The techniques for hypnosis should be learned through personal supervision by an experienced clinician. The actual wording and type of suggestion varies with different hypnotherapists, many of whom
have extensively described their techniques in print. T w o of the most respected therapists in this regard are Wolberg, whose two-volume
Medical Hypnosis (1948) is a rich sourcebook, and Erickson (1967), whose hypnotic techniques have been collected by Haley.
While induction methods are simple, the real skill of the hypno-therapist lies in his or her knowledge and understanding of psychodyn-amics, including the possible complications of transference reactions.
Such knowledge is usually acquired only in a formal training program for clinical psychology or psychiatry or through long supervision by a qualified hypnotherapist.
The casual application of hypnotic techniques without full under-standing of psychological theories and their clinical application is as irresponsible as amateur brain surgery.
Our own induction technique involves steady, monotonous rep-etition of suggestions for relaxation and rest, coupled with a constant
readiness to investigate, in the waking or hypnotic state, any sign of negative reaction to the hypnotic procedure. It has been shown by Dittborn, Munoz, and Artistequieta (1963) that a monotonously re-peated light flash did not, in itself, produce sleep unless specific
suggestions for sleep were included. Evans (1967) has demonstrated that hypnotic phenomena can often be induced, even if the subjects do not recognize that hypnosis is involved. By "teaching relaxation" he was able to produce phenomena equivalent to those achieved with a
usual hypnotic induction. Hartland (1967) emphasizes using rhythm and certain stressed words and phrases ( " Y o u ' r e so sleepy, so
re-laxed. . . . " ) . The effectiveness of pauses is mentioned by Blum (1967), who feels that in hypnosis the patient tends to think of the last thoughts presented before the
pause-It is important that the transition from waking to the trance state be as gentle as possible for the patient. Conforming the induction to his or her expectations arouses less anxiety, as does a setting of quiet relaxation, free from such interruptions as the telephone. The subject should be comfortable, usually seated in a chair with an ottoman, or reclining on a couch, with head support, or reclining on an examining table. Lighting should be adequate, but there should be no direct light in the patient's eyes. If the patient wears contact lenses they should always be removed before induction.
Rapport is the initial consideration. In the usual professional setting this is often taken for granted, being conferred by the reputation of the therapist, the recommendations of the referring physician, and
the appearance of a well-ordered and appropriate office setting. A few inquiries about the patient's previous knowledge of hypnosis, fear, or expectations may allay otherwise unexpressed anxieties and will strengthen the rapport between patient and therapist.
Before induction is begun, the therapist should explain the stages of hypnosis to the patient, assuring the patient that he or she may well remember everything that is said, for he or she is unlikely in the initial session to enter the deeper stages where spontaneous amnesia might occur. The therapist informs the patient that, contrary to popular thought, hypnosis is not like anesthesia. No one will " b l u d g e o n " him or her into unconsciousness, nor is it a case of the therapist's " s t r o n g e r "
mind controlling his or her " w e a k e r " o n e . It is a cooperative effort in which the therapist aids the patient, by means of specialized knowledge and technique, to achieve a purpose that both have agreed upon as valid and worthwhile.
T h e specific purpose of the induction is reviewed—to help the patient achieve a specific goal, such as stopping smoking, controlling pain, decreasing excessive appetite, or other such goals. T h e value of achieving the desired result is emphasized.
Induction is then begun, using techniques with which the therapist is comfortable, tailored to the individual needs of the patient. A slow, monotonous, soft, and assuring tone is used. Patients easily detect anxiety and insecurity in the therapist, often responding by tenseness and a failed induction. T h e approach should be positive and direct, with suggestions such as " Y o u will feel less p a i n . " The patient's attention is gently guided to relaxing bodily sensations and away from thoughts associated with anxiety.
T h e method of induction is ideally based upon an understanding of the patient's personality structure. For example, a patient with a positive response to authority may find an authoritarian approach most acceptable, while a patient with authority conflicts might be resistant to such a tone. If a particular technique is not working, the therapist should be prepared to unobtrusively move toward a different approach, a shift that can often be accomplished with a mere change in the tone of the voice. Some subjects will respond to slightly indirect suggestions for induction, such as " N o w tell yourself to relax your b o d y , " instead of the more authoritarian " N o w relax your b o d y . "
The type of vocabulary used will depend on the patient's verbal skills. It is not wise to "talk d o w n " to a patient, for if he or she feels that the therapist is assuming a superior attitude, he or she might
respond by marked resistance. We normally use the same vocabulary as we would in a standard psychotherapeutic session.
The therapist should speak in a calm tone, enunciating the words clearly. We use a tempo of suggestions that is coordinated with the patient's breathing. If at all possible, an induction should occur in a quiet room devoid of distracting sounds or noises. We have, however,
hypnotized patients in a teaching hospital under conditions where other patients were in the same room and radios blared in the outer office. In one hospital we conducted hypnotherapy in an area where sirens could be heard entering the hospital grounds virtually 24 hours a day. If the unconscious motivation of the patient is sufficient, he or she will
respond by entering a hypnotic trance.
Many actual " w o r d i n g s " are discussed in chapters dealing with specific clinical entities, such as obesity and pain. Here we shall emphasize the necessity for the therapist keeping his or her mind on what is being said so to avoid hesitancy or inconsistent suggestions.
One must not, for example, begin a suggestion of a light floating sensation in the right arm and then, by error, speak of the left arm. Such inconsistencies arouse anxiety in the subject. One neophyte therapist reported that when attempting to treat plantar warts hypnotically he forgot on which foot they were and suggested that they would diminish on the other foot, which was actually free of warts. Although this
inconsistency did not awaken the patient, when she was brought out of trance, she had a hoarseness, apparently a hysterical symptom ex-pressing both the desire to speak, to tell the therapist of his mistake, and the inability to do so because of the need to remain in a trance state.
The hoarseness soon passed, but she discontinued treatment. In rare circumstances confusing suggestions may be deliberately employed as an induction technique, but this "confusion method'' is best left to expert and experienced therapists (Erickson, 1965).
In addition to suggestions being clear and accurate, they must be discretely limited to the purpose intended. For example, a patient burned over 80 percent of his body was in severe negative nitrogen balance and rapidly losing weight. He was given the posthypnotic suggestion that he would be very hungry and would eat ' a n y t h i n g and everything" offered to him. Soon after he awakened, he rapidly con-sumed an entire box of 24 candy bars that a friend had brought him as
a gift. He consequently developed severe diarrhea, temporarily losing ail the additional weight he had acquired.
Since hypnotic suggestions may act as artificially induced com-pulsive ideas, it is most important that they be clearly worded. It would not be wise, for example, to remove all lower abdominal pain from a patient suffering from separation of the pubic symphysis since the absence of pain might prevent the detection of some other treatable
condition, even cancer, which might subsequently arise. Lerner (1958) suggests that as hypnosis is achieved, the operator's image acts as if it is intrapsychic, becoming a source of security and reassurance.
At times a patient may consciously or unconsciously resist the
induction of hypnosis, particularly when some emotionally charged material is involved in the treatment. There are a number of possible psychodynamicsfor such resistance (Cheek and LeCron, 1968;Gravitz, 1971). Motivation, as previously discussed, is a prime factor, but it should be maximized if a careful screening procedure has been con-ducted and if rapport has been established. Some patients seek hyp-nosis because of pressure from members of their families; they must be
led to discover motivations in themselves before hypnotherapy can be successful. Misunderstandings about hypnosis are a frequent source of resistance, as already noted. Many people equate it to a traumatic experience previously associated with anesthesia. There may have been earlier actual experience of loss of consciousness, to which hypnosis is mistakenly assimilated in the patient's mind. Many other forms of unconscious psychodynamic resistance may exist, and these must be uncovered in difficult cases. They may include fantasies of loss of control, fear of dominance, and activation of sexual fantasies of an aggressive, submissive, or homosexual nature.
After induction, various "challenges" may be used to demonstrate to the patient that he has been hypnotized. A usual challenge is, "Your
eyes are tightly closed, so tightly closed that you cannot open them even if you try; now try to open your e y e s ! " It is essential that such challenges not be used to excess or continued to the point that they tire the patient and interfere with the basic set of relaxation. In some of the challenge tests, such as inducing insensitivity to pain in a finger, it is necessary for the therapist to touch the patient. This should never be done without warning. The patient should never be surprised or startled by the therapist's actions.
After several successful inductions have established the trance as a pattern, the trance can then be elicited by a shorter cue, which has been presented as a posthypnotic suggestion on previous inductions (Kubie, 1961),
Since hypnosis may involve heightened transference reactions, it is even more important than in conventional psychotherapy that the therapist himself or herself be relatively free of neurotic countertrans-ference problems and that he or she remain highly conscious of those areas of conflict that remain partially unresolved. In addition, he or she must realize that the heightened tendency of the patient to form transferance ties prohibits suggestions that might have double mean-ings, such as "You will become hot ail over." Stein (1966) has listed a number of items that may suggest to a therapist that he or she is having an unrecognized countertransference reaction to a patient; alterations in usual fees, overlooking failures to take medications as prescribed,
signs of familiarity (as first names), allowing abuses of the telephone, repeated discussions with colleagues concerning a particular patient, neglect of history taking, and others. Orne (1972) lists warning signs that might indicate to a therapist that he or she has power problems: if he or she (1) uses hypnosis for all patients, (2) enjoys inductions but is less concerned about effectiveness, (3) is overly concerned with always obtaining maximum depth of trance, (4) is afraid of patients falsifying hypnosis, (5) experiences induction as a test of wills, or (6) particularly looks forward to hypnotizing attractive patients.
At times a third person should be in the room during hypnotic induction, both as a reassurance to the patient that fantasies are not
likely to be acted out and as a legal protection to the therapist. A nurse or professional secretary might act as chaperone when the patient is
likely to enter deep levels and experience spontaneous amnesia, unless, of course, the purpose of the trance is to elicit cloistered material that the patient might not wish revealed to a third party. When treating women for sexual unresponsiveness, we have found it particularly helpful to ask the woman's husband to act as chaperone; this decreases the possibility of an embarrassing situation should the women expe-rience spontaneous orgasm during trance. If she awakens with newly aroused libidinous feelings, as is hoped for in the treatment, the husband's presence allows these feelings to focus immediately on him as an appropriate person. There can also be no doubt that the feelings are due to posthypnotic suggestions rather than any impropriety during the trance state.
At the termination of trance, posthypnotic suggestions should be given for a slow gradual return to the waking state. Although it is possible to awaken the patient rapidly, this is seldom indicated.
After awakening the patient, it is often useful to inquire about whether he or she experienced any unusual images or feelings during trance. If so, the material is handled in a psychotherapeutic way.
Toward the final stages of a treatment program, we add to the posthypnotic suggestions the following statement:
"You will never allow anyone to hypnotize you who is not professionally qualified, and only then if you so desire. Should you experience hypnotic
suggestions under other conditions you simply will not respond, in any sense of the word."
As o n e ' s training and experience increase, these considerations of technique become automatic and integrated into a smooth, flowing induction.