wake up awful hungry.

The child did as instructed and was dismissed in the care of his parents, who had been given instructions privately.

Two weeks later he was used as a demonstration subject for a group of physicians. No therapy was done.

During the last month of the school year, the boy each morning dramatically crossed off the current calendar day.

Toward the last few days of the month he remarked cryptically to his mother, You better get ready.

On the 31 st day, his mother told him there was a surprise for him. His reply was, It better be black-and-white. At that moment his father came in with a puppy. In the boy's excited pleasure he forgot to ask questions.

Eighteen months later the boy's bed was still continuously dry.

A careful study of these examples reveals the same pattern. In each case the senior author associates (1) what patients can do well with (2) trance behavior in which (3) they can now experience what they want in a hallucinated inner reality. This binds their real behavioral capacities to hallucinated wishes so that the wishes can become actualized. Therapeutic trance is the binding glue, the state of concentration or the medium in which fantasies and wishes are associated and bound to behavioral capacities so that what is desired can be actualized in real behavior. In hypnotherapeutic practice we are continually building bridges between what patients can do and what they want to do. This will become more and more evident in the next chapter on posthypnotic suggestion and in practically all the case studies that follow.

Exercises

1. Listen to tape recordings of your therapy sessions and determine to what degree you are utilizing the patients' own behaviors, interests, and personality characteristics to facilitate their therapeutic work.

2. As you study these recordings, consider where you might have introduced alternative remarks and suggestions that could utilize the patient's repository of life experiences and more highly developed functions to facilitate therapeutic progress. Explore those forms of indirect suggestions that fit easily within your own verbal repertory so that you can utilize them most effectively to facilitate the patient's inner searches and unconscious processes even without the formal induction of trance.

3. Study video recordings of your therapy sessions to discover those moments of rapt response attentiveness when your patient was most focused on you. How well did you utilize these moments to introduce therapeutic remarks?

4. Plan how you could use these moments of response attentiveness to introduce indirect forms of suggestions that could facilitate free association related to therapeutic issues. Some simple examples are as follows.

Do your eyes feel like resting and closing for a moment while your unconscious mind explores that [whatever]?

I want you to be quiet for a moment, and as you think that over we will see what else your unconscious mind brings up about it. And you don't have to talk until you really feel comfortable about it.

Therapists must find the combination of words that is natural to them and their patients in order to facilitate the inner search and unconscious processes in a casual and comfortable manner.

5. The above approach easily lends itself to indirect forms of trance induction. During those moments of common everyday trance when the patients may be apparently absorbed within themselves, looking out a window, staring at their hands, the floor, the ceiling, or whatever, therapists can introduce options for trance via indirect forms, such as the following:

You are absorbed in something now, and if your unconscious agrees that this is a comfortable moment for you to enter trance, you will find that your eyes will seem to close all by themselves.

Does your unconscious want those eyes to close so you can just continue as you are even more comfortably?

Just let yourself continue as you are and your body won't even have to move until your unconscious has a surprising solution to that, even though your conscious mind may not yet know what it is, exactly.

During a moment of rapt response attentiveness, when the patient's attention is focused on the therapist, trance could be introduced as follows:

I know you are not entirely aware of it, but I'm noticing something about you that indicates you may be ready to enter trance. And if your unconscious really wants to, you'll find those eyelids closing [handlifting, or whatever].

6. Absolutely refuse to permit yourself to use any ritualized and mechanical form of hypnotic induction until you have noticed half a dozen or more of the patient's patterns of manifest behavior, interests, abilities, inner life experiences, frames of reference, resistances, or symptoms that you can incorporate into the induction procedure. Then practice the process of integrating each patient's individuality into all the standard forms of trance induction such as eye fixation, hand levitation, and so on.

7. Study the patient's manifest behavior and symptoms to determine how they can be channeled into therapeutic responses. Practice building associative bridges between the known and possible to the unknown and desired.

8. Further study in the lore of hypnotic induction comes from many unexpected quarters. A volume on hypnotic poetry (Snyder, 1930), for example, presents the thesis that there are two basic types of poetry: hypnotic (spell-weaving) and intellectualistic. The former tends to induce trance, while the latter appeals more to the intellect. The author discusses many of the literary devices that may induce a hypnotic effect, such as (1) a perfect pattern of sound and stress, with heavy vocal stress falling at half-second intervals; (2) absence of abrupt changes or intellectual challenges; (3) vagueness of imagery, permitting each individual's personal unconscious to fill in the details; (4) fatigue for what we would call depotentiating habitual mental frameworks ; (5) the use of repetition or refrain; and (6) giving an unusually clear and direct suggestion or posthypnotic suggestion only after lulling the listener into an agreeable state with the foregoing. He goes on to point out how poetic inspiration and perhaps artistic creation in general always involve an autohypnotic state. A careful study of the poems he presents gives the hypnotherapist a broader conception of the creative work involved in every hypnotic induction.

9. Classical studies like the above lend credence to the many current efforts to understand trance as a function of the specialized activities and interaction patterns of the left and right cerebral hemispheres (Ornstein, 1972, 1973; Hilgard and Hilgard, 1975; Bandler and Grinder, 1975; Erickson, Rossi, and Rossi, 1976; Rossi, 1977). Analyze the inductions in this and the remaining chapters of this volume for their relative appeal to the left and right hemisphere. We have introduced a number of speculations in this area in our commentaries on Case 12 in Chapter 9.

CHAPTER 4

Posthypnotic Suggestion

Traditionally, posthypnotic suggestion has been used to assess the effectiveness of trance and to reinforce a therapeutic process. It was believed that a person who receives a suggestion during trance and then carries it out afterward proves by that very fact that an effective trance was experienced. Trance was conceptualized as a blank state during which an individual was easily programmed just as one might write upon a blank slate. We now recognize that this blank slate and programming model of hypnosis is misleading for psychotherapeutic work. Individuals retain their own personality dynamics during trance. Therapeutic trance is a means of focusing attention and utilizing personality dynamics in a manner that permits unconscious processes to mediate responses that are of clinical value. In the broadest sense we can speak of posthypnotic suggestion whenever we introduce an idea during a moment of receptivity that is later actualized in behavior. That moment of receptivity can occur during a formally induced trance or during the common everyday trance in which attention is fixed and absorbed in a matter of great interest.

1. Associating Posthypnotic Suggestions with Behavioral Inevitabilities

The traditional approach to direct posthypnotic suggestion usually takes the form, After you awaken from trance, you will do [or experience] such and such. Indirect posthypnotic suggestion, by contrast, involves the use of the indirect forms of suggestion together with a number of other processes found in everyday life as well as clinical practice. The most useful of these are contingency suggestions and associational networks, whereby we tie the posthypnotic suggestion to inevitable patterns of behavior that the patient will experience in the future. These inevitable behavior patterns function as cues or vehicles for the execution of the posthypnotic suggestion. The patient's own associations, life experience, personality dynamics, and future prospects are all utilized to build the posthypnotic suggestion into the patient's natural life structure. An example from the senior author's own family life can introduce us to this concept of indirect posthypnotic suggestion in its broadest sense.

The first time an orthodontist worked on a daughter of mine I said to her, You know, all of that baling wire in your mouth is miserably uncomfortable. Why shouldn't I tell her the truth? She knew it, she was certain of it. I then said to her, That mouthful of hardware that you've got with all those rubber bands is wretchedly miserable, and it's going to be a deuce of a job to get used to it. Well, what did I suggest? You will get used to it. Getting used to it was the indirect suggestion. She heard me agreeing with her misery, but her unconscious also heard the rest of the sentence. Always know how inclusive, how comprehensive your statement is. It is a deuce of a job to get used to it. When you put it that way, she accepts both parts of the sentence, though she doesn't know she has accepted the second part. Then I told her, You are only a little girl now, but what kind of a smile do you think you will have in your wedding picture? Mrs. Erickson and I kept that posthypnotic suggestion in mind for a long time until she was married. We never ever betrayed it by talking about it or telling anyone. When our daughter got married ten years later and saw her wedding pictures, she said, Daddy, this is my favorite one. Look at the smile. That was an indirect posthypnotic suggestion that worked over a period of ten years even though she could not recognize it as such. When she first went to the orthodontist, marriage was the farthest thing from her mind. She wasn't thinking of marriage at all, but she did know that women get married and there was the remote possibility that she was making the beautiful smile she would have in her wedding picture. That's what goes into the most effective posthypnotic therapeutic suggestion. When you offer a posthypnotic suggestion in the form of a hopeful prognosis to a patient, tie it to a reasonable future contingency. Marriage was a reasonable expectation for us to entertain regarding our daughter.

This example illustrates a number of basic principles for offering posthypnotic suggestion. The process was initiated, as always, by first recognizing and fully acknowledging the individual's current ongoing experience. The daughter's attention was immediately fixated when her father gave expression to the current reality by acknowledging her misery over her new orthodontic treatment. He then utilized a compound statement to tie his indirect suggestion getting used to it to her ongoing and undeniable reality. He then reinforced the suggestion even further by associating it with a reasonable future contingency, when getting used to it would be rewarded with a beautiful smile on her wedding day. Four major factors facilitating this posthypnotic suggestion can be listed as follows:

1. 1. Fixing attention and opening a yes set by recognizing and acknowledging current experience.

2. 2. Associating a suggestion with this current experience by way of an indirect hypnotic form (compound suggestion).

3. 3. Utilizing the person's own personality dynamics (need for a nice smile on her wedding day) as a vehicle for the suggestion.

4. 4. Associating the suggestion with a reasonable future contingency (her future wedding).

A number of other illustrations of posthypnotic suggestions associated with behavioral inevitabilities are as follows. The suggestion proper is in italics:

Shortly after you awaken, I'm going to say something to you. I'm going to arouse you and put you back into trance. In spite of any thinking you do, what I say will be true.

2. Serial Posthypnotic Suggestions

It is most instructive to realize that it is more difficult to reject two or more suggestions given together in an associational network than it is to reject a single suggestion standing alone. Consider the following example by the senior author (Erickson and Erickson, 1941), which utilizes a five-year-old girl's interest in her favorite doll.

A five-year-old child who had never witnessed a hypnotic trance was seen alone by the hypnotist. She was placed in a chair and repeatedly told to go to sleep, and to sleep very soundly,'' while holding her favorite doll. No other suggestion of any sort was given her until after she had apparently slept soundly for some time. Then she was told, as a posthypnotic suggestion, that some other day the hypnotist would ask her about her doll, whereupon she was to (a) place it in a chair, (b) sit down near it, and (c) wait for it to go to sleep. After several repetitions of these instructions, she was told to awaken and to continue her play. This three-fold form of posthypnotic suggestion was employed, since obedience to it would lead progressively to an essentially static situation for the subject. Particularly did the last item of behavior require an indefinitely prolonged and passive form of response, which could be best achieved by a continuation of the spontaneous posthypnotic trance. Several days later she was seen while at play, and a casual inquiry about her doll was made. Securing the doll from its cradle, she exhibited it proudly and then explained that the doll was tired and wanted to go to sleep, placing it as she spoke in the proper chair and sitting down quietly beside it to watch. She soon gave the appearance of being in a trance state, although her eyes were still open. When asked what she was doing, she replied, Waiting, and nodded her head agreeably when told insistently, Stay just like you are and keep on waiting. Systematic investigation, with an avoidance of any measure that might cause a purely responsive manifestation to a specific but unintentional hypnotic suggestion, led to the discovery of a wide variety of the phenomena typical of the ordinarily induced trance.

A series of subtle posthypnotic suggestions suitable for facilitating the trance training and the reinduction of trance for adults might run somewhat as follows.

1. 1. When you awaken, you will open your eyes. . .

2. 2. Move and perhaps stretch a bit. . .

3. 3. You can talk a bit about what interests you in your experience. . .

4. 4. And forget all the rest. . .

5. 5. Until I ask you to go back into trance. . .

6. 6. So you can experience and remember something more.

The first three lines of the above are a series of truisms that together form an associational network of behaviors that are inevitabilities. Since they are inevitable, they tend to initiate a yes set within the patient, who probably won't even recognize line 4 as a subtle suggestion for hypnotic amnesia. Line 5 is a fairly direct posthypnotic suggestion to reenter trance that contains an important contingency with the word until. Until means that on reentering trance the patient will remember something forgotten due to a hypnotic amnesia when he was awake. Line 6 continues the associational network binding a future trance with the current experience, and it also contains a subtle ambiguity: Will the patient merely experience and recall what was lost in the amnesia, or will there be a new experience that will then be recalled? Will it be recalled only during trance or after trance as well? The therapist usually does not know the answers to these questions - they are a means of exploring the patient's unique system of responding. If it is found that significant amnesias are present that can be lifted by further suggestion, the therapist may decide to utilize this ability therapeutically. If new experience is forthcoming with each trance, this may become the ideal therapeutic modality for helping patients explore their inner worlds.

3. Unconscious Conditioning as Posthypnotic Suggestion

Most therapists automatically alter the tone and cadence of their voice during trance work. The patients, in turn, become automatically and usually unconsciously conditioned to experience trance in response to these vocal alterations. If the therapist adopts these vocal changes during an ordinary conversation, the patient will frequently begin to experience partial aspects of trance without quite knowing why. Since these minimal cues bypass the patient's conscious frames of reference, they are often surprisingly effective. When therapists notice these beginning manifestations of trance (e.g., eye blinking, minimal movements, blocking, some confusion, and so on), they can reinforce them with other nonverbal or verbal cues they typically use during the initial stages of trance induction. For example, when the patient is looking directly at the senior author during trance induction, he will frequently look directly at the patient's face but focus his eyes at a distance beyond. When he later does this during an ordinary conversation, the patient initially feels a bit disconcerted, then begins to experience a disorientation that can only be resolved by going into trance (Erickson, Rossi, and Rossi, 1976). At such moments the senior author may reinforce the process with a look of happy expectation and double bind questions such as the following:

I wonder just how awake you are now?

Just how much trance are you beginning to experience?

Is that a trance you're beginning to experience?

It's comfortable to just let that happen, isn't it?

You don't have to talk, do you? It's nice just to let yourself be.

When we begin to look into the matter, we realize that there are innumerable patterns of unconscious conditioning that are taking place between therapist and patient all the time. Many patients become conditioned unconsciously and automatically to begin the process of trance experience as soon as they enter the therapist's waiting room. The observant therapist need not engineer such patterns of unconscious conditioning or set them up intentionally. It is far more effective simply to observe them as they occur naturally and then to utilize them as important indicators of unconscious processes. Some patients, for example, position their bodies in certain characteristic ways during trance. Later, during an ordinary therapeutic session, the therapist may notice aspects of that trance position developing. Perhaps a head, arm, leg, hand, or finger falls into trance position. This may be a nonverbal and unconscious body signal that the patient is reexperiencing an association to trance on some level and now needs to do trance work. When therapists recognize these body cues, they can facilitate the process with an expectant look and questions somewhat like the following:

Are you aware of what's happening to you now?

Pause for a moment. Can you sense what's taking place within you?

Do you feel you are really completely awake?

How much trance are you beginning to experience?

When the patient's body language is, indeed, a signal that trance work needs to be done, the patient will frequently use the inner search initiated by these questions to enter more deeply into trance. If the body language meant something else (such as an important association to previous trance experience that now needs to be talked about), the therapist's question provides an opportunity for it to be expressed in the awake state or perhaps in a light trance state that is difficult to distinguish from the awake state.

4. Initiated Expectations Resolved Posthypnotically

A most effective approach to posthypnotic suggestion is to initiate expectations, tensions, or patterns of behavior that can only be completed or resolved after trance is formally terminated. This approach has experimental validation in numerous studies of the Zeigarnic effect (Woodworth and Schlosberg, 1954), which demonstrate how children will return to an uncompleted task after an interruption because of the tension or disequilibrium aroused by their set for closure. In the previous section we saw how unconscious conditioning could initiate partial aspects of trance that could only be resolved by the patient actually going into trance or that could only be resolved after trance by some therapeutic behavioral change. Our five-stage paradigm of the dynamics of trance induction and suggestion in Figure 1 is particularly evident in this approach (see page 4).

The senior author frequently uses this approach with patients experiencing trance for the first time. During their first trance he will casually remark how interesting and therapeutic it can be to experience a pleasant surprise. He then obtains their willingness to experience a pleasant surprise after they awaken. A pleasant expectation is thus set up within the patients that can be resolved by a therapeutic shock or surprise after they awaken. This expectation is an unresolved tension that heightens their sensitivity to the therapeutic surprise that the therapist has planned. The expectation of a pleasant surprise tends to suspend patients' habitual sets and attitudes and to initiate unconscious searches and processes for the promised pleasant surprise.

After the patient has been awake for a while, the senior author guides the patient's hand and arm upward with a look of bemused expectation. The patient's arm usually remains suspended in midair because it has been given subtle but directive tactile cues to remain so (Erickson, Rossi, and Rossi, 1976). Patients usually do not recognize these tactile cues on a conscious level, however, so they are indeed surprised at the apparently peculiar behavior of their arms. The senior author will reinforce this surprise and imply that it means the patients are entering trance in fulfillment of the posthypnotic suggestion he gave previously with remarks such as the following:

Surprising, isn't it?

Does your hand always remain up when someone touches it?

And it can be a pleasant surprise to find yourself going back into trance without any effort.

Are your eyes beginning to close?

And that hand won't go down until the other hand goes up.

The patient's surprise and puzzlement about what is happening is essentially a confusion approach to depotentiating habitual conscious sets and frameworks so that an altered state is facilitated. In the following section we will further elaborate our conception of this use of surprise and expectation to facilitate the execution of therapeutic posthypnotic suggestions.

5. Surprise as a Posthypnotic Suggestion

Surprise in a posthypnotic suggestion heightens expectancy while providing a fail-safe channel for the expression of the patient's individuality after awakening. Consider the following posthypnotic suggestion, which is most appropriately offered at the end of a period of successful trance work during which the patient is in a positive mood and experiencing a yes set.

Would you like to experience a pleasant surprise after you awaken?

A patient who responds in the affirmative to this question (by head nodding, finger signaling, verbal response, smiling, and so on) is in the following situation:

1. 1. The positive yes set of the trance work is carried over into the posthypnotic period.

2. 2. Awakening is accompanied by a sense of heightened expectation and positive motivation to experience something new.

3. 3. The patient's usual conscious sets do not know what the surprise, the new, will be. The patient's habitual conscious and limiting sets are therefore depotentiated in favor of something new that can only come from the patient's own unconscious. The suggestion for a pleasant surprise has been given in the form of a question which in itself initiates an unconscious search that may uncover and permit a new potential or another aspect of the patient's individuality to become manifest.

4. 4. The suggestion tends to be fail-safe because whatever patients experience or report after a period of successful trance work can be accepted as a pleasant surprise. If patients are happily excited, that can be a pleasant surprise. If patients are more thoughtful and appear to lapse back into body immobility as they reflect on their trance experiences, the therapist can facilitate a surprise with a suggestion such as, As you notice how quiet your body is, it may be surprising how easily your eyes can close as you go back into trance to reach a complete understanding of that. The therapist may not know what that is, but whatever it is can be facilitated.

5. 5. When the patient experiences a surprise in some form after trance, a therapist's final comment such as And that was a pleasant surprise, wasn't it? tends to ratify the therapeutic work that has just taken place as well as the value of trance as a valid approach to solving problems.

A number of examples illustrating this surprise form of posthypnotic suggestion will be found in the cases of this book.

Exercises

1. Associating therapeutic suggestions with behavioral inevitabilities can be practical in everyday life as well as in the consulting room. It is an approach particularly suitable for use with children provided the adult avoids sermonizing.

2. The serial posthypnotic suggestions require much thought and planning. Together with contingency suggestions, associational networks, and double binds they can constitute an almost impenetrable thicket for snagging practically any random association or behavioral potential the patient may have and holding it fast to the therapeutic endeavor. It becomes a fascinating exercise to interpenetrate each individual patient's behavioral inevitabilities with a serial pattern of suggestions so they mutually reinforce each other and, it is hoped, displace the patient's symptom.

3. Unconscious conditioning as posthypnotic suggestion requires a careful observation of patients' patterns of behavior and responsiveness whenever they come into the therapist's presence after having had a successful hypnotic experience. The therapist must then learn to follow up such careful observations with the type of questions that can facilitate inner search and deepening trance involvement. The beginner in this area may find it difficult to believe and to learn to see those spontaneous and conditioned patterns of trance behavior that develop in most patients when they meet the therapist again after a successful trance experience. Because of this it may be instructive to question every patient routinely on that next meeting in the manner suggested in this chapter. If ideomotor signaling has already been developed, it is very easy to ask within the first few minutes of that next meeting, Now if you are already beginning to experience some trance, your right hand will lift (or your eyes will close, and so on). It is important to assess the patient's state within the first few minutes of the next meeting, because after that, the initial conditioned response of trance may be rapidly extinguished, since it is displaced by the conventionalities of consciously relating to the therapeutic situation.

4. Initiated expectations resolved posthypnotically with surprise is a skill that develops along with the use of contingent suggestions and associational networks. They can be most easily learned by expressing the simple expectation of feeling rested and comfortable upon awakening. This is generally fail-safe, since such responses almost inevitable. To these inevitabilities one can gradually add suggestions particularly suited to the patient's needs and fitting the patient's expectations of what should be experienced.

CHAPTER 5

Altering Sensory-Perceptual Functioning: The Problem of Pain and Comfort

Recent clinical (Lassner, 1964; Melzack and Perry, 1975) and experimental research (Hilgard and Hilgard, 1975) has validated anew centuries of experience with the hypnotic alteration of sensory-perceptual functioning for coping with pain and facilitating comfort. Hypnotherapeutic approaches have been successful in reducing pain from obvious somatic sources (such as accidental physical trauma, surgery, dentistry, obstetrics, cancer, and so on) as well as psychosomatic problems. It has been established on an experimental basis that hypnotic pain relief is due to something more than the placebo effect (McGlashan, Evans, and Orne, 1969) or anxiety reduction (Hilgard and Hilgard, 1975). Since the usefulness of hypnosis in this area has been so well established, we will focus our attention on the practical approaches that have been developed by the senior author in clinical situations.

Introduction
[The following material was written by the senior author, and originally appeared in the Proceedings of the International Congress for Hypnosis and Psychosomatic Medicine. J. Lassner, (ed.) 1967.]

Hypnosis is essentially a communication to a patient of ideas and understandings in such a fashion that he will be most receptive to the presented ideas and thereby motivated to explore his own body potentials for the control of his psychological and physiological responses and behavior. The average person is unaware of his capacities for accomplishment which have been learned through the experimental conditionings of his body behavior throughout his life experiences. To the average person in his thinking, pain is an immediate subjective experience, all-encompassing of his attention, distressing, and to the best of his belief and understanding, an experience uncontrollable by the person himself. Yet as a result of experiential events of his past life, there has been built up within his body, although all unrecognized, certain psychological, physiological, and neurological learnings, associations, and conditionings that render it possible for pain to be controlled and even abolished. One need only to think of extremely crucial situations of tension and anxiety to realize that the severest amount of pain vanishes when the focusing of the sufferer's awareness is compelled by other stimuli of a more immediate, intense, or life-threatening nature. From common experience, one can think of a mother suffering extremely severe pain and all-absorbed in her pain experience. Yet she forgets it without effort or intention when she sees her infant dangerously threatened or seriously hurt. One can think of men in combat who have been seriously wounded, but do not discover their injuries until later. Numerous such comparable examples are common to medical experience. Such abolition of pain occurs in daily life situations where pain is taken out of awareness by more compelling stimuli of another character. The simplest example of all is the toothache forgotten on the way to the dentist's office, or the headache lost in the suspenseful drama portrayed at the cinema. By such experiences as these in the course of a lifetime, be they major or minor, the body learns a wealth of unconscious psychological, emotional, neurological and physiological associations and conditionings. These unconscious learnings repeatedly reinforced by additional life experiences constitute the source of the potentials that can be employed through hypnosis to control pain intentionally without resorting to drugs.

Considerations Concerning Pain

While pain is a subjective experience with certain objective manifestations and accompaniments, it is not necessarily or solely a conscious experience. It occurs without conscious awareness in states of sleep, in narcosis, and even under certain types of chemoanesthesia as evidenced by objective accompaniments and as has been demonstrated by experimental hypnotic exploration of past experiences of patients. But because pain is primarily a conscious subjective phenomenon, with all manner of unpleasant, threatening, even vitally dangerous emotional and psychological significances and meanings, an approach to the problem can be made frequently through the use of hypnosis, sometimes easily, sometimes with great difficulty. Furthermore, the extent of the pain is not necessarily a factor.

In order to make use of hypnosis in dealing with pain, one needs to look upon pain in a most analytical fashion. Pain is not a simple uncomplicated noxious stimulus. It has certain temporal, emotional, psychological, and somatic significances. It is a compelling motivational force in life's experience. It is a basic reason for seeking medical aid.

Pain is a complex, a construct, composed of past remembered pain, of present pain experience, and of anticipated pain in the future. Thus, immediate pain is augmented by past pain and enhanced by the future possibilities of pain. The immediate stimuli are only a central third of the entire experience. Nothing so much intensifies pain as the fear that it will be present on the morrow. It is likewise increased by the realization that the same or similar pain was experienced in the past, and this and the immediate pain render the future even more threatening. Conversely the realization that the present pain is a single event which will definitely come to a pleasant ending serves greatly to diminish it. Because pain is a construct, it is more readily vulnerable to hypnosis as a successful treatment modality than it would be were it simply an experience of the present.

Pain as an experience is also rendered more susceptible to hypnosis because it varies in its nature and intensity and hence, through life experiences, it acquires secondary meanings resulting in varying interpretations of the pain. Thus the patient may regard his pain in temporal terms, such as transient, recurrent, persistent, acute, or chronic. These special qualities each offer varying possibilities of hypnotic approaches.

Pain also has certain emotional attributes. It may be irritating, all-compelling, troublesome, incapacitating, threatening, intractable, or vitally dangerous. Each of these aspects leads to certain psychological frames of mind with varying ideas and associations, each offering special opportunities for hypnotic intervention.

One must further bear in mind certain other very special considerations. Long continued pain in an area of the body may result in a habit of interpreting all sensations in that area as automatically painful. The original pain may be long since gone, but the recurrence of that pain experience has been conducive to a habit formation that may in turn lead to actual somatic disorders painful in character.

In a somewhat similar category are iatrogenic disorders and disease arising from a physician's poorly concealed concern and distress over his patient. Iatrogenic illness has a most tremendous significance because in emphasizing that there can be psychosomatic disease of iatrogenic origin, its converse cannot be overlooked: that iatrogenic health is fully as possible and of far greater importance to the patient. And since iatrogenic pain can be produced by fear, tensions, and anxiety, so can freedom from it be produced by the iatrogenic health that may be suggested hypnotically.

Pain as a protective somatic mechanism should not be disregarded as such It motivates the patient to protect the painful areas, to avoid noxious stimuli and to seek aid. But because of the subjective character of the pain, there develop psychological and emotional reactions to it that eventually result in psychomatic disturbances from unduly prolonged protective mechanisms. These psychological and emotional reactions are amenable to modification and treatment through hypnosis in such psychosomatic disturbances.

To understand pain further, one must think of it as a neuro-psychophysiological complex characterized by various understandings of tremendous significance to the sufferer. One need only ask the patient to describe his pain to hear it variously described as dull, heavy, dragging, sharp, cutting, twisting, burning, nagging, stabbing, lancinating, biting, cold, hard, grinding, throbbing, gnawing, and a wealth of other such adjectival terms.

These various descriptive interpretations of the pain experience are of marked importance in the hypnotic approach to the patient. The patient who interprets his subjective pain experience in terms of various qualities of differing sensations is thereby offering a multitude of opportunities to the hypnotherapist to deal with the pain. To consider a total approach is possible. But more feasible is the utilization of hypnosis in relation first to minor aspects of the total pain complex and then to its increasingly severe and distressing qualities. Thus, minor successes will lay a foundation for major successes in relation to the more distressing attributes of the neuro-psycho-physiological complex of pain, and the understanding and cooperation of the patient for hypnotic intervention are more readily elicited. Additionally, any hypnotic alteration of any single interpretive quality of the pain sensation serves to effect an alteration of the total pain complex.

Another important consideration in the comprehension of the pain complex is the recognition of the experiential significances of various attributes or qualities of subjective sensation, and their differing relationships in such matters as remembered pain, past pain, immediate pain, enduring pain, transient pain, recurrent pain, enduring persistent pain, intractable pain, unbearable pain, threatening pain, etc. In applying these considerations to varying subjective elements of the pain complex, hypnotic intervention is greatly accelerated. Such analysis offers greater opportunity for hypnotic intervention at a more comprehensive level. It becomes easier to communicate ideas and understandings through hypnosis and to elicit the receptiveness and responsiveness so vital in securing good response to hypnotic intervention. It is also important to acknowledge adequately the unrecognized force of the human emotional need to demand the immediate abolition of pain, both by the patient himself and by those attending him.

Hypnotic Procedures in Pain Control

The hypnotic procedures for handling pain are numerous in character. The first of these most commonly practiced but frequently not genuinely applicable is the use of direct hypnotic suggestion for total abolition of pain. With a limited number of patients, this is a most effective procedure. But too often it fails, serving to discourage the patient and to prevent further use of hypnosis in the patient's treatment. Also, its effects, while they may be good, are sometimes too limited in duration which may limit the effectiveness of the permissive indirect hypnotic abolition of pain. This is often much more effective, and although essentially similar in character to direct suggestion, it is worded and offered in a fashion much more conducive to patient receptiveness and responsiveness.

A third procedure for hypnotic control of pain is the utilization of amnesia. In everyday life we see the forgetting of pain whenever more threatening or absorbing experiences secure the attention of the sufferer. An example is the instance already cited of the mother enduring extreme pain, seeing her infant seriously injured, forgetting her own pain in the anxious fears about her child. Then of quite opposite psychological character is the forgetting of painful arthritis, headache or toothache while watching an all-absorbing suspenseful drama on a cinema screen.

But amnesia in relationship to pain can be applied hypnotically in a great variety of ways. Thus one may employ partial, selective, or complete amnesias in relationship to selected subjective qualities and attributes of sensation in the pain complex as described by the patient, as well as to the total pain experience.

A fourth hypnotic procedure is the employment of hypnotic analgesia, which may be partial, complete, or selective. Thus, one may add to the patient's pain experience a certain feeling of numbness without a loss of tactile or pressure sensations. The entire pain experience then becomes modified and different and gives the patient a sense of relief and satisfaction, even if the analgesia is not complete. The sensory modifications introduced into the patient's subjective experience by such sensations as numbness, an increase of warmth and heaviness, relaxation, etc. serve to intensify the hypnotic analgesia to an increasingly complete degree.

Hypnotic anesthesia is a fifth method in treating pain. This is often difficult and may sometimes be accomplished directly, but is more often best accomplished indirectly by the building of psychological and emotional situations that are contradictory to the experience of the pain and which serve to establish an anesthetic reaction to be continued by post-hypnotic suggestion.

A sixth hypnotic procedure useful in handling pain concerns the matter of suggestion to effect the hypnotic replacement or substitution of sensations. For example, one cancer patient suffering intolerable pain responded most remarkably to the suggestion of an incredibly annoying itch on the sole of her foot. Her body weakness occasioned by the carcinomatosis and hence inability to scratch the itch rendered this psychogenic pruritis all-absorbing of her attention. Then hypnotically, feelings of warmth, of coolness, of heaviness and of numbness were systematically induced for various parts of her body where she suffered pain. And the final measure was the suggestion of an endurable but highly unpleasant and annoying minor burning-itching sensation at the site of her mastectomy. This procedure of replacement substitution sufficed for the patient's last six months of her life. The itch of the sole of her foot gradually disappeared but the annoying burning-itching sensation at the site of her mastectomy persisted.

Hypnotic displacement of pain is a seventh procedure. This is the employment of a suggested displacement of the pain from one area of the body to another. This can be well illustrated by the instance of a man dying from prostatic metastalic carcinomatosis and suffering with intractable pain in both states of drug narcosis and deep hypnosis, particularly abdominal pain. He was medically trained and understood the concept of referred and displaced pain. In the hypnotic trance he readily accepted the idea that, while the intractable pain in his abdomen was the pain that would actually destroy him, he could readily agree that equal pain in his left hand could be entirely endurable, since in that location it would not have its threatening significances. He accepted the idea of referral of his abdominal pain to his left hand, and thus remained free of body pain, becoming accustomed instead to the severe pain in his left hand which he protected carefully. This hand pain did not interfere in any way with his family life during the remaining three months of his life. It was disclosed that the displaced pain to the left hand often gradually diminished, but the pain would increase upon incautious inquiry.

This possibility of displacement of pain also permits a displacement of various attributes of the pain that cannot otherwise be controlled. By this measure these otherwise uncontrollable attributes become greatly diminished. Thus the total complex of pain becomes greatly modified and made more amenable to hypnotic intervention.

Hypnotic dissociation can be employed for pain control, and the usual most effective methods are those of time and body disorientation. The patient with pain intractable to both drugs and hypnosis can be hypnotically reoriented in time to the earlier stages of his illness when the pain was of minor consideration. And the disorientation of that time characteristic of the pain can be allowed to remain as a posthypnotic continuation through the waking state. Thus the patient still has his intractable pain, but it has been rendered into a minor consideration as it had been in its original stages.

One may sometimes successfully reorient the patient with intractable pain to a time predating his illness and, by posthypnotic suggestion, effect a restoration of the normal sensations existing before his illness. However, although intractable pain often prevents this as a total result, pleasant feelings predating the illness may be projected into the present to nullify some of the subjective qualities of his pain complex. Sometimes this effects a major reduction in pain.

In the matter of body disorientation, the patient is hypnotically dissociated and induced to experience himself as apart from his body. Thus one woman with the onset of unendurable pain, in response to posthypnotic suggestions, would develop a trance state and experience herself as being in another room while her suffering body remained in her sickbed. This patient explained to the author when he made a bedside call, Just before you arrived, I developed another horrible attack of pain. So I went into a trance, got into my wheel chair, came out into the living room to watch a television program, and I left my suffering body in the bedroom. And she pleasantly and happily told about the fantasized television program she was watching. Another such patient remarked to her surgeon, You know very well, Doctor, that I always faint when you start changing my dressings because I can't endure the pain, so if you don't mind I will go into a hypnotic trance and take my head and feet and go into the solarium and leave my body here for you to work on. The patient further explained, I took a position in the solarium where I could see him (the surgeon) bending over my body but I could not see what he was doing. Then I looked out the window and when I looked back he was gone, so I took my head and feet and went back and joined my body and felt very comfortable. This particular patient had been trained in hypnosis by the author many years previously, had subsequently learned autohypnosis, and thereafter induced her own autohypnotic trance by the phrase, You know very well, Doctor. This was a phrase that she could employ verbally or mentally at any time and immediately go into a trance for the psychological-emotional experience of being elsewhere, away from her painful body, there to enjoy herself and remain until it was safe to return to her body. In this trance state which she protected very well from the awareness of others, she would visit with her relatives, but experience them as with her in this new setting while not betraying that personal orientation.

A ninth hypnotic procedure in controlling body pain, which is very similar to replacement or substitution of sensations is hypnotic reinterpretution of pain experience. By this is meant the reinterpreting for the patient in hypnosis of a dragging, gnawing, heavy pain into a feeling of weakness, of profound inertia, and then as relaxation with the warmth and comfort that accompanies deep muscular relaxation. Stabbing, lancinating and biting pains may sometimes be reinterpreted as a sudden startle reaction, disturbing in character, but momentary in duration and not painful. Throbbing, nagging, grinding pain has been successfully reinterpreted as the unpleasant but not distressing experience of the rolling sensations of a boat during a storm, or even as the throbbing that one so often experiences from a minor cut on the fingertip with no greater distressing characteristics. Full awareness of how the patient experiences his pain is required for an adequate hypnotic reinterpretation of the pain sensation.

Hypnotic time distortion, first described by Cooper and then later developed by Cooper and Erickson (Cooper, L., and Erickson, M., Time Distortion in Hypnosis, Baltimore: Williams and Wilkins, 1959) is often a most useful hypnotic measure in pain control. An excellent example is that of the patient with intractable attacks of lancinating pain which occurred approximately every twenty to thirty minutes, night and day, and which lasted from five to ten minutes. Between the attacks the patient's frame of mind was essentially one of fearful dread of the next attack. By employing hypnosis and teaching him time distortion, it was possible to employ, as is usually the case in every pain patient, a combination of several of the measures described here. In the trance state, the patient was taught to develop an amnesia for all past attacks of pain. He was then taught time distortion so that he could experience the five to ten minute pain episodes in ten to twenty seconds. He was given posthypnotic suggestions to the effect that each attack would come as a complete surprise to him, that when the attack occurred he would develop a trance state often to twenty seconds duration, experience all of the pain attack, and then come out of the trance with no awareness that he had been in a trance or that he had experienced pain. Thus the patient, in talking to his family, would suddenly and obviously go into the trance state with a scream of pain, and perhaps ten seconds later come out of the trance state, look confused for a moment, and then continue his interrupted sentence.

An eleventh hypnotic procedure is that of offering hypnotic suggestions effecting a diminution of pain, - not a complete removal of the pain, since it had become apparent that the patient was not going to be fully responsive. This diminution is usually best brought about by suggesting to the hypnotized patient that his pain is going to diminish imperceptibly hour after hour without his awareness that it is diminishing until perhaps several days have passed. He will then become aware of all pain or of special pain qualities. By suggesting that the diminution occur imperceptibly, the patient cannot refuse the suggestion. His state of emotional hopefulness, despite his emotional despair, leads him to anticipate that in a few days there may be some diminution; particularly that there may be even a marked diminution of certain attributes of his pain experience. This, in itself, serves as an autosuggestion to the patient. In certain instances, however, the patient is told that the diminution will be to a very minor degree. One can emphasize this by Utilizing the ploy that a one percent diminution of his pain would not be noticeable, nor would a 2 percent, nor a 3 percent, nor a 4 percent, nor a 5 percent diminution, but that such an amount would nevertheless be a diminution. One can continue the ploy by stating that a 5 percent diminution the first day and an additional 2 percent the next day still would not be perceptible. And if on the third day there occurred a 3 percent diminution, this, too, would be imperceptible. But it would total a 10 percent diminution of the original pain. This same series of suggestions can be continued to a reduction of pain to 80 percent of its original intensity, then to 70 percent, 50 percent, 40 percent, and sometimes even down to 10 percent. In this way the patient may be led progressively into an even greater control of his pain.

However, in all hypnotic procedures for the control of pain one bears in mind the greater feasibility and acceptability to the patient of indirect as compared with direct hypnotic suggestions, and the need to approach the problem by indirect and permissive measures as well as by employing a combination of the various methodological procedures described above.

Summary

Pain as a subjective experience is perhaps the most significant factor in causing people to seek medical aid. Treatment of pain as usually viewed by both physician and patient is primarily a matter of elimination or abolition of the sensation. Yet pain in itself may be serving certain useful purposes to the individual. It constitutes a warning, a persistent warning of the need for help. It brings about physical restriction of activity, thus frequently benefiting the sufferer. It instigates physiological changes of a healing nature in the body. Hence, pain is not just an undesirable sensation to be abolished, but rather an experience to be so handled that the sufferer benefits. This may be done in a variety of ways, but there is a tendency to overlook the wealth of psycho-neuro-physiological significances pain has for the patient. Pain is a complex, a construct composed of a great diversity of subjective interpretative and experiential values for the patient. Pain, during life's experience, serves to establish body learnings, associations, and conditionings that constitute a source of body potentials permitting the use of hypnosis for the study and control of pain. Hypnotic procedures, singly or in combination, for major or minor effects in the control of pain described for their application are: Direct Hypnotic Suggestion for Total Abolition of Pain; Permissive Indirect Hypnotic Abolition of Pain; Amnesia; Hypnotic Analgesia; Hypnotic Anesthesia; Hypnotic Replacement or Substitution of Sensations; Hypnotic Displacement of Pain; Hypnotic Dissociation; Reinterpretation of Pain Experience; Hypnotic Suggestions Effecting a Diminution of Pain.

Case 1 A Conversational Approach to Altering Sensory-Perceptual Functioning: Phantom Limb Pain and Tinnitus.

Our first case illustrates the simultaneous therapy of a married couple who presented two apparently different symptoms: The seventy-two-year-old husband (H) suffered from phantom limb pain; his seventy-five-year-old wife (W) was bothered by tinnitus, an unpleasant ringing in her ears that had bothered her constantly for years. The husband had seen Erickson (E) for the first time a week earlier and had experienced some relief. Erickson and Rossi (R) then asked him and his wife to join them for a hypnotherapeutic session that would be free of charge if they were willing to be tape-recorded for possible publication. This offer was gratefully received by them. The rapport that Erickson had already established with the husband was now enhanced since they both appreciated the therapy and special consideration they were receiving. They entered the therapy room wide-eyed with hopeful expectation and immediately focused their entire attention on Erickson. Their response attentiveness was already at an ideal level. As can be seen from the transcript, they are both very respectful, cooperative, and eager for help. They have no evident misconceptions or resistances to hypnosis, so Erickson can introduce them immediately to the concept of learning to alter their own sensory-perceptual functioning for relief of their symptoms. He does this with a rather relaxed and seemingly casual conversation wherein he tells them interesting stories about his youth and the fascinating ways people can learn to regulate and alter many of their bodily processes. This enjoyable talk is actually a careful preparation during which Erickson is structuring frames of reference about their abilities to alter their own sensory-perceptual processes. He is preparing them for the relatively brief period of therapeutic trance that will follow, when he will offer suggestions to help evoke their repertory of sensory-perceptual skills that can be utilized for ameliorating their symptoms.

A Conversational Approach to Altering Sensory-Perceptual Functioning: Structuring a Therapeutic Frame of Reference

W: Well this phantom pain-if we could lick that, it would be wonderful.

E: All right. Now I am going to give you a story so that you can understand better. We learn things in a very unusual way, a way that we don't know about. In my first year of college I happened to come across that summer a boiler factory. The crews were working on twelve boilers at the same time, and it was three shifts of workmen. And those pneumatic hammers were pounding away, driving rivets into the boilers. I heard that noise and I wanted to find out what it was. On learning that it was a boiler factory, I went in and I couldn't hear anybody talking. I could see the various employees were conversing. I could see the foreman's lips moving, but I couldn't hear what he said to me. He heard what I said. I had him come outside so I could talk to him. And I asked him for permission to roll up in my blanket and sleep on the floor for one night. He thought there was something wrong with me. I explained that I was a premedic student and that I was interested in learning processes. And he agreed that I could roll up in my blanket and sleep on the floor. He explained to all the men and left an explanation for the succeeding shift of men. The next morning I awakened. I could hear the workmen talking about that damn fool kid. What in hell was he sleeping on the floor there for? What did he think he could learn? During my sleep that night I blotted out all that horrible noise of the twelve or more pneumatic hammers and I could hear voices. I knew that it was possible to learn to hear only certain sounds if you tune your ears properly. You have ringing in your ears, but you haven't thought of tuning them so that you don't hear the ringing.

Since rapport and response attentiveness were already established with this couple, the senior author was able to immediately structure a therapeutic frame of reference with this story about how the unconscious automatically learns to adjust our sensory-perceptual functioning in an adaptive manner even when we are asleep. He does not tell them in a direct and intellectual manner that they will have to learn to alter their sensory-perceptual functioning. If he did, they might find some issue to argue about or, as so commonly happens with patients who have experienced a great deal of failure, they might immediately plead that they could not alter their functioning; they would not know how to do it, or would not be able to believe that it could happen to them. His stories about himself and the illustrations he continues to present are all established facts that together structure the basic frame of reference which the couple will need for their therapeutic work. He continues now in a rather humorous vein.

Interspersing Therapeutic Suggestions

E: Now this matter of tuning yourself. I spent three months on the Mississippi River and I got invited into a home and I felt so cooped up after being out in the open. Getting into a room, everywhere you look, your looks come to an end. When you read the old-time sailing stories, where you look to the end of the earth with nothing interfering. And the old-time stories of sailors' claustrophobic reactions. Fear of closed spaces.

Also when I got back from that canoe trip . . . have you ever tried to sleep on a soft bed? You are miserable. I had learned to sleep on theground, in brush piles. inside the canoe. My ribs fighting with canoe ribs.

When I got home and had a mattress, that was torture. The Indians did not like, in the early days, the white man's bed. They wanted the ground to sleep on. They wanted comfort. Just nothing but sheer comfort.

On the Tribal Eye program on KAET. Those nomads from Iran. How can they dress with all those petticoats? And be comfortable in the hot sun on those desert plains? And you can get so used to the ringing in your ears that you don't hear it.

I grew up on the farm. I had to be away from the farm for quite some years before I learned the barn smell on your hands when you live on the farm. I never smelled it when I was on the farm. I had to be away from it for a long time before I discovered the barn smell.

R: I guess that is why it is so hard to convince someone who doesn't wash often enough that he has to wash more often. He doesn't smell himself!

E: I can tell you a funny story about that. One year the boy in the next room at the rooming house had a fellow roomer who came from South Dakota. And Hebbie came from Milwaukee. And Hebbie told Lester, ' 'You stink, go take a bath.'' It was the latter part of September and Lester said, But I took a bath last July. I won't need one until at least Thanksgiving Day. But he really stunk, and Hebbie said, You are going to take a bath if I have to put you in the tub myself. What people don't know, that they can lose that pain and they don't know they can lose that ringing in the ears. When I discovered that that barn smell had come back, I could really smell it. I wondered how long it would take me that day to lose it? Then by midafternoon I couldn't smell it. All of us grow up believing that when you have pain, you must pay attention to it. And believing when you have ringing of the ears that you must keep on hearing it.

As the senior author continues with one illustration after another, he gradually begins to intersperse therapeutic suggestion (in italics) about how she can learn to tune out her ringing and he can lose his pain. Because these suggestions are interspersed within a network of stories they are interested in hearing, the patients tend to accept the suggestions (without even realizing that therapy is taking place) particularly since the senior author moves quickly on to another interesting anecdote before they can protest or reject or even think about the interspersed therapeutic suggestions..

Although Erickson has not made any effort to induce a trance in a formal manner, it is evident that his stories are so absorbing the couple's attention that they are actually a bit entranced.

They simply sit quietly with their eyes fixed upon him. They are obviously relaxed and oblivious to anything else that might be going on around them. They are exhibiting a state of response attentiveness that is ideal, for the receptivity will enhance their experience of therapeutic trance.

Accepting the Therapeutic Frame of Reference

E: Now, the pain you feel, where? Where do you feel the pain?

H: Right at the present time, in my foot.

E: Yes.

W: Where there is no foot.

H: Where there is no foot.

E: All right, I had a friend named John. He was a psychiatrist, and we were visiting. He reached down and scratched his ankle. I said, John, that really itches, doesn't it? And he said, Yes. We both knew it was a wooden leg.

H: My understanding is that when I was in the hospital there was a double amputee over there. I saw him twice. I had seen him at the hospital and I had seen him over at Good Sam's taking therapy. But the nurse taking care of him at St. Joseph, when he said his foot itched, she'd reach down and scratch his sheet and relieve it.

W: Where his foot would have been?

H: Where his foot would have been! She would scratch the sheet down there and said that it would relieve it.

After listening to the senior author recount his anecdotes and stories of the relativity of sensations and phantom limb pain, the husband now shows evidence of accepting and joining this therapeutic frame of reference by telling his own anecdote about it. He goes further as he now begins to make an emphatic effort to convince his own wife when she asks a doubting question.

Creating Expectancy by Introducing New Response Possibilities: Phantom Pleasure

E: Like I asked my friend John, So you scratched it, how does your foot feel now? He said, Good. That nurse was very wise. Because you can have good feelings in the foot. Not just painful ones.

H: Oh, I hope so, Doctor.

E: That's what is overlooked in these amputees. They forget that they can also have good feelings.

H: I was at the leg man's yesterday. My leg wouldn't unlock. I went to him. He had three different rooms. No, two different besides mine. In each one they were talking about what can we do for this phantom pain that he got. He said, It is driving me nuts. Of course, I never opened my mouth, because I was in another room. I didn't say I was out here or nothing. I knew I had had relief from what you done before.

E: All right. Now I want to have you two recorded so that Dr. Rossi could include it in the book. Now if you have phantom pain in a limb, you may also have phantom good feelings. And they are delightful.

H: That I haven't had yet.

E: That's right.

H: That I haven't had yet.

E: But you can learn them!

Since the husband obviously accepted the therapeutic frame of reference, Erickson immediately pressed on with a further suggestion of how he can cope with phantom limb pain by converting it to phantom limb pleasure. Erickson introduces pleasure only tentatively as a possibility at this point. The patient certainly is not yet ready for a direct suggestion about experiencing pleasure. When the husband admits he has not experienced pleasure, Erickson utilizes the learning frame of reference he has so carefully developed earlier with his stories. With this background of illustrations he can now confidently say to the husband, But you can learn them! Since the husband enjoyed and accepted all those anecdotes about learning to change sensory-perceptual experiences, he cannot now reject Erickson's direct suggestion about his eventually learning also.

Thus, even before trance experience is formally begun in this session, Erickson has structured the basic therapeutic frame of reference for the husband in such a way that he finds himself accepting it. It is now only a question of when he will begin to utilize that therapeutic frame. When the husband responds with, Oh, I hope so, doctor, we can recognize that a high degree of expectancy for a therapeutic response is being created.

Autohypnosis: Therapy by Geometric Progression

H: But I will say this, that in the afternoon I will lay down for an hour and I just go into a complete trance and I don't think of nothing.

W: After he [H] came to you [E].

H: After I come from you, I think of nothing. And it is not a sleep. I know I am not asleep. But I am in a trance. I have no pain whatsoever. And when I get up, I feel so much different.

E: All right. And your next problem is learning to keep that good feeling a second longer. And two seconds longer. Then four seconds longer. And six! And eight!

H: You know, doctor, you told me, the best that I can recall, when I was over here the other time, start in at twenty and count backward. That is what I do when I lay down. Now I don't recall all of what you said, but I remember something you said about nine, six, and three. I remember that before I went into this trance or whatever you might call it. And I try to think of those numbers each time that I lay down and try to count from twenty backward. I emphasize on that nine, six, and three. But as I say, I am not asleep. I can lay there. It seems to me as though I can lay there forever. Two or three hours, but I am not asleep, I am in a trance. My eyes are closed. I hear nothing. My wife can come in the room and I don't hear her. But after a certain length of time, I'm wide awake.

E: And we had it directly from his lips.

R: Yes. Isn't that beautiful. A good description of trance.

H: That's just the way it is. It has been with me, and I have only been out here since last Monday, wasn't it?

W: I think so.

The husband now acknowledges the senior author's belief in the ability to learn to alter phantom pain sensations by describing his experiences of autohypnosis, which he learned just a week ago. Already he has learned to eliminate pain during the autohypnotic trance. Erickson seizes upon that and seeks to extend comfort for longer periods - second by second. This is one of his favorite therapeutic approaches - geometric progression. It is usually quite easy for patients to experience relief from their symptoms during autohypnosis. The problem is when they come out of it. The senior author then asks them if they can extend their symptom-free condition for one second after trance today. Then double it to two seconds tomorrow. And double it again to four seconds the day after. If they continue doubling the amount of symptom-free time in this geometric progression every day, in eighteen days they will be extending it for more than twenty-four hours.

An interesting aspect of the husband's description of his autohypnotic trance experience is his emphasis on 9, 6, and 3 when he awakens. Erickson frequently trains people to go into trance by counting from 1 to 20 and to awaken by counting backward. He had no conscious awareness on this occasion of having said or done anything special with the numbers nine, six, and three. This appears to be a purely subjective, idiosyncratic response on the husband's part. It is accepted nonetheless as a valid and worthwhile part of his personal experience of trance. Precisely because it is a purely subjective experience, it is perhaps even more valuable in facilitating his trance experience, because in some way or other it utilizes his own internal associations in a constructive manner.

The husband and wife go on now to discuss their caring relationship for each other. Erickson utilizes this to talk about his daughter Roxanna who is studying to be a nurse. The point of his introducing Roxanna soon reveals itself as yet another example of someone who has done well in life because she was willing to learn.

Facilitating the Therapeutic Frame of Reference: Open-Ended Suggestions

H: Of course my wife is very concerned over me. She takes care of me just like she does a baby, you might say. I am concerned over her because she is concerned over me. So. But as she said as we crossed these steps out here a while ago, We are going to make it, we are going to make it together.

E: Well. I tell my wife not to be concerned about me. I'm just in a wheelchair. That's all! I want to put her energy toward enjoying things.

H: She used to be very active. She used to swim. She didn't learn to swim till she was fifty years old.

W: Fifty-five.

H: Fifty-five. She swam five miles without stopping. Won a woman's trophy at the YWCA. She works with the retarded children. And stuff like that. That is what I want her to get back into, instead of thinking that she has to stay at home to take care of me.

W: When he gets able, I will.

H: Well, I think I am able enough for you to start it. I really do.

W: When I worked with a little retarded child, it did me more good than it did him.

E: Where, in Sun Valley? W: A little boy on the piano.

H: My wife would play a piece, and he would get down and look all round that piano and everything. She would put it on her cassette. When she would get through, she would say, Now Kenny, you play it.

W: The piano would be in the auditorium. And I would say, Now Kenny, just pretend like you are playing before a crowd of people. Close your eyes and smile. He would close his eyes and smile. Then sit there and play.

E: All right.

H: She enjoyed it and I enjoyed her doing that type of work. It done her more good than it done the child. It really did.

E: [Gives a detailed account of how his daughter put herself through many work and training experiences before she was certain she wanted to become a nurse.] Now my daughter was willing to learn.

W: Right!

E: Your husband knows how he can feel pain in that foot. He saw another patient learn how to get comfortable from a nurse scratching a sheet.

H: That he did.

E: That's correct. My friend John said, It feels so good when I scratch my wooden leg. He had his Ph.D. and his M.D.

R: Scratching a wooden leg!

W: Sounds fantastic, doesn't it?

R: Yes, really! The power of the mind!

E: A true story. John was marvelous. And I discussed with him the importance of having nice feelings in your wooden foot, your wooden knee.

H: You discussed what, now?

E: I discussed with him the importance of having good feelings in the wooden foot, the wooden knee, the wooden leg. Feeling it to be warm. Cool. Rested. But most patients with phantom limb pain just think of only the pain. And if you can have phantom pain, you can have phantom pleasure.

H: Oh, boy!

W: It sounds good, dear, I never thought of it.

H;. Yeah, I'll take the pleasure.

R: All right, sir!

E: And you saw someone else demonstrate scratching your sheet. It felt good. And that nurse was very successful.

With these remarks the senior author reinforces the therapeutic frame of reference with further examples of altering phantom pain to warmth, coolness, rest, and the possibility of pleasure. He is introducing many therapeutic possibilities in an open-ended manner. At this point Erickson still does not know which of these response possibilities the husband's system will be able to utilize. He will allow the husband's own individuality to choose between them. This is a basic principle of therapeutic suggestion: The therapist offers possibilities, and the patient's unconscious chooses and mediates the actual response modality of therapeutic change in keeping with his own capabilities. Therapeutic suggestion cannot impose something foreign on patients; it can only help patients to evoke and to utilize what is already present within their own response repertory.

The conversation now shifts to visiting nurses, their medical doctor, and the heart pacemaker that the husband has. The senior author utilizes this latter topic to give further illustration of our ability to alter physiological functions such as heart rate and blood pressure.

Further Structuring of the Therapeutic Frame of Reference: Altering Heart Rate and Blood Pressure

E: All right. Now a doctor from Michigan and one from Pennsylvania were visiting me, and my daughter Roxanna was then taking blood pressures all over the city. She asked them if she could take their blood pressure. And they both said, Do you want it as it is normally, or would you like it ten points lower or ten points higher? She said, All three. So she got the normal reading and then they told her she would find out whether it is lower or higher. She found out.

W: How could they control it?

E: Blood pressure changes according to where the blood is. When you go to sleep at night, your blood drains out of your brain and into a plexus, a collection of blood vessels in the abdomen. You wake up and blood pressure is increased and shoves blood back into your brain.

H: That is what I have to do every morning, first thing I go in and she fixes me a cup of coffee. I take my pulse and it averages between seventy and seventy-one every morning. They told me if it got below sixty-nine to call them. My granddaughter lives up in Flagstaff, and I haven't been up there since they bought a business and are buying a home. I asked my doctor if I could go up there. He said, Well go up there for an hour and a half or two hours, but be very careful with your heart condition and things. Well, I went over there an hour and half, and it was hard to breathe from there on down. I could only breathe from here on up, you might say. So they said let's get him to the emergency hospital, and I said no, I didn't want to go to an emergency hospital. I wanted to go home. So after we hit around 3,500-4,000-foot level, it began to come back. It was down to fifty-nine. It was down to fifty-nine. Then it came up a little bit when I came over Sunset Point. That is 5,000-foot altitude. I found I can't go any higher than that altitude.

W: I never feel it.

E: Now my friends have experimented, and they can raise the heartbeat for 5,000 feet or 10,000 feet voluntarily.

W: Really? Imagine that.

E: And I wanted your husband to realize that there is a lot he can do for himself. A friend of mine said, I have never been able to blush in my whole life. Will you help me to learn to blush? I told him I would. I often dropped by there in various hours of the day, and his wife was my secretary. One evening I dropped in when they were at the table. We exchanged news and all of a sudden I said, Bill! What are you blushing about? He turned bright red. Half an hour later he said, Please turn it off. My face is still burning.

W: Sounds impossible, doesn't it?

E: But it isn't! Have you ever lived where it is cold weather?

W: Yes.

E: Well, you sit in a warm room and go into the cold, what happens? Your nose gets hard.

W: A complete change.

E: Your blood vessels in your face have been turning on and off. You learned that in the wintertime. Yes. You have got that learning. Ordinarily people don't use it. But this Michigan doctor and Pennsylvania doctor had worked with me, and then they started using the thing that they already knew but had never thought of using. You run, your blood pressure goes up. You rest, your blood pressure goes down. Your heart rate can go up, it can go down. You can think about increasing your heart rate and you can speed it up. And you can do it comfortably and easily. So long as you know that you can do it. And that is why I am having you here today. Just to give you more information about yourself.

In these further examples, the senior author gives more suggestions about controlling physiological functioning. He deals with the important problem of H's coping with minor variations in the functioning of his pacemaker. Such variations, when they are not expected and understood, can panic patients and worsen their condition. Whenever he deals with symptom problems, Erickson always casually mentions how a momentary or temporary return of a symptom can be a normal signal about the body's functioning rather than the persistent return of the symptom or illness per se. This forestalls many lapses back into illness. In his example of blushing Erickson gives a humorous illustration of his surprise approach to altering physiological functioning (Erickson, 1964; Rossi, 1973; Erickson, Rossi, and Rossi, 1976).

Trance Induction: Modeling Trance Behavior

E: [To H] Now I would like to have you go into a trance. [To W] Watch him now.

Pause as the husband adjusts his body comfortably, closes his eyes, and goes into a trance. Just at this critical moment a youth from the street knocks loudly on the door of Erickson's office, opens it, and boldly invites us to attend his Baptist church. All of us are startled by his sudden intrusion except for H, who shows absolutely no reaction as he continues with his trance. In asking the wife who has never experienced trance to watch her husband enter trance, Erickson is using one of his favorite approaches to trance training. He simply has the new subject watch another more experienced subject go into trance.

Facilitating Normal Variations in Physiological Functioning

E: I've seen variations in blood pressure already. Now he wants to keep the heart rate about seventy. But it is all right when sleeping for his heart rate to be less than seventy. In the waking state, yes, seventy is all right, seventy-two is all right. If it drops below sixty-nine in his sleep, that's all right too. If it drops to sixty-eight, that is all right too. There is no occasion for alarm because the heart normally slows during sleep, and I don't want him to keep his heart at the waking level of beating. Now the heart can slow down in different ways. It can beat the same number of times per minute, but beat so it does not push as large a volume of fluid. It can beat the same number of times but beat less blood through the veins. He needs less blood circulating in his body when he is asleep, so the heart does not need to beat as hard as when he is awake. And he can regulate that. Now as you see, his entire body is at rest, and in the trance he can let one arm be awake while the rest of his body is in a trance. He can let his right leg go into a trance while the rest of his body is awake.

The senior author immediately notes a variation in H's blood pressure as he enters trance from the variations in his pulse that can be seen (usually some place on the temple, throat, arm, etc) by therapists who have trained themselves to look for it. His mentioning this variation tends to ratify trance as an altered state and lead into therapeutic suggestions about the normal variations to be expected in his heart rate. Note the easy manner with which the senior author is open-ended in his suggestion to permit the heart to vary in its functioning in any way that is necessary (number of beats, volume of fluid). In mentioning how one part of the body can be awake and move while the rest of the body is immobile in trance, he is indirectly suggesting how patients can spontaneously shift for comfort now and then without feeling they are thereby waking up.

Dissociation Training

E: [To W] He said that he could be in a trance and you could come in and he would not know it. And Dr. Rossi knows that in a trance state I have a subject here, oh, she and I are here, but he isn't. She can't see him, she can't hear him, but she can see and hear me. In other words, human beings can isolate various parts of the body.

With these remarks addressed to the wife Erickson is giving indirect suggestions to the husband for learning how to dissociate one's attention or a part of the body. Such dissociations are useful in facilitating trance depth as well as coping with symptomatic problems.

Indirect Open-Ended Suggestions

E: With enough experience he can go to Flagstaff and take with him his breathing habits of Phoenix. Because you can take habits with you. That's one of the problems that the airline pilots have. They all grow up with clock habits. And their sleep cycle is disturbed. They have to learn how to get a changing sleep cycle. I'm talking to you while he [H] is learning something. He doesn't know what he is learning, but he is learning. And it isn't right for me to tell him, You learn this or you learn that! Let him learn whatever he wishes, in whatever order he wishes.

This is another illustration of the senior author's indirect and open-ended approach to offering therapeutic suggestions that permit the patient's unconscious to find its own individual mode of optimal functioning.

Facilitating Unconscious Search and Unconscious Processes: Suggestion by Surprise and Association

E: Now I mentioned the ringing in your ears. I mentioned blushing. I mentioned breathing. Elevating blood pressure, lowering it. You always have to be aware, and we know a lot of things we don't know we know. My friend Bill said he wanted to blush. He never had. I knew that he could get pale. He could get a red face in the heat. Blood would decrease in his face when he went to sleep. He had all those learnings. All I did was say something that took him by surprise. And he reacted that way. He did not know how to turn it off. But I so surprised him that the automatic working of his body wasn't in gear. All I said was OK, and his body went back into automatic gear.

W: Yes

In an indirect manner the senior author associates W's ringing-ear problem with the previous illustrations of successful coping with symptoms by learning to alter sensory-perceptual and physiological functioning. If he had directly told her at this point that she would have to learn to control the ringing in her ears, she would almost certainly have demurred and protested that she did not know how. She would be right. Certainly her conscious mind does not know how to alter the ringing. The control she will learn is still an unconscious potential at this point. By conversationally associating the ringing problem with the other anecdotes of successful perceptual alteration, however, the senior author is indirectly creating an associational network or belief system that will later enable W to accept further suggestions that will evoke and utilize whatever unconscious mechanisms she has available to effect a therapeutic transformation. Before she has any chance to discuss and possibly reject even this mild association, Erickson immediately shifts his remarks to the husband. Since she is intensely interested in learning trance by watching her husband, the wife's conscious attention is distracted to him, and the therapeutic association that Erickson just gave her remains lodged within her unconscious. This therapeutic association may now automatically begin a process of unconscious search for the unconscious processes that will eventuate in the therapeutic transformation to be experienced later as a hypnotic response.

Direct Suggestions in Trance

E: [To H] Now listen to me because you can listen to me. You can have nice feelings in both feet, in both legs. You can enjoy having your heart beat strongly and gently. You can learn the feelings of breathing, the feelings of breathing that you have in Phoenix. If your wife didn't learn swimming until she was fifty-five, I can tell her one thing she learned as soon as she got into the water. First time she went into the water up to her neck, she found it difficult to breathe.

W: I had to learn to relax.

E: And small children wading into the water find their breathing gets choked. And that scares them. After a while they learn to breathe with that water pressure against their chest. And when they learn to do that, then they don't use that learning outside the pool. As soon as they get back in the pool, they use that water pressure learning so they breathe normally. Now he pays attention in the back of his mind to his Phoenix breathing patterns, habits, and when he goes to Flagstaff, he can keep on using those same muscle patterns, muscle habits. Now in med school when you got into an air chamber with decreased air pressure and you notice how your breathing changes, you pay close attention to it. When you come out, you notice the change. You can go back in the air chamber and breathe comfortably because you start using your new breathing patterns.

Erickson has carefully structured a therapeutic frame of reference about our ability to alter body functions before and during the initial stages of trance. H's response has been so positive that Erickson now judges that it is appropriate to drop a few direct suggestions into that therapeutic frame. Even now, however, he elaborates the direct suggestions with a further illustration about learning to alter body functioning while swimming. His choice of this particular example is very apt because it is very meaningful to both H and W; both have recently spoken of it. By choosing such illustrations close to the patients' personal life experiences, the therapist can make a sounder bond of contact with patients' inner lives and real potentialities.

Trance Induction and Facilitating Unconscious Processes

E: [To W] Now suppose you lean back and uncross your legs. Look at that spot there. Don't talk. Don't move. There is nothing really important to do, except go into a trance. You have seen your husband do it. And it is a nice feeling. Your blood pressure is already changing. You may close your eyes now [pause as W closes her eyes and visibly relaxes her facial muscles] and go deeper and deeper into the trance. You do not have to try hard to do anything. You just let it happen. And you think back; there are a goodly number of times this afternoon when you stopped hearing the ringing. It is hard to remember things that don't occur. But the ringing did stop. But because there was nothing there, you don't remember it.

Having prepared her for trance induction by using her husband as a model, the senior author now induces trance with a few instructions that have three objectives: to fixate attention ( look at that spot ), to depotentiate her habitual frames of references ( Don't talk. Don't move. There is nothing really important to do ), and to give free reign to her unconscious ( go into a trance ).

He then states a common though little recognized fact about the experience of symptoms. Symptoms may seem constant and unchanging. Yet invariably there are moments when we are so distracted that they are outside the central focus of our awareness. This automatic mental mechanism that shifts our attention and thereby attenuates and usually completely obliterates the experience of the symptom is evoked as the senior author describes it. This little-recognized fact is usually received with a sense of surprise by patients - a surprise that further depotentiates their old symptom-laden frame of reference and initiates a search on an unconscious level for those unconscious processes that may now be utilized for symptom relief.

Relying upon Unconscious Learning: The Conditions for Direct Suggestion

E: Now the important thing is to forget about the ringing and to remember the times when there was no ringing. And that is a process you learn. I learned in one night's time not to hear the pneumatic hammers in the boiler factory - and to hear a conversation I couldn't hear the previous day. The men had been told I had come in the previous evening, and I talked to them and they kept trying to tell me, But you can't hear us, you haven't gotten used to it. And they couldn't understand. They knew I have only been there a short time - one night - and they knew how long it had taken them to learn to hear conversations. They put their emphasis upon learning gradually. I knew what the body can do automatically. [Pause] Now rely upon your body. Trust it. Believe in it. And know that it will serve you well.

The senior author now strongly emphasizes that symptom changes will take place via an unconscious process. It is important for the conscious mind to rely upon your body, trust it, and so on. He drops the direct suggestion to forget about the ringing'' into the frame of reference he structured before trance induction in his story about learning not to hear the pneumatic hammers in his sleep at the boiler factory. Thus when direct suggestions are used, they are always placed like a key in the lock of a frame of reference that was previously structured by the therapist and accepted by the patient.

We can summarize the requisite conditions for the successful use of direct suggestion as follows:

1. - creating frames of reference as an internal environment or belief system that can accept the direct suggestion.

2. - patient's reliance on unconscious processes to automatically mediate the suggestion and new learning that is needed.

3. - therapist's partially evoking and thereby facilitating the utilization of such unconscious processes by illustrating them in ways that are personally meaningful in the patient's actual life experience.

Further Suggestions and Illustrations: Symptom Substitution; Synesthesia

E: Another patient of mine with ringing of the ears, a woman of thirty, said that she had worked at a war plant where there was music all day long,

and she wished she could have that music instead of the ringing. I asked her how well she remembered that music. And she named a great number of tunes. So I told her, use that ringing to play those tunes softly and gently. Five years later she said, I still have that soft gentle music in my ears.

She worked at a war plant in Michigan. You described a little boy and piano playing and the cassette, and you demonstrated with your hands the

way he moved his fingers. Part of the pleasure of seeing him, hearing him, became a part of your finger movements.

[Pause]

And you can put that part of pleasure with your finger movements into your ears. And you can do it so easily, so gently, without trying, without even noticing. And you can really enjoy good feelings, good sounds, and good quiet.

[Pause]

And you both can breathe for us, and neither of you need to be concerned about the other. You need to enjoy knowing each other. And enjoying what you can do as meaningful to you.

By now the reader can easily recognize how the senior author is offering further suggestions and illustrations of the sort of sensory-perceptual transformations that may effect symptom relief. As we will see later, by the end of this session, W was actually able to utilize one of these illustrations successfully for symptom relief. Notice again how carefully the senior author intersperses his suggestions with the woman's own relevant life experiences in pretending to teach the retarded child to play the piano. In suggesting, You can put that part of pleasure with your finger movements into your ears, he is actually trying to evoke and utilize unconscious processes of synesthesia whereby pleasure from one sense modality (kinesthetic or proprioceptive sensations from the fingers) could be shifted to another (her auditory perceptions).

Awakening from Trance: Facilitating Unconscious Processes by Learning and Utilizing Hypnotic Pain Control Without Awareness

E: You go into a trance, I suggest, by counting to 20, and awaken by counting backward from twenty to one, but each person should go into a trance in the way he learns naturally by himself, and you have learned an excellent way and it's your way and be pleased with it and be pleased with extending usefulness of that trance in many different ways. You both can learn from each other without trying to learn. There are so many things we learn from others, and we don't know we are learning. And our main, very difficult learnings we achieve without knowing that we are achieving those learnings. And you both are very responsive people. Which in less technical language means you both can learn easily things about yourself and learn them without needing to know that you have learned them. That you can use those learnings without needing to know that you know those learnings. I am going to ask both of you to awaken gently and comfortably.

In this awakening procedure the senior author incorporates many direct suggestions to emphasize learning without awareness. Ideally, learning to alter and transform the sensory-perceptual aspects of physical symptoms is an unconscious process that proceeds on an unconscious level. Consciousness usually does not know how to cope with these transformations and is best eliminated from the process. Erickson's last suggestion, That you can use those learnings without, needing to know that you know those learnings, contains some subtle implications. The patients can learn to use pain-transforming mechanisms on an unconscious level to such an automatic degree that they need not even know they are successfully dealing with pain. Since consciousness is not even aware of the automatic operation of these newly learned pain-control processes, consciousness need not know about the presence of current and future pain. The senior author has emphasized that pain has three components: (1) memories of past pain, (2) current pain, and (3) anticipation of future pain. His last suggestion can be understood as a means of coping with the latter two without giving consciousness an opportunity to dwell on the process and possibly interfere with it. This approach is to be used with appropriate clinical caution. With this couple the pain did not serve any useful function as a signal about body malfunction that their physician needed to know. Thus their pain could be eliminated completely for optimal relief. When pain is an important signal about a body process that the physician needs to know about, then the presence of pain should certainly not be eliminated from consciousness entirely. In such cases the pain can be transformed into a warmth, coolness, itch, numbness, and other symptoms. The aversive quality of pain is thereby eliminated, but its signal value is maintained.

Facilitating Amnesia by Structuring an Associative Gap and Distraction

[Pause as they both reorient to their bodies by blinking, stretching, yawning, and so on.]

E: My daughter spent three years in Africa. She is married to an Air Force officer. And he was assigned to Ethiopia. Shortly after her arrival in Ethiopia, she remarked to her husband, You see that statue? That is just exactly what my Daddy likes. Yes, she knew I would like it. It was a statue of a woman, and how can you describe it?

[Shows statue to the group]

R: It's very unique.

E: It is a weird looking thing.

W: She knew you would like it?

E: She knew I would like it! I was delighted when I saw it. And my son picked out that little rug right there on the floor. He mailed it to me for a birthday present ten years ago. He knew I would like it. When I unrolled it, my two young daughters in grade school commented, That is not North American Indian? Is it South American Indian? My wife said, It isn't Indian! I said, It is Hindu. . . .

The senior author demonstrates two means of facilitating hypnotic amnesia in these few remarks made immediately upon the awakening from trance. He first returns to a topic of conversation about his daughter that came just before trance induction. By picking up an associative thread from this period, the trance events are placed into an associative gap. Trance events and associations cohere together, but there are no associative bridges to the patient's mental framework (a conversation about Erickson's daughter in this case) which occur immediately before or after trance. Because of the relative lack of associative bridges, trance events tend to remain dissociated from the patient's habitual frameworks and may thus become amnesic. The following diagram may clarify the matter (Erickson, Haley, and Weakland, 1959), where the upper line is a conscious memory line with only a small gap that tends to cover the lower line of trance events.

Milton C. Erickson and Ernest Rossi - Hypnotherapy - an exploratory casebook-1.jpg

The senior author's second approach to facilitating amnesia is to distract the patient from trance associations by introducing topics of conversation that are far distant from the trance work that has just been completed (in this case gifts, rugs, Indians.) These distracting topics also tend to prevent the development of associative bridges between the contents of trance and the contents of the awake state, thereby facilitating an amnesia for trance events. This amnesia is often therapeutically valuable, since it prevents the patient's limited and maladaptive belief systems from later working and possibly undoing the suggestions accepted during trance. The amnesia also tends to vividly ratify trance as an altered state for the patient.

Spontaneous Acknowledgment of Therapeutic Change

H: Well, doctor, I'll say this. This has done as much good as that other one has done. This is going to be wonderful.

E: You'll be surprised at all the new learnings that both of you will develop.

W: Good, Good.

E: We will call it a day.

[The session is ended, but just before she leaves the woman comments as follows]

W: When I think of the ringing in my ears now, I'm beginning to think of a melody that I play. One of several that I like very much. Now the ringing is still there but the melody is there also.

This acknowledgment of an immediate experience of therapeutic change came spontaneously from both patients. This is the ideal situation, where the therapist does not have to ask about the change and by doing so possibly distort the change process itself. Some patients might take such a question as implying a doubt in the therapist's mind, while others would tend either to exaggerate or to underestimate the amount of change experienced.

The husband expresses an important and valuable expectation of present and future therapeutic gains ( this is going to be wonderful ), while the wife, more analytically, describes how a melody is being added to her ringing. It is hoped that future work may entirely replace the ringing with the melody. Since both spontaneously acknowledge a satisfactory therapeutic change, there was no need for the senior author to end this session with any further evaluation and ratification of therapeutic change. (This final stage of evaluation and ratification will be well illustrated in our next case.)

Case 2 Shock and Surprise for Altering Sensory-Perceptual Functioning: Intractable Back Pain

This is another case where Erickson worked simultaneously with husband and wife. This couple was in their early twenties, however, and they came to therapy in a very negativistic and doubting mood. Because of their extreme doubts Erickson used a very dramatic approach to establish rapport, response attentiveness, and trance induction.

Archie and Annie were high school sweethearts. They were idealists who went ahead with their plans to be married even after Archie's back was broken and his spine severed in the Viet Nam war. Archie had returned to civilian life permanently in a wheelchair with intractable back pain. His physicians said he would have to learn to live with it. They had warned him against any sort of black magic with hypnosis, which was certainly not worth his time. Archie and Annie nevertheless wanted to try, although by the time they came to their first interview they were in a hostile, negative, and doubting mood regarding their prospects.

The senior author's first task was to recognize and accept their hostility and doubt and, if possible, actually to utilize it in some manner. He had to accept their negative frame of reference and yet introduce his own belief in the potential value of hypnotherapy. Erickson watched a few of Archie's spasms of pain and recognized that they were of psychogenic origin, much like that of phantom limb pain. After listening to the outline of their story, he decided to demonstrate a dramatic form of trance induction with Annie in order to orient Archie to the genuine therapeutic potential of hypnosis.

Trance Induction: Displacing and Discharging Hostility and Doubt

Erickson first asked Annie to stand in the middle of a small Indian rug about a yard in diameter that was on his office floor. He then proceeded with an unusual trance induction.

E: Annie, you are not to move off that carpet. And you are not going to like what I am doing. It will be offensive to you. It will be offensive to Archie. Now here is a strong oak cane, Archie. You can hold it and you can clobber me at any moment that you think I am doing wrong. You won't like what I'm going to do, Archie, but watch me carefully and clobber me just as soon as you think it is necessary.

Now I'm going to take this other cane and you watch what I'm doing. You will feel what I'm doing Annie. Archie will see what I'm doing. I will stop as soon as you close your eyes and go into a deep trance.

The senior author gently and tentatively touched about her upper chest area with the tip of his cane and then began to gingerly push the upper part of her dress apart, as if to expose her breasts. She closed her eyes, remained rigidly immobile, and apparently went into a deep trance. She had to escape the unpleasant reality of that cane. As soon as she closed her eyes and manifested a trance state, Archie was so surprised he almost dropped his cane.

What are the dynamics of such an induction? With his apparently shameless poking about Annie's dress, Erickson was channeling their very evident hostility and vague doubts about hypnosis in general into a very specific rejection of Erickson's initial behavior. Annie was so constituted psychologically that she had no alternative in the situation.

The poking cane certainly fixated her attention, and the shock of it all certainly depotentiated whatever conventional mental framework she had about how doctors behave and what hypnosis was about. As she stood there, desperately uncertain about what was happening, she was sent on an unconscious search for the trance-inducing processes within her own mind that would release her from her embarrassment. The senior author said he would stop only when she went into trance. She could only escape the unpleasant poking by going into trance. She need not reject the whole situation outright, because, after all, her husband was right there with a stout cane supposedly protecting her. By giving Archie the cane, the senior author was very carefully giving him a channel through which he could focus his hostility. He was also fixing Archie's attention so intently that the young man was in that state of intense response _; attentiveness characteristic of therapeutic trance as he watched the unorthodox proceedings with disbelief. Thus his general doubt and disbelief about hypnosis could now be channeled, displaced, and discharged onto the apparently ridiculous behavior he was witnessing. Without quite realizing it, he also became convinced that Erickson could perform the unspeakable, the unorthodox, and, by implication, an unusual cure.

A Two-Level Posthypnotic Suggestion to Utilize and Depotentiate a Doubting Conscious Framework

E: Annie, when you awaken, you can sit in your chair, and no matter what you think, whatever I say is true. Do you agree to that?

[Annie nods her head yes repetitiously in the slight and slow manner characteristic of the perseverative behavior of trance.]

Whatever I say is true, no matter what you think.

This was a carefully formulated two-level suggestion: (1) No matter what you think is a phrase recognizing her conscious doubts that enables Erickson to focus her attention by utilizing her own mental framework of doubt and resistance. She could think whatever she liked within this doubtful frame. At the same time (2) on an unconscious level she was to make true or real whatever Erickson was to later suggest. We could also say that two realities or belief systems were permitted to coexist side by side in a more or less dissociated manner: (1) The conscious belief system of doubt and resistance to hypnosis that she brought to the therapy situation, and (2) the new reality of hypnosis Erickson was introducing in such a suddenly shocking manner that neither she nor her husband could properly evaluate and understand it. She was permitted to indulge in her previous belief system even while Erickson's reality was being introduced in a manner that she could not avoid or resist. Whatever the doubts or resistances of her previous beliefs, she was certainly not prepared to cope with a cane probing her dress while her husband stood poised with another heavy cane ready to clobber the crippled doctor. Since her conscious mental framework could not cope with the situation, her unconscious had to intervene with the appropriate responses of going into trance and accepting Erickson's suggestions.

The senior author assessed and deepened her trance by obtaining her positive response to his two-level posthypnotic suggestion. He then asked her to awaken and sit down. She sat down with a look of expectation, doubt, and hostility. He then addressed her as follows.

Truisms, Implication, and Not Knowing to Initiate an Unconscious Search

E: Now you are awake, Annie. You don't know what has happened. You can think that you wish you knew, but you don't know.

With this the senior author was stating the obvious. Certainly Annie did have questions on her mind about what, if anything, had happened. Thus the truth of the first part of the statement, You can think that you wish you knew opened a yes or acceptance set for the critical suggestion that follows, but you don't know. This suggestion is critical because it implies that something important did happen, but she does not know what. The implication that something happened means she may no longer be what she has always experienced herself as being. The something that happened may be hypnosis; it may mean she now will be able to experience whatever reality Erickson is going to suggest. The not knowing thus opens a gap in her belief system that initiates an unconscious search for the internal resources (unconscious processes) that will be needed to carry out Erickson's further suggestions. Not knowing thus facilitates the utilization of inner resources that she had never been able to contact previously in a voluntary manner.

Surprise Question for Not Doing

E: Aren't you surprised you can't stand up?

With this suggestion in the form of a question, Annie did indeed experience amazement at not being able to stand up. The senior author said she would be surprised, and she certainly was. His question quickly filled the gap and expectation that had been opened in her belief system by setting into operation mental processes that somehow prevented her from standing up. Annie probably did not know why she did not stand up. Neither was she aware that the senior author had also prescribed her reaction of ''surprise at not being able to stand up. Certainly it was true that she would be surprised at not being able to stand up. His question was thus another obvious truism that anyone would have to accept. Even without the previous gap having been opened in her belief system, this question of surprise could stand as beguilingly effective suggestion that anyone would have to accept as true. And most would also experience its implication of the involuntary behavior of not being able to stand.

Self-Test for Anesthesia

E: No matter how hard I struck you with this cane, you would not feel it. And suppose you take your hand and hit yourself hard on the thigh. It's difficult for me to come over and do it myself, so go ahead. Hit yourself as hard as you can on your thigh. It won't hurt!

With this Annie did indeed strike a numb thigh and was startled at the effect. She replied, I felt it in my hand but I didn't feel anything in my leg. Having successfully experienced one fairly easy hypnotic phenomenon in not being able to stand, Erickson judged that she was now ready to experience the really important phenomenon of anesthesia. He made a veiled threat with the thought of striking her with his fearsome cane, so that she cannot help but feel some relief at being permitted to test the anesthesia by herself. Erickson then offers further relief with the fact that he really cannot come over to her (since he is crippled) and thus reinforces her further for a successful self-test of anesthesia. Erickson (Erickson, Rossi, and Rossi, 1976) has stated, The unconscious always protects the conscious. Certainly Annie did feel a need for protection at this moment. The protection came from her unconscious, which effectively mediated the neuropsychological mechanisms that permitted her to say she had indeed experienced an anesthesia in her leg. Pressing on, the senior author now extends the anesthesia further.

Generalizing Anesthesia

E: Now Annie, you can hit your thigh again but won't feel it in either your thigh or your hand.

The senior author now generalizes her successful anesthesia of the thigh to her hand by associating them together in this strong direct suggestion. Annie then slapped her thigh again and exclaimed, I heard that slap, but I didn't feel it in my hand or my thigh. Thus Annie spontaneously confirmed the reality of the anesthesia to her husband. He could doubt Erickson's explanations, but he could not doubt his wife's reactions. Hence the negative attitude induced by his physician was not disputed by his witnessing Annie's experience - it was depotentiated. That is, he was now experiencing a suspension of his previously doubtful and disbelieving frame of reference. Before he could reassert his doubt, Erickson quickly introduced him to a formally labeled trance.

Compound Suggestion Introducing Trance

E: You heard that, Archie, you can go into trance now.

Annie's experience was an effective use of modeling hypnotic behavior for her more resistant husband. The senior author then formally induced trance with a compound statement. You heard that was an undeniable truth that opened an acceptance set for the suggestion, Archie, you can go into trance now. Archie could not deny the reality of his senses regarding his wife's experience, and thus had to accept Erickson's suggested reality of trance.

Utilizing Previous Sense Memories to Replace Pain: A Pun

E: Now, Archie, you've had many long years of happy feelings. Why not get those happy feelings back? You've had all the pain you need.

With such suggestions the senior author began to evoke Archie's sense memories of previous years of good body feelings before his back injury. These memories of good body feelings will be utilized to replace his current pain. Notice the therapeutic pun contained in the phrase happy feelings back. Without realizing it Archie was receiving associations of happy feelings with his injured back.

Realistic Expectations of Pain Relief and Booster Shots

E: I cannot guarantee you against all future pain, but I can tell you to use pain as a warning.

With such suggestions Archie was able to experience considerable relief from pain. A few months later he caught the flu and telephoned Erickson for a booster shot, since with the flu there was a recurrence of back pain.

R: Why was there a recurrence of back pain with the flu? Were his body and mind debilitated so he could no longer maintain the hypnotic suggestion of good feelings? Is it the same situation as with you, Dr. Erickson, that when you go to sleep you sometimes lose your own hypnotic control over your body pain? [E's pain is due to constantly atrophiating muscles associated with his second bout with anterior poliomyelitis.] Is hypnosis being mediated on the highest cortical levels which are sensitive to body illness as well as sleep?

E: Yes, just as I induce a trance on the highest cortical level.

R: People really are not asleep in trance; in fact, there is a high degree of mental activity. Perhaps those who say everyone cannot experience trance means you cannot put everyone in a sleeplike state of being an automaton responding indiscriminately to everything that is suggested.

E: Yes, you cannot put everyone into such a passive or submissive state.

R: By hypnosis and trance you mean focused concentration, focused attention. You certainly can facilitate that with anyone whose motivations and needs you understand.

E: Therapeutic trance is focused attention directed in the best manner possible to achieve the patient's goals.

Case 3 Shifting Frames of Reference for Anesthesia and Analgesia

E: When I want a patient to develop an analgesia, I'm very likely not to mention this question of analgesia. I'm very willing to let the patient tell me all about that pain until I can see from the expression on his face that he thinks I understand. I'm not averse to saying a few things, little things that makes the patient think I do understand. And then I'm very likely to ask him some simple question that takes him far away from this question of the pain: Where did you spend last summer? The patient can be rather surprised at that question about last summer. Last summer he didn't have that pain. We can go into the question of the pleasures and joys and satisfaction of last summer. Emphasize comfort, physical ease, joys, and satisfactions, and point out to the patient how nice it is to continue to remember the joys and satisfactions of last summer, the physical ease of last summer. When the patient seems to be getting just a little bit edgy, I remind him of when he was rowing the boat and got that blister on his hand. It hurt quite a bit but fortunately healed up.

I haven't been afraid to mention hurt or pain or distress, but it is far away from that backache the patient started telling me about. I've mentioned pain from a blister due to rowing a boat last summer and I haven't been shocked by that uneasy expression on his face. Because you see in hypnosis your task is to guide the thinking and the association of ideas that the patient has along therapeutic channels. You know very well that you can have a painful spot on your body and go to a suspenseful movie and lose yourself in the action on the screen and forget all about that pain in your leg or the pain in your arm, aching tooth or wherever. You know that, so why not do exactly the same sort of thing with your patient? If you are operating on a patient in your office and you are aware of the fact that it can cause pain, you can direct your patient's thinking to an area far removed from the pain situation.

I'm thinking of a patient of mine who said, I'm afraid to go to the dentist, I agonize so much, I perspire so frightfully, I'm in absolute misery. I asked the patient immediately, Did you do that as a child?

I was listening to her complaint about pain, anxiety, distress, and I asked her what she did in her childhood. I made good contact with her by talking of the distress she was interested in, but I shifted to another frame of reference - childhood. She now talked about her childhood distress, but that was so far away that it was less disturbing and she felt a bit more comfortable. My next step was to ask her what her favorite pleasure was as a child. Now, how do you get from pain, anxiety, distress, to pleasure as a child? In this case it took only two associative steps. It was so delightful to switch and discuss with me a favorite activity of her childhood. Now she discussed this pleasure in immediate connection with my first question of her experience of distress in childhood. By that immediate succession of questions I tied the two together - distress and favorite activity.

After she told me all about her favorite pleasures as a child, one in particular, I suggested that when she went to the dentist's office, she should really settle in the dental chair. As she really squirmed around in the chair and really felt her seat on the chair seat, her back on the back of the chair, her arms on the arms of the chair, and her head on the headrest, she would have an overwhelming recollection of her favorite childhood activity that would absolutely dominate the entire situation. Now, what had I done? I had taken the painful realities of the dental chair, squirming around trying to get a nice comfortable seat (and I wiggled around in my seat to role-play the way I wanted her to find herself in that dental chair), and associated it with one of her favorite childhood activities. The thing that she remembered was playing in the leaves on the lawn. In the autumn you can build great big houses out of the leaves, nice pathways through piles of leaves, you could bury yourself in the leaves. You could squirm around and get nice and comfortable in those leaves and the rest of the real world would seem far away.

With that she simply went into a very nice anesthetic trance in the dentist's office without any direct suggestions for anesthesia. Now and then the dentist would ask her some stupid question when she really wanted to think about the leaves. The dentist thought that she was an awfully cooperative patient. Mentally she would notice that here was some stupid person trying to talk to her when she was burying herself in the leaves, probably some grownup yelling at her, but she was more interested in the leaves. She could have dental surgery done and not be bothered by it.

You can achieve anesthesia indirectly by shifting the person's frames of reference. In this case the critical shift was to, What was your favorite activity as a child? And then I could really elaborate on that. In other words, you very carefully raise a question. You raise it in such a way that you can slide past the difficulty and start up another train of mental activity, of emotional activity, that precludes the possibility of feeling pain. Some of my sophisticated subjects with training in clinical psychology and psychiatry, that I have used as subjects, will pick apart the technique that I have used on them. They then recognize the validity of it from their own experiences. They will have me employ precisely the same techniques on them again because they know that they are human and that you can do the same thing with pleasure, over and over again.

I think it is an error to always strive to get an anesthesia or an analgesia directly. I think you should be willing to accomplish them indirectly because every time you ask somebody Forget that this is a watch, you're asking them to do a specific thing - to forget - to forget what? A watch. Now, remember, forget that watch. That's what you're saying when you say,'' Forget the watch. But you can ask them to look at this, an interesting thing. It rather amuses me. It's rather fascinating how you can look at something and become tremendously fascinated with it, and then the topic of conversation changes, and you drift far away to that trip you had in Europe. Now what was it I came up here for? You drifted far, far away from your original preoccupation because you started following your different trains of thought.

Now the next thing that you should bear in mind is that when you take away the sense of feeling, anesthesia or analgesia, you've asked your patient to make a different kind of a reality orientation. In some of my earliest experimental work I asked students to discover what the mental processes were in picking up an imaginary apple and putting it on a concrete reality table in front of them (Erickson, 1964). What are the mental processes? A goodly number of the students complained of feeling funny all over and gave up the task; they left without completing the experimental situation. They were losing their contact with reality. Therefore, they felt funny. Now when you induce an analgesia, you are asking your patients to lose a certain amount of their reality contact. You are asking them to alter it. Then they begin to feel funny - they may recognize it or they may not. But they can react to that by getting out of the situation because it is strange and uncomfortable. Therefore, whenever you induce an analgesia or an anesthesia, you must see to it that your patients don't get frightened in one way or the other by the loss of their usual reality relationship. I let those students feel funny all over and let them run out on me because it was an important experimental finding that I wanted to study.

In working with patients in the office, when they get a funny feeling, whether they recognize it as a funny feeling or they just experience it as discomfort, they want to run out, too. But they can't afford it, and neither can you. Therefore, it is your obligation to tell them that one of the astonishing things is that as they begin to feel more comfortable or they get more and more interested in this or that, perhaps they will notice the light in the office is of a softer hue. Quite often I have told patients in my office, I hope you don't mind here as we continue our work if the light automatically dims and becomes softer or lighter.'' Whenever their reality orientations are altered, I know patients are going to tell me the office is getting lighter or darker, or getting warmer or colder, or they feel afraid, or that they feel the office is getting bigger or smaller, that they are feeling taller or shorter. They get all manner of changes in their sense of reality whenever we explore anesthesia or analgesia. These spontaneous sensory-perceptual alterations are all indications that the patients' reality orientations are altered; trance is developing whether a formal hypnotic induction has been carried out or not. As patients learn to be more comfortable with these spontaneous alterations, they can allow themselves to go deeper into trance. They learn to give up more and more of their generalized reality orientation (Shor, 1959), and they become more capable of experiencing all the classical hypnotic phenomena as well as achieving their own therapeutic goals.

Case 4 Utilizing the Patient's Own Personality and Abilities for Pain Relief

E: I wanted to produce an anesthesia, a relief of terminal cancer pain for Cathy. She was suffering intolerable pain that could not be relieved by morphine, Demerol, or anything else. She was in a desperately debilitated state of mind in which she just repeated, Don't hurt me, don't scare me, don't hurt me, don't scare me, don't hurt me, don't hurt me. A continuous, monotonous, urgent crying out of those two particular sentences. My opportunity of intruding upon her was rather small. What could I do in order to bring about a relief of the pain? I had to use Cathy's own learnings. I had to use my own thinking, and my thinking, of course, would not be in accord with the thinking of this high school graduate who knew she had only a couple of months left to live. She was thirty-six years old with three children; the oldest was eleven years old. Therefore, her thinking would be totally different, her desires would be so totally different, all of her understandings would be totally different from mine, and my task was, of course, to bring about a hypnotic state in which I could stimulate her to do something with her own past learnings. I didn't want to try to struggle in a futile way when the woman had already learned morphine had no effect on her, when Demerol, no matter how large the dose, seemed to have no effect on her. I didn't want to try to struggle with her and tell her she should go into a trance, because that would be a rather futile thing. Therefore, I asked her to do something that she could understand in her own reality orientations. I asked her to stay wide awake from the neck up. That was something she could understand. I told her to let her body go to sleep. In her past understandings as a child, as a youth, as a young woman she had had the experience of a leg going to sleep, of an arm going to sleep. She had had the feeling of her body being asleep in that hypnagogic state of arousing in the morning when you are half awake, half asleep. I was very very certain the woman had some understanding of her body being asleep. Thus the woman could use her own past learnings. Just what that meant to her, I don't know. All I wanted to do was to start a train of thinking and understanding that would allow the woman to call upon the past experiential learnings of her body.

I did not ask her to contend with me about going into a trance, because that, I thought, was futile. I did not ask her to try her level best to cooperate with me in going into a trance, because she didn't know what a trance was. But she did know what being wide awake was. She did know what a body being asleep was, because she had a lifelong experience of both states. The next thing I asked her to do after her body was asleep was to develop an itch on the soles of her feet. How many people have had itches on various parts of their bodies? Miserable itches, uncontrollable itches, distressing itches. We all have had that sort of experience, therefore I was again suggesting something to her that was well within her experience, within her physiological, psychological, neurological experience; within her total body of learnings. I was asking her to do something for which she had memories, understandings, and past experience. I was very, very urgent about this development of an itch. The woman shortly reported to me that she was awfully sorry she could not develop an itch. All that she could do was to develop a numb feeling on the dorsum of the foot. In other words the woman was unable in her state of pain to add to her state of pain. She did the exact opposite. She developed a feeling of numbness, not on the sole of the foot, but on the dorsum of the foot.

Now, what was my purpose in seeing her? That is the thing that all of you should keep in mind in dealing with patients. You are seeking to alter their body experiences; their body awareness; their body understandings; their body responses. Every change that develops should be grist for your mill, because it means that the patient is responding. When Cathy told me she had the numbness on the dorsum of the foot, I accepted that as a most desirable thing and I expressed regret, politely, that she had not been able to develop an itch. Why did I express a polite, courteous regret that she had not developed an itch? Why should I criticize or find fault with my patient's responses? I should be gracious about it, because Cathy had a lifelong history of experience with people who had been courteous, who had expressed regret, and who thereby put her at ease since earliest childhood in various situations. Cathy had a background of experience into which my courteous regret could fit.

Now the point I am trying to establish is this: When you talk to patients, talk to them to convey ideas and understandings in such a way that your remarks fit into the total situation with which you are dealing. You try to elicit an ever-widening response on the patients' part so that they respond more and more with their experiential learnings, with their past memories and understanding. Cathy could accept my apology and feel obligated. Since she failed me in one regard, she could feel obligated to put forth more and more effort on the thing that I accepted. While accepting Cathy's numbness on the dorsum of her foot, / also utilized her own background and personality to intensify her efforts to please me. Since I had been so gracious in accepting her failure to produce the itch, I intensified her motivation to cooperate with me in any further tasks.

The next thing I did was to suggest that the numbness extend not only over the dorsum of the foot but perhaps to the sole of the foot and the ankle. Well, of course, in suggesting the sole of the foot where Cathy had failed to put an itch, she would be all the more eager to produce the numbness. As surely as she did that, she would be obligated to develop a numbness of the ankle. Of course Cathy had had plenty of experience being unaware of the sole of her foot, unaware of her ankle. Cathy knew what numbness was, and she had body learnings of those things. Therefore, when I asked her to do those things, she could make a response. Now Cathy was not paying any attention to her bed, to the pictures on the wall, to the presence of the other physician with me, to the tape recorder that was in full view. Cathy was directing her mental attention to her body learnings. In the use of hypnosis you need to be aware of the total unimportance of external reality. Now as Cathy developed the numbness in the sole of her foot and the numbness in her ankle, she withdrew more and more completely from the reality of the room. She was giving her reality orientation to her body, not in terms of cancer pain but in terms of body learnings of numbness. Cathy became very greatly interested in letting the numbness progress from her ankles to the calf, to the knee, to the lower third of the thigh, the middle third, the upper third, having it cross over to the other side of her pelvis and go down the other leg so that she had a numbness from the umbilicus down. Now that interested Cathy. At that moment, of what interest was the ceiling, the bed, the doctor, the walls, or anything else? Cathy's interest was directed to that state of numbness just as dental patients should be so fascinated by the thought of the control of capillary circulation, by the thought of dental anesthesia, by the thought of learning how to chew their food with a different kind of bite so that they won't have temporal mandibular pain. The thing that interests the patients, the reason they are in your office, should be the point of orientation.

With Cathy oriented to the numbness of her leg and pelvis it was a simple matter to extend the numbness up to her neck. Cathy had metastases throughout her torso, she had lungmetastases, metastases in the bones in the spine as well as the bones of the pelvis. When you consider that sort of thing, you make every effort to extend the numbness. Here is a patient who knows that she is going to die within a few months. She has been assured of that by physicians whom she trusts and believes, so death is an absolute reality, while the walls of the room, the bed itself might not be an important part of reality. This matter of impending death, this matter of her family, was an unforgettable reality, and so in dealing with her experience of pain it was necessary to include some of the ordinary reality of her daily existence. Cathy had had that cancer for about a year. If I want to help Cathy, I have to organize any hypnotic suggestions that I give her in such a fashion that they incorporate some of Cathy's own thinking, some of Cathy's own understanding. The first thing I did for Cathy in the matter of numbness of the chest was to mention that her cancer first started in her right breast and then to mention that there was still an area of ulceration at the site of the surgery and that that ulcerated area was painful. That is a bit of external reality but it is also a bit of body reality, because Cathy could look down at that ulcerated area, which made it external to her because it was something she was looking at. The pain was a personal experience within her body. The visual thing was external and unpleasant and disagreeable, and that external vision could threaten her life. The pain and distress was an internal experience so far as Cathy was concerned. Therefore, I made Cathy aware of some of the external environment. She was already aware of the internal environment, so I merely made certain to include external environment, but an important part of external environment. The walls in her bedroom, the pillows on her bed, weren't important parts of external reality, but her visual impression of that ulcerated area was a most important part of her external orientation, and so I directed her attention to that.

Cathy had expressed regret because she had not been able to develop an itch on the sole of her foot. What should I do? Now, too many operators, too many people who use hypnosis try to be perfectionists, they try to accomplish too much. That is one of the reasons for failure in many instances - the effect to try to accomplish too much. Any student in high school or college will tell you: certainly I can't make 100, I might make 95, or I might make 90, I can't do better than an 85, I am lucky to get an 80. We have that sort of an orientation. Even the expert marksman says: I hope to get 10 out of 10, but I am not at all certain of that. Expert bowlers would like to make a certain score, but they never really honestly expect in every game to have a perfect score; they expect a certain amount of failure. Those who use hypnosis had better bear in mind that the patients they are working on have a lifetime of experience in expecting a certain amount of failure. You, as the therapist, ought to utilize, you ought to go along with, the patients, and you ought to be the one that picks out the area of failure. It was tremendously important that Cathy be relieved of that pain, but she had an experience of going to high school Cathy knew by virtue of a lifetime of experience that she could not achieve perfection in her performances. Therefore, in suggesting relief I was very very careful to ensure a certain percentage of failure. What had failed Cathy in the first place? Her first failure was in that right breast, that is where the cancer started, that is where she had her first sense of personal failure. Her right breast had let her down. Her right breast had doomed her. There is no way of getting around that understanding on Cathy's part. That right breast had doomed her. So now I express my sorrow, my regret that I couldn't take away the pain at the site of that awful ulcerated area on her chest. I recognized aloud to Cathy that that was a minor pain, a minor distress, and I was awfully sorry that I failed. Now Cathy could agree with me, and she could agree with me when I wished that I could produce the same numbness there that I had produced elsewhere in her body. In other words I made use of the double bind: As long as she had distress at the breast area, she had to have numbness elsewhere in her body. Thus I had all of Cathy's general experience substantiating the numbness of most of her body.

Now, there is nothing magical about what I did - it was a recognition of the thinking that Cathy would do . . . the thinking and the understanding that would derive out of Cathy's ordinary life. A woman who grew up in this culture, in this age, would have certain learnings as a result of just being alive. Now, when I left that minor pain, that minor distress, it proved that I was not God. It just gave Cathy another goal to strive for, even though she had the feeling that she would fail as far as this minor pain was concerned. Cathy lived from February, when I saw her, until August. She lapsed into coma and died rather suddenly. But during that length of time, Cathy was free of pain except in this one particular area, but as Cathy said, she didn't hold my failure against me. Why should she? By letting her keep that minor pain, I ensured the success of the rest.

We need to understand the way we behave emotionally. We can take only so much, but there is always one last straw. In the use of hypnosis we make use of that particular learning: We get rid of everything but leave that last straw as a distraction because it is a minor thing. I removed the major part of her pain but just left that last straw which Cathy could consider unimportant. Now I have stressed this because I want to impress upon you the tremendous importance in offering your suggestions not as the thing the patient is to do but as the stimulus to elicit patient behavior in accord with individual body learnings, individual psychological experiences. I suggested an itch on the foot, which would be adding to her pain. My purpose was not really to produce an itch on the sale of her foot. My purpose in suggesting that was merely to start Cathy functioning within herself - to start Cathy using her own body learnings and to use them according to her own pattern of response. Then when Cathy developed the numbness on the dorsum of the foot and expressed her regret, I used that regret and numbness. I could use it intelligently to bring about the relief of pain that would meet Cathy's needs. When I first approached Cathy, I had no understanding at all about how I could produce a relief of pain for her, because I didn't know her. I knew nothing really about the uniqueness of her own individual learning. My initial task was to say something that would get Cathy's attention and allow her to make her own personal responses. I then utilized those responses. In the use of hypnosis in medicine, dentistry, and psychology there is a need to explore the kind of thinking and responding that is characteristic of the individual patient. We need to recognize the actual unimportance of what we say as being the goal to be achieved. The importance of what we say lies in its being a stimulus for the elicitation of responses peculiar to the patient. We then help the patients utilize these responses in new ways to achieve their therapeutic goals.

Selected Shorter Cases: Exercises for Analysis

In this section are summaries of cases by the senior author and others illustrating the basic principles we have explained. Some are reported here for the first time; others have been published elsewhere. The student would do well to analyze the dynamics of their effectiveness in terms of the concepts introduced in this and precedings chapters. Some guides for this analysis are placed in italics at the end of each case.

A Tiger Under the Bed

A woman dying of terminal cancer was brought to Erickson's office in an ambulance. She was in desperate pain, and drugs no longer diminished it. She was frankly skeptical of hypnosis and immediately told Erickson of her doubts upon entering his office. He proceeded impressively as follows: Madam, I think I can convince you. And you know how much pain you are suffering, how uncontrollable it is. If you saw a hungry tiger walking through that doorway, licking its chops and looking at you, how much pain would you feel? She was apparently stunned by this unexpected question and said, Not a bit. In fact, I'm not feeling any pain now either. Erickson then replied, Is it agreeable to you to keep that hungry tiger around? She said, It certainly is ! All the associations to hungry tiger had so focused her attention that she was in a walking trance, from which she need not be awakened. She presented the entire appearance of being awake in all other respects. Yet she could see and experience the presence of that tiger at any time, day or night. The hypnotherapist simply evokes surprising sets of emotional, cognitive, or behavioral responses to interfere with the symptoms he needs to alter.

The senior author then told her that her doctors and nurses might not believe it, but she now experienced the truth of pain relief. And, indeed, her physicians and nurses did not understand. Whenever they came to offer her an injection for pain relief, the woman responded with a warm smile, No, thank you, I don't need any. I have a hungry tiger under my bed. They suspected she was hallucinating and perhaps losing contact with reality, but in those last months of her life she lived in apparent comfort without the use of narcotics or tranquillizing medication. Her family thought she was just fine, however.

Shock; Surprise; Fixation of attention; Common everyday trance; Distracting associations; Altered frames of reference; Posthypnotic suggestion to protect the therapeutic work

Chin on a Chair

The senior author has had to deal with personal pain problems all his life because of poliomyelitis. He usually can control pain effectively during the daytime by simply going into autohypnotic trance. When he gets very tired or goes to sleep at night, however, the pain sometimes returns and wakes him up. He then has to rearrange his muscles and mental composure to get rid of the pain again. Sometimes in the middle of the night this is just not easy. On such occasions he confesses to having sometimes pulled a chair to the side of his bed, hooking his chin over the back of the chair, and pressing down until he could no longer stand the pain he produced voluntarily (Erickson and Rossi, 1977).

Hypnotic suggestion as a highly developed cognitive frame of reference that can sometimes fail during sleep; Distracting involuntary pain with voluntary control over pain

Shaggy Dog Stories

Then there was the patient with paralysis from the level of the twelfth thoracic vertebra who had severe recurring attacks of pain associated with an acute cystitis and poliomyelitis. He would endure his pain until he could no longer control his outcries. Since his general condition was chronic, narcotics were inadvisable. Because he was an earnest, sincere, considerate, socially-minded man, but totally lacking any sense of humor or capacity to understand wordplays and puns, his pain was handled by the simple procedure of instructing the nurses to tell him shaggy-dog stories, especially those employing word-plays and puns. He would listen earnestly, appreciative of the sociability of the nurse, and struggle absorbedly in trying to make sense of her narrative. As time went on the patient spontaneously would summon a nurse and state that his pain was starting up - could she spare a minute or two of her time to talk to him, and he would try to understand her story.

Fixation of attention; Distraction; Unconscious search and processes

Head and Shoulder to the Solarium

In a case of terminal-illness pain in a woman with a young daughter the senior author addressed the young daughter as follows: Now your mother wants to be convinced that she can be free from pain. That is what you are going to do - convince your mother. Now just sit in this chair here, and while you're sitting in that chair, go into a trance and go over to the other side of the room. And I want you to lose all sense of feeling everywhere. You will be without feeling in a deep trance. You are sitting here, but you're over there on the other side of the room and you are watching yourself there. . . . Now you watch, mother. Your daughter is in a deep trance. She thinks she's on the other side of the room. Now keep your eye on me because I'm going to do something that no mother would ever want done. I rolled the girl's skirt up to expose her bare thighs. The mother looked on in horror as I did that. I raised my hand and I brought it down on her thigh with a terrific slap. The girl was watching herself on the other side of the room. Now I can't slap a girl on the other side of the room, can I? The mother was aghast that there was not a single wince out of the girl. Then I slapped the other thigh. The girl was still comfortable.

This mother was highly addicted to television so I eventually taught her that whenever she had a pain she could not tolerate, she was to leave her body there in bed and take her head and shoulders out into the living room and watch T.V.

This dissociative approach to pain relief was one of the senior author's favorites. In hospital practice he would frequently have patients take their head and shoulders out to the solarium while their surgeon did the necessary work on their bodies in the operating room.

Shock; Surprise; Modeling hypnotic behavior; Dissociation

Numb with Conversation

The conversational approach to fixating and holding the patient's attention can be very useful in traumatic stituations. There was an automobile accident in Portland, Oregon, and a man skidded on his face on a gravel road for about thirty feet. A gravel dirt road. He was brought into the hospital as an emergency case. One of the members of the American Society of Clinical Hypnosis - we will call him Dan - who does a great deal of plastic surgery and oral surgery was on emergency call that night. He went in and found that the man was conscious and suffering a great deal of pain. Those of you who know Dan know what a marvelous talker he is. He has a steady stream of words, of humor, of interest, of information, a tremendous wealth of knowledge and humor. Dan said, You really filled your face full of gravel and you know what kind of a job that makes for me. I've got to take tweezers and pick out every confounded little granule of sand and dirt and I am really going to have a job and I've really got to mop up that face and get half the hide off it and you have been suffering pain and you want some help out of it and you really ought to get some kind of pain relief and the sooner you start feeling less pain the better and I don't know what you ought to do while you're waiting for the nurse to bring something to inject in your arm but you really ought to listen to me while I am talking to you and explaining to you that I have to do certain things about your face. You know there is a gash here, that must have been a pretty sharp stone that cut that one, but here is a short one and here is a bad bruise and I really ought to mop it off with alcohol. It will hurt at first a little, but after it is done a few times the sting will deaden the tip of the nerves that are exposed and you stop feeling the sting of the alcohol, and did you ever try to make a violin? You know you can make violins out of myrtle wood, you can make them out of spruce wood. Did you ever try making one out of oak? Dan had won a national award for the best tone violin that he himself built out of myrtle wood, and Dan kept up his steady stream. Now and then he discussed the tremendous difficulty of really mopping up that face and putting in the stitches and wondering when the nurse would get around to the hypodermic. All the while, behind him, the nurse was passing Dan the right sort of instrument, the right sort of suture, the right sort of swab, and so on. Dan just kept up that steady stream and the patient said, You are awfully gabby, aren't you? Dan said, 'You haven't heard me at my best I can talk with a still greater rate of speed just give me a chance and I'll really get into high. Then Dan started getting into high, You know I think fast too and did you ever hear anybody sing the Bumble Bee? I'd better hum it to you. So Dan hummed the Bumble Bee and finally he said, You know that is about all. The patient said, What do you mean about all? Dan said, Here's a mirror, take a look. The patient looked and he said, When did you put in those sutures? When did you clean my face? When did I get an injection? I thought you were just talking to me, just getting ready. Dan said, I've been working hard for over a couple of hours, about two and a half hours. The patient said, You didn't. You've been talking about five or ten minutes. Dan said, No, take a look, count those stitches if you want to, and how does your face feel? The patient said, My face is numb.

Conversational approach; Fixation of attention; Distraction; Inter-spersal of suggestions; Time distortion

Calloused Nerves

Recently I had a patient sent to me with chronic hip pain. Very serious pain. I knew better than to try to induce a direct trance in the patient. What did I need to do? Everything I said to that patient, I think, was horribly unscientific, but the patient wanted certain understandings that she could accept, that could justify that chronic uncontrollable hip pain. I accepted the patient's absolute statements of uncontrollable pain. I accepted every one of her statements, so she knew that I believed and thought the way she did. Then I began an entirely specious explanation of h

Contents

Foreword

Preface

Acknowledgments

CHAPTER 1

The Utilization Approach to Hypnotherapy

1. Preparation

2. Therapeutic Trance

Fixation of Attention

Depotentiating Habitual Frameworks and Belief Systems

Unconscious Search and Unconscious Process

The Hypnotic Response

3. Ratification of Therapeutic Change

The Recognition and Ratification of Trance

Ideomotor and Ideosensory Signaling

Summary

Exercises

CHAPTER 2

The Indirect Forms of Suggestion

1. Direct and Indirect Suggestion

2. The Interspersal Approach

2a. Indirect Associative Focusing

2b. Indirect Ideodynamic Focusing

3. Truisms Utilizing Ideodynamic Processes

3a. Ideomotor Processes

3b. Ideosensory Processes

3c. Ideoaffective Processes

3d. Ideocognitive Processes

4. Truisms Utilizing Time

5. Not Knowing, Not Doing

6. Open-Ended Suggestions

7. Covering All Possibilities of a Class of Responses

8. Questions That Facilitate New Response Possibilities

8a. Questions to Focus Associations

8b. Questions in Trance Induction

8c. Questions Facilitating Therapeutic Responsiveness

9. Compound Suggestions

9a. The Yes Set and Reinforcement

9b. Contingent Suggestions and Associational Networks

9c. Apposition of Opposites

9d. The Negative

9e. Shock, Surprise, and Creative Moments

10. Implication and the Implied Directive

10a. The Implied Directive

11. Binds and Double Binds

11a. Binds Modeled on Avoidance-Avoidance and Approach-Approach Conflicts

11b. The Conscious-Unconscious Double Bind

11c. The Double Dissociation Double Bind

12. Multiple Levels of Meaning and Communication: The Evolution of Consciousness in Jokes, Puns, Metaphor, and Symbol.

Exercises

CHAPTER 3

The Utilization Approach: Trance Induction and Suggestion

1. Accepting and Utilizing the Patients' Manifest Behavior

2. Utilizing Emergency Situations

3. Utilizing the Patient's Inner Realities

4. Utilizing the Patient's Resistances

5. Utilizing the Patient's Negative Affects and Confusion

6. Utilizing the Patient's Symptoms

Exercises

CHAPTER 4

Posthypnotic Suggestion

1. Associating Posthypnotic Suggestions with Behavioral Inevitabilities

2. Serial Posthypnotic Suggestions

3. Unconscious Conditioning as Posthypnotic Suggestion

4. Initiated Expectations Resolved Posthypnotically

5. Surprise as a Posthypnotic Suggestion

Exercises

CHAPTER 5

Altering Sensory-Perceptual Functioning: The Problem of Pain and Comfort

Introduction [The following material was written by the senior author, and originally appeared in the Proceedings of the International Congress for Hypnosis and Psychosomatic Medicine. J. Lassner, (ed.) 1967.]

Considerations Concerning Pain

Hypnotic Procedures in Pain Control

Summary

Case 1 A Conversational Approach to Altering Sensory-Perceptual Functioning: Phantom Limb Pain and Tinnitus.

A Conversational Approach to Altering Sensory-Perceptual Functioning: Structuring a Therapeutic Frame of Reference

Interspersing Therapeutic Suggestions

Accepting the Therapeutic Frame of Reference

Creating Expectancy by Introducing New Response Possibilities: Phantom Pleasure

Autohypnosis: Therapy by Geometric Progression

Facilitating the Therapeutic Frame of Reference: Open-Ended Suggestions

Introduction
[The following material was written by the senior author, and originally appeared in the Proceedings of the International Congress for Hypnosis and Psychosomatic Medicine. J. Lassner, (ed.) 1967.]