CONTRAINDICATIONS
The two most important contraindications to the use of hypnosis by the nonpsychiatrist are the queerly acting or unstable “crackpot” and the psychotic. The prepsychotic is difficult to recognize. He usually can be discerned by the intensity of his mood swings. The psychotic, especially the withdrawn, apathetic type, whose thinking is unreal, will be a liability for anyone but the trained psychotherapist. Conn has observed: “Neither one nor many hypnotic sessions can precipitate psychoses if no psychotic process has been at work.”1 Of course, organic conditions amenable to medical therapy should be given a careful differential diagnosis and not treated exclusively by hypnosis.
DANGERS OF SYMPTOM REMOVAL
Conn believes that there is no danger in the removal of a symptom and that one symptom is not replaced by another except in very disturbed, unstable persons.1 As Eysenck says, “let those who castigate symptom removal even get symptom removal with their approach.”* It is best, however, to use permissive suggestions oriented around the needs of the patient when hypnotherapy is employed for symptom removal. Symptom substitution or “trading down” to a less disturbing one enables the well-established symptom to be manipulated more readily, and this prevents other symptom equivalents from being substituted. Spiegel suggests that the therapist should not expect or tacitly suggest that a substitute symptom may occur.5 He uses the term “symptom alteration,” which refers to directing the attention away from the symptom while simultaneously reminding the patient that more resourceful means are available for coping with his problems. Hartland also feels that past fears about symptom removal have been excessive.4 He uses ego-strengthening technics prior to removal of the symptom.
Even if hypnosis is used for direct symptom removal there is very little danger that the original symptom will recur. In a 5-year follow-up study of two groups of patients who had phantom limb pain and hiccoughs, respectively, Dorcus noted that not a single one of these symptoms returned when hypnotherapy for symptomatic relief was employed.2
The dangers attributed to hypnotic removal of symptoms are grossly exaggerated. Such reasoning is not applied to generalists at nonhypnotic levels when symptomatic therapy is used. Furthermore, since other symptoms often make their appearance concomitantly during any form of psychotherapy, how can a new symptom necessarily be related to the “symptom removal”? And is not the bulk of nonpsychiatric treatment directed toward symptom removal? Moreover, there are no accurately controlled data to prove that other symptoms replace those that have been removed by hypnosis, especially when autohypnosis and permissive technics are employed.
It is often stated that repeated hypnotization can lead to emotional instability. There is no reliable evidence to substantiate this statement. Individuals who have been hypnotized hundreds of times have exhibited absolutely no harmful effects.
DANGERS TO THE OPERATOR
There are certain dangers to the operator, such as a charge of unethical conduct. This can be obviated if a third party, such as a nurse, is present. Taperecording each session is also helpful. Permission of parents should be obtained when employing hypnotherapy in children. The inexperienced therapist should have another individual present when hypnotizing a disturbed female, or a subject who one suspects might be hysteroid, psychopathic or psychotic; psychopathic personalities often resort to confabulations characterized by wishful thinking, deceit, or actual fabrications.
A female patient may develop a spontaneous hypnotic amnesia and claim that the physician had raped her (this unfortunate situation can also occur at nonhypnotic levels), and because of the oft-associated idea that hypnosis can overpower the will, the hapless operator may find himself charged with unethical conduct. Aware of such possibilities, many operators obtain a signed release if unable to have a third person present. Three malpractice cases stemming from hypnosis were reported in a survey.3 In each, the defendant was accused of assault during a hypnotic session; each case was later dropped by the prosecution, and each patient was subsequently judged insane.
Fortunately, most malpractice insurance policies protect physicians and psychologists against such lawsuits (see Chap. 23).
DANGERS TO THE METHOD
To protect hypnotherapeutic methods from adverse criticism, the therapist should not promise more than can be accomplished, and a guarantee of cure should not be made. However, if there is a valid indication, one can state that everything will be done to help the patient recover. All patients should be informed that the results obtained in hypnosis are based wholly on the patient's cooperation and willingness to cooperate. The following remark is helpful: “You are not being treated by hypnosis but rather in hypnosis. Hypnosis merely facilitates the understandings so necessary in all successful therapy. You are the one who developed the condition that you wish removed; therefore, it can be accomplished only by reversing those faulty thinking patterns which produced the symptom. Naturally, this will require your utmost concentration, receptivity, self-objectivity and understanding.”
Hypnosis should always be employed for definitive goals. The dictum that “Hypnosis should be used for the good of the patient, not to enhance the prestige of the operator” must be kept in mind. It should never be used for entertainment by a physician or a dentist. Otherwise, respect for the method and the operator is destroyed. Finally, as emphasized, the inexperienced operator must never attempt to elicit deeply repressed and traumatic material unless he has been trained to recognize it and to know what to do with it when it appears. Otherwise, the patient will develop what has been referred to as “traumatic insight.”
REFERENCES
1. Conn, J.H.: Preparing for hypnosis in general practice. Roche Report, 3:3, 1961.
2. Dorcus, R.M.: The treatment of symptoms with special reference to removal by hypnosis (paper read before the University of Kansas Symposium on Hypnosis Research and Clinical Psychology, May 8, 1960).
3. Could you use hypnosis in your practice? Med. Economics, May 22, 1961.
4. Hartland, J.: The value of “ego-strengthening” procedures prior to direct-symptom removal under hypnosis. Am. J. Clin. Hypn., 8:89, 1965.
5. Spiegel, H.: Is symptom removal dangerous? Am. J. Psychiat., 123:10, 1967.