FAITH IN RELIGION AND HYPNOSIS
When therapeutics began to divorce itself from magic and superstition, all mental healing split into religious and nonreligious movements. The latter group consisted primarily of physicians, who used suggestive procedures in one form or another to heal. The former group, however, maintained that all cures were due either to metaphysical factors or divine faith. “Faith” is a loaded word and difficult to define. However, because it plays a significant role in all forms of psychotherapy, the dynamics of faith and its relation to religious and hypnotic types of healing will be discussed.
All faith is built up by conviction and the imagination. d'Eslon, the successor to Mesmer, discerned that conviction and imagination were responsible for the curative effects of mesmerism. He asked, “But since the medicine of conviction and imagination cures, why do we not use it?” In spite of his cogent observations almost 200 years ago, healers, both medical and nonmedical, do not use it as such, but unwittingly stimulate the imagination by some type of misdirection in the form of a new approach or method over which the public becomes enthusiastic, especially if it is mysterious and fashionable.
Faith-healing also depends to a degree on psychosocial and cultural factors. The savage expects to be healed by the incantations of the shaman because he is convinced that he will help him. For similar reasons, the civilized person is aided by the belief and faith engendered by the rapport and prestige suggestions from the omniscient figure—the doctor.
When an emotionally disturbed individual sees a religious healer, his faith is strong because of a previous conviction that “God heals.” In other words, his faith in a cure has been continually validated or computed by the already thought-out conviction that the clergyman-healer is an emissary of God. He recovers, often as the result of a single session, because he expects to recover.
When the average person consults a physician initially for psychotherapy, he comes in with uncomputed conviction because he does not have the powerful built-up faith in psychiatry that he has in religion. However, with successive visits, a positive rapport develops and eventually his uncomputed conviction becomes computed conviction leading to faith in the therapist. He recovers for the same reason as with the religious healer—expectant faith in a cure.
When a patient sees a physician-hypnotist healer, his uncomputed convictions or negative attitudes are generally increased. Not only does he have to establish confidence in the doctor, but he has to be “sold” on the hypnosis; it invariably connotes something “magical.” His uncomputed convictions become computed convictions as the result of the hypnotic-induction procedure; he attributes the ideosensory and ideomotor responses, such as lid and limb heaviness and arm levitation, to the hypnotherapists's suggestions.
After these convictions are established, then he readily believes other suggestions even though they may be at variance with reality. Thus hypnotic healing does not require faith in a cure but only faith in the fact that he was hypnotized!
The question as to whether religious or hypnotic faith-healing is more effective obviously relates to previous conditioning of the subject. There is no ideal method applicable to all persons, nor is there a preferential religious approach. All methods can heal—the specific one being the one for which the person has been “programmed.”
Paracelsus shrewdly observed: “Whether the object of your faith is real or false, you will nevertheless obtain the same effects.” It is amazing that there are relatively few scientific observations on the relationship between faith-healing and hypnosis. One would expect that a medium which has such a pronounced effect on human emotions, autonomic functioning, mood changes, mental associations, and sensory imagery would be worthy of further investigation.
On the basis of the observed data, all faith-healing makes use of suggestion by effecting a temporary dissociation produced by selective cortical inhibition—the attention is diverted through misdirection—and the favorable attitude or the mind-set resulting from previously invoked beliefs allows the acceptance of faith-laden ideas. The misdirection is obtained by the ritualism that accompanies all religious healing. This also occurs as well in hypnotic procedures, but differs as mentioned above.
When a headache is relieved by hypnosis, for instance, the conviction that hypnosis has been established causes the subject to accept the hypnotherapist's suggestions as true statements. Then he behaves differently because he thinks and believes differently through the alteration in his beliefs. The power of hypnosis is the power of belief! Thus hypnosis is merely a catalytic agent through which conviction phenomena can be established. As such, hypnotic behavior is a particular branch of faith phenomena.
Most faith-healers and even unsophisticated medical hypnotherapists have the tendency to “play God”; they usually are unaware that psychogenically based symptoms are removed by activation of the latent recovery forces.18 The sick person usually has his own mental representation of the disease, of the recovery he hopes to achieve and, often, even of the psychotherapeutic procedure he desires.13
An attempt has been made to explain how most cases of miraculous faith-healing, which appear in the professional and the nonprofessional literature, follow the principles of faith described in this section. However, occasional cures of organic illnesses occur in which faith is only part of the rationale. At Lourdes, for instance, many of the countless “miracles” can be explained as the result of the subjects' expecting to be cured. However, 51 official miraculous cures have been recognized by the Catholic Church, a Canonical Commission, the Medical Bureau, and the International Medical Commission.
Shapiro states:
If they are indeed produced by faith, then they are certainly not dependent on the intensity of faith. The devout and saintly believer may remain unhealed while the skeptic who suffers the same disease may be miraculously cured.24
(When this happens, the skeptic usually becomes a devout believer.)
Shapiro continues:
But the time, the circumstances and the person who evaluates the miracle always modify the description of the nature of the event. One man's religion is another man's superstition, and one man's magic is another man's science.
The only scientific explanation of this type of faith-healing is that a nonformalistic technic of hypnosis by misdirection would tend to mobilize the recovery processes that are inherently present in every individual. Here too, a placebo action, described in the next section, would exert an influence.
The rise of pastoral psychiatry and the human potential movement is evidence of the ability of faith to help large numbers of mentally ill individuals because of their previously invoked beliefs in the religionist. As a result, some psychiatrists are working hand in hand with theologians and lay healers to utilize the latent capacity for faith that is inherently present in all humans. Both a religious and a psychiatric approach are appealing to blind faith rather than to logical reasoning or persuasion. If the latter were better for mentally sick people, then more people would be cured by appealing to logic and common sense. Every psychotherapist knows that this is not the case.
PLACEBO-EFFECT CONCEPT
There is a growing recognition that the placebo effect plays a key role in drug therapy,4,5,15,19,26 and also applies to all forms of psychotherapy as well as hypnosis. In this section, emphasis will be placed on an explanation of the placebo effect of drugs and psychotherapy as these relate to suggestion and hypnosis. The clinical applications and ethics of the placebo effect will not be stressed. If one substitutes “placebo effect” for “faith,” one finds that in many instances the cause of the physicians' dramatic cures of today is similar to the cause of the miraculous healing of yesteryear.
DRUGS AND THE PLACEBO EFFECT
Osler points out that doctors often are ignorant of their own faith cures when prescribing medications and are just a wee bit too sensitive about those performed outside their ranks.20 This observation hints that most drugs have no more value than a placebo. This dynamic placebo force sustained the medical profession for centuries, even when drugs were physiologically detrimental. One cannot help being impressed by the fact that placebo action has been the one constant in medicine—by whatever term it was called. And it is certain that our present cure rate for many of the psychogenic entities would not differ appreciably from that of any other period.
Chiefly responsible for the physician's placebo effect is the enthusiasm and the faith inculcated by his approach. This is transmitted to the patient, who develops the necessary confidence and faith for recovery. Thus the physician himself is still the most important therapeutic agent. The expression “the art of medicine” means nothing more than the rapport that exists between the patient and the physician. If the common denominator in medicine is the placebo effect (faith), then its chief ally is the imagination, for without imagination there would be no placebo cures. Oliver Wendell Holmes was cognizant of this when he stated that the greatest benefit can accrue to patients “through the influence exerted on their imaginations.” Voltaire once stated, “There is probably more cure in the doctor's words than in many of the drugs he prescribes.”
Factors other than rapport which contribute to the “success” of the placebo are not only the suggestive effect of prescribing a drug but also the spontaneous recoveries which occur in any illness. Environmental factors and cultural attitudes toward new drugs and procedures also enhance the placebo effect. Another interesting factor recently postulated is that all placebos are more effective in the presence of stress or in pain due to organic causes. All these factors simply illustrate the power of words!
At present, enthusiastic physicians are prescribing “wonder drugs” in all fields of medicine; the patient often obtains the effect that he has been told to expect. This is not to imply that the author is a therapeutic nihilist; he is not. It has been noted that whenever a new drug loses its popularity, its effect is markedly reduced. Conn remarked:
This is what occurred after the introduction and initial wide acceptance of bromides, chloral hydrate and the barbiturates, each of which was hailed as a “wonder” drug, and it also will happen to the “tranquilizers.”8
Trousseau6 facetiously advised, “You should treat as many patients as possible with the new drugs while they still have the power to heal.”13
One of the most difficult things for any individual, living in any period, is to be able to shake off the rigid dogmas of his own culture. Future historians may laugh at what we consider modern-day therapies. The author has often wondered, after each new “wonder” drug has been exploded, how and why the honest and conscientious investigators were misled.
Obviously, these drugs, despite statistical validation, acted by virtue of their placebo effect. Usually such variables as the emotional relationship, the dosage, the choice of subject, the use of inadequate controls, an improper assay of the data, the operator's attitude or bias, and other factors influenced the results. One author significantly states, “The ability of inert compounds … to modify a variety of conditions … has begun to have a serious impact on medical thinking.”12 Others believe that much time and money would be saved if placebo effects were analyzed before it was assumed that a drug had value.
In an excellent review of the history of the placebo effect, Shapiro writes that until recently, there was virtual silence about the placebo effect in spite of the fact that this effect is the unwritten therapeutic agent in almost every prescription.25 The effect of placebos can be very powerful and often permanently modifies physiologic functioning. These effects are not superficial or transient. Yet their everyday use has been neglected.
PLACEBO EFFECT IN PSYCHOTHERAPY
The fact that there are contradictory theories being employed with identical results in a wide variety of psychotherapies indicates that here, too, a placebo effect is in operation! Psychiatrists need to know more about placebo effects because their rapport with patients is great and, as a result, the placebo potential of their therapy is thereby enhanced. With every physician, this potential consists of the patient's confidence, faith, and belief, interacting with the therapist's personality. The hypnotic situation contains within it the mystery, the ritualism, the repetitive conditioning, and the other factors that lead to increased suggestibility.
Recently, several authors have noted that hope and faith on the part of the patient and suggestion and persuasion on the part of the therapist constitute some of the universal factors operative in mental healing.11,22 Curiously, however, hypnotic suggestion was not distinguished from persuasion, and hypnosis from classic conditioning.
Most authorities do not even mention the placebo effect in psychotherapy, and those that do seldom equate it with their cures. Bromberg, who discusses faith-healing and suggestibility, does not mention it as it applies to medication or psychotherapy, past or present.7 Although there is a subtle placebo effect in many forms of psychotherapy, nothing has been done about it, despite the fact that more therapeutic methods have been introduced into psychiatry than ever before. Using more knowledge of the placebo effect, modern-day psychiatry could more objectively understand its failures and eliminate ineffective methods.
Rosenthal and Frank, who have studied the placebo effect in psychotherapy, believe that all forms of psychotherapy, including hypnosis, uniformly yield successful results in about 60 percent of cases.21They stress the effects of the interpersonal relationship, and that psychotherapists fit their results into their theories and therapeutic rationale, indicating that “the efficacy of any particular set of therapeutic operations lies in their analogy to a placebo in that they enhance the therapist's and patient's conviction that something useful is being done.”
A placebo effect accounts for psychotherapy by nonpsychiatrists as well as for intensive psychoanalysis.2 In short, improvement does not prove the correctness of the theory on which the therapy was based, or the efficacy of a specific technic employed, unless the improvement is greater than that produced by the patient's faith in the efficacy of the therapist and his technic—“the placebo effect.”
On this basis, the old family doctor was a good psychotherapist because of his humanistic approach and willingness to listen to a patient's story. An analysis of the placebo effects of “homespun” psychotherapy should help to elucidate the roles of suggestion, waking hypnosis, and hypnosis in all forms of psychotherapy.
HYPNOSIS AND THE PLACEBO EFFECT
The nature of the placebo effect as it operates in hypnotherapy has been described by several investigators.7,20 In the light of newer knowledge gained from the placebo effect, the nature of the therapeutic deficiencies of early concepts now can be understood.
During the period when mesmerism and hypnosis reached their peak, emphasis was on a very authoritative approach directed toward symptom removal. Even today, authoritarian methods employing suggestion or hypnosis by an omniscient father-figure are successful in helping some patients, at least temporarily. It has been observed, “It is surprising how frequently these so-called ‘transference cures’ persist even if no further treatment is administered.” Genuine recoveries have been observed in patients “without any psychodynamic insight into their condition.”13 There is no experimental study which indicates that therapeutic effects based on insights or perceptual reorganization are less superficial or less transitory.21
Although suggestion and hypnosis are related to the placebo effect and have much in common, they differ from each other in some ways. The difference is analogous to the comparison made between religious and hypnotic healing. Healing by hypnosis requires belief in the validity of the induction of hypnosis, that is, in the “power” of the hypnotist. Cortical inhibition produced by misdirection of attention is common in hypnosis but not in placebo administration. Faith in the placebo merely indicates faith achieved by previously invoked belief in all drugs as well as the prestige of the physician. Here there is a proper mind-set, based on a high degree of enthusiasm or motivation, belief, confidence, and an expectant attitude.
Wickramasekera has intimated that sensory restriction and anxiety reduction contribute to the role of hypnosis in heightening the patient's faith and hope in the therapist.27 He also reviews an extensive literature on the placebo effect, urging that it should be used rather than eliminated in psychological treatment procedures.
An experiment was performed to test for a placebo factor in hypnosis.17 A tourniquet-exercise ischemic test was employed. There were three groups: a normal control without hypnosis, one with hypnotic analgesia, and a placebo condition. The placebo effect was fairly pronounced for the nonhypnotizable, but not at all for the hypnotizable. Hypnotic analgesia was very effective for the highly hypnotizable, but for the nonhypnotizable it was equivalent only to the placebo. It can be concluded that for subjects insusceptible to hypnosis, pain reduction can be achieved by hypnotically suggested analgesia, but will be analogous to a reduction by a placebo. For highly susceptible hypnotic subjects, pain reduction through hypnotically suggested analgesia is far greater than the placebo; the average placebo response is practically nonexistent. Such work indicates that response in hypnosis and placebo response are not one and the same. In a clinical setting, where motivation is high, hypnosis might well prove to be the acme of the scientifically applied placebo effect!
We are safe in concluding that all human beings need motivation, self-esteem, and something to believe in so that they can face their everyday tensions. The emotionally ill patient's value systems have failed him. As a result, he is ready to accept the therapist's, especially if they are presented with confidence, and it appears that they have a chance of helping him. It is also surprising how, on the basis of conviction, the incorporation of the therapist's suggestions can help large numbers of patients.
It is a sad commentary that those who now subscribe wholeheartedly to the concept that psychotherapy operates through a placebo effect still avoid hypnotherapy. The cumulative effect of successive and successful suggestions often results in a conviction of cure that cannot be achieved as rapidly by other psychotherapeutic modalities, especially if the therapy is directed to establishing the need of a symptom in a patient's emotional economy. When indicated, every psychotherapist owes it to his patients to utilize his unquestioned placebo effect at the highest level—hypnosis. Although hypnotherapy cannot be successfully applied to all disturbed individuals, there are certain cases, which respond to hypnotherapy, that orthodox psychotherapy cannot treat.
Considerable attention has been given to the placebo effect in psychotherapy, religious healing, and drug therapy. Obviously, the most suggestible patients will be the best reactors. However, response will vary from individual to individual and will even change in the same individual from time to time. Some respond because of the “halo effect,” in which patients expect to improve because of a self-fulfilling prophecy. Many psychiatrists are opposed to placebos because they feel they should never be substituted for psychotherapy, even though there is a placebo effect in the latter.19
Recently, the placebo effect of tranquilizers has been noted.3 According to uncontrolled and subjective methods of evaluation, from 53 to 80 per cent of the patients benefited from the new “drugs” (both drugs given were placebos, but patients were informed that one was real and the other a placebo). The authors point up the dubious value of the studies, which do not employ double blind and other controlled procedures.16
The capacity to respond to what is believed and accepted as true is simply amazing and, as hypnotic phenomena attest, is very valuable. The success of charlatans in beguiling the public is an unfortunate by-product of the placebo. Yet this only indicates how powerful the placebo is in the use of drugs and psychotherapy. Our thesis is that if the placebo is effective, then hypnosis employed prudently by a competent physician for a valid indication will serve the patient's best interest.
REFERENCES
1. Alexander, F.: Discussion of Hoch, P.H.: Aims and limitations of psychotherapy. Am. J. Psychiat., 112:321, 1955.
2. Appel, K.E., et al.: Long term psychotherapy. In Psychiatric Treatment (A.R.N.M.D. series), vol. 31. Baltimore, Williams & Wilkins, 1951.
3. Baker, A.A., and Thorpe, J.G.: Placebo response. Arch. Neurol. Psychiat., 78:57, 1957.
4. Beecher, H.K.: The powerful placebo, J.A.M.A., 159:1602, 1955.
5. Benson, H., and Epstein, M.D.: The placebo effect: a neglected asset in the care of patients. J.A.M.A., 232:1225, 1975.
6. Bernheim, H.: Translation from Trousseau's Dictionnaire, 1833. Paris, Libraire de la Faculté de Médecine, 1889.
7. Bromberg, W.: Man Above Humanity: A History of Psychotherapy. Philadelphia, J. B. Lippincott, 1954.
8. Conn, J.H.: Cultural and clinical aspects of hypnosis, placebos, and suggestibility. Int. J. Clin. Exp. Hypn., 7:179, 1959.
9. Op. cit., pp. 181-182.
10. Feldman, P.E.: The personal elements in psychiatric research. Am. J. Psychiat., 113:52, 1956.
11. Frank, J.D.: Persuasion and Healing: A Comparative Study of Psychotherapy. Baltimore, Johns Hopkins University Press, 1961.
12. Gliedman, L.H., et al.: Reduction of symptoms by pharmacologically inert substances and by short term psychotherapy. Arch. Neurol. Psychiat., 79:345, 1958.
13. Hoch, P.H.: Aims and limitations of psychotherapy, Am. J. Psychiat., 112:321, 1955.
14. Holmes, O.W.: Medical Essays, 1842, 1892. Cambridge, Mass., Riverside Press, 1891.
15. Lasagna, L.: Placebos. Sci. Am., 193:68, 1956.
16. Loranger, A.W.: The Placebo Effect in Psychiatric Drug Research, J.A.M.A., 170:920-925, 1961.
17. McGlashan, T.H., Evans, F.J., and Orne, M.T.: The nature of hypnotic analgesia and the placebo response to experimental pain. Psychosom. Med., 31:227, 1969.
18. Milechnin, G. S., and Milechnin, A.: Concerning the criterion of recovery. J. Clin. Exp. Hypn., 6:1, 1958.
19. Modell, W., and Houde, R.W.: Factors influencing clinical evaluation of drugs. J.A.M.A., 167:2190, 1958.
20. Osler, W.: Medicine in the Nineteenth Century in Aequanimatas. Philadelphia, Blakiston, 1905.
21. Rosenthal, D., and Frank, J.D.: Psychotherapy and the placebo effect. Psychol. Bull., 55:294, 1956.
22. Sargant, W.: Battle for the Mind. New York, Doubleday, 1957.
23. Shapiro, A.K.: Hypnosis, miraculous healing, and ostensibly supernatural phenomena. In Kline, M. (ed.): A Scientific Report on the Search for Bridey Murphy. New York, Julian Press, 1956, p. 133.
24. Op. cit., p.147.
25. __________: A contribution to a history of the placebo effect, Behav. Sci., 5:109, 1959.
26. __________: Placebo effects in psychotherapy and psychoanalysis. J. Clin. Pharmacol., 10:73, 1970.
27. Wickramasekera, I.: The effects of sensory restriction on susceptibility to hypnosis: a hypothesis, some preliminary data, and theoretical speculation. Int. J. Clin. Exp. Hypn., 17:217, 1969.
ADDITIONAL READINGS
Barber, T.X.: Death by suggestion. Psychosom. Med., 23:153, 1961.
__________: “Hypnosis,” analgesia, and the placebo effect. J.A.M.A., 172:680, 1960.
Bowers, M.: Hypnotic aspects of Haitian voodoo. Int. J. Clin. Exp. Hypn., 9:269, 1961.
Glass, L.B., and Barber, T.X.: A note on hypnotic behavior, the definition of the situation and the placebo effect. J. Am. Ment. Dis., 132:539, 1961.