ALCOHOLISM
Chronic alcoholism is a symptom of a deep-seated personality disorder usually selected to avoid intolerable life situations. There is no typical personality profile, but hostility, insecurity, and feelings of inadequacy are usually present. Alcoholics have a low frustration tolerance, increased sensitivity, and feelings of omnipotence characterized by the belief that “nothing can happen to me.” Outwardly they present a diffident appearance, which is usually a façade for their deep-seated dependency needs.
Some have little or no concern about the trouble caused by the habit. For instance, a binge, with its days of misery and sickness, often results in a lost job, a ruined career, and a broken marriage. The alcoholic is an “injustice collector” for whom the overt self-punishment fulfills a pleasurable need, as well as a rationalization for the inability to face reality. Seldom is he aware of his masochistic needs to suffer.
Such individuals do not have the courage to commit suicide and are, in reality, slowly destroying themselves by the noxious habit. To allay their tensions they retreat to a childlike behavior pattern, with a need for attention, pity, and love. By becoming inebriated, the alcoholic develops a greater capacity to give and receive attention from others. This temporarily increases his self-esteem and well-being.
Many alcoholics have never emerged from adolescence—the undifferentiated period of their psychosexual development which is characterized by homosexual tendencies. The esprit de corps noted among gregarious drinkers at any bar illustrates the desire to be a “part of the gang” spirit. The homosexual manifestations are seldom overt, but merely represent a strong identification with an individual of the same sex. The alcoholism serves the purpose of fending off unrecognized homosexual drives (panic). Often, however, the drunkenness removes the inhibitions and allows these tendencies to emerge.
In the typical history of the alcoholic there is a compulsive pattern represented by repeated incidents involving self-debasement, various types of sexual involvements, and defiance of authoritarian and other surrogate figures. When the demands for sympathy and attention are not met, more frequent “binges” are usually necessary to provide a respite from the mounting tensions. Exhortations aimed either at shaming the individual into sobriety or pointing out the harmful medical sequelae are useless. Since the alcoholic seldom realizes the needs for his habit, he cannot control his drinking. Successful therapy requires that these needs must become self-evident to him. Intellectualizing or moralizing on the dire mental and physical dangers is utterly futile in the chronic alcoholic.
Treatment
The purpose of therapy is first to motivate the individual to stop drinking and then to teach him how to adapt to his difficult problems, rather than using regressive behavior patterns at the first sign of stress. Here a sympathetic, noncondemnatory attitude will make the patient feel that he is being treated like an adult, and this helps to establish healthy motivation. Chronic drinkers are seldom motivated if their immaturity and strong dependency preclude admitting that they have a drinking problem.
Since most alcoholics are generally passive and dependent, the hypnotic relationship initially helps the patient in therapy at a time when he is most resistant. Later this dependency is dissolved, and the needs for it and other reasons are worked through. Because of greater rapport with the therapist, the patient now is willing to trade his self-destructive tendencies and immature attitudes for healthier goals.
The chronic alcoholic who does not wish to be helped, or who is literally brought in by friends or relatives against his will, cannot be helped by any psychotherapeutic approach unless he is institutionalized for long-term psychotherapy. The prognosis is usually poor, as each recovery is only a “flight into health.” His ardent protests that he is cured and his vows that he will never drink again are only rationalizations for the breaking off of therapy. Overcompliance merely follows the old adage, “If you can't fight them, join them.” Follow-up studies indicate that severe cases are difficult to help, irrespective of the therapy employed.
Conditioned Reflex Treatment by Hypnosis
Conditioned reflex treatment has been successful for some patients. In this approach the individual is given a drink and an emetic is administered. An association between vomiting and drinking is produced by this method, but it is not helpful unless the patient is highly motivated or is seen immediately after a “hangover.” Relatively permanent recovery in carefully selected patients is obtained by reinforcing this technic through posthypnotic suggestions to vomit at the sight, taste, or smell of liquor.21 Under sensory-imagery conditioning, the patient recalls repeatedly the horrible nausea and the disgusting sensations produced by the emetic. Thus the unpleasant memory is seldom forgotten, and the constant revivification of a repugnant experience dissuades him from drinking.
If a healthy relationship exists between therapist and the patient, the recovery forces will be mobilized. The desire to abstain is reinforced by appropriate posthypnotic suggestions. Motivation is increased by such other posthypnotic suggestions as the setting of a deadline for the daily or the weekly decrease in the quantity consumed, the stressing of the health factor, and, above all, the effect of the patient's self-esteem that has been enhanced by the permissiveness of the therapeutic regimen.
The key points in the conditioned reflex treatment under hypnosis, outlined by Kroger,21 Wolberg,44 Miller,30 and others,22 are based on repeatedly emphasizing, under hypnosis, the deleterious effects of alcohol, the conditioned repugnance for alcoholic beverages, and the patient's ability to control his own behavior, and finally establishing the emotional needs for the symptoms. The self-destructive drives should be channeled into healthy outlets such as hobbies, sports, social activities, and other constructive endeavors.
Aversion Treatment
After hypnosis and autohypnosis have been instituted, strong suggestions are given, such as, “Each time that you even think of drinking, you will develop a horrible disgust and taste for the liquor by associating it with the most horrible, repugnant smell and taste that you have ever experienced. After you have said this to yourself again and again, you will really begin to believe that a drink will smell and taste awful.” Such autosuggestions are repeated continuously for reinforcement purposes. After sobriety has been maintained, these can be made at longer intervals.
Wolberg has described a very interesting technic in which symptom substitution is utilized.44 He informs the patient that “Every time you crave a drink you will reach for a malted milk tablet and this will give you a sense of pleasure and relaxation.”
Another effective method is to open a bottle of whiskey while the patient is hypnotized and to assure him that the bottle has not been tampered with or opened. He is offered a drink, and requested to hold it in his mouth for several minutes to get the full taste. Naturally, a burning sensation on his tongue is created. After the patient has finally swallowed the drink, he is asked how he liked it. His usual reply is, “It tasted fine,” whereupon the therapist informs the subject that he has been deceived. “You have not been given whiskey but a mixture of lemon juice and ammonia.” If hypnotized, the subject will exhibit marked revulsion and disgust.
If this is unsuccessful, the procedure is repeated and the chances are that the next time he will react in the expected manner. Before concluding the hypnotic session, the patient should be given a posthypnotic suggestion that any time he is offered a drink, these reactions will certainly occur. Even the thought or the smell of a drink will induce profound distaste.
A substitute habit should be suggested to take the place of the drinking. For instance, drinking nonalcoholic beverages satisfies the oral cravings. Whenever a deeply ingrained habit pattern is changed, it should be replaced by a more innocuous substitute habit. Tranquilizers or amphetamines can be employed during the “weaning-off” period.
Before terminating every session, suggestions should be made that the patient will feel very relaxed. Immediately after dehypnotization, he can be offered a drink to see how much disgust is immediately produced. In selected subjects, this approach often produces a 60 to 70 per cent total abstinence. Social drinking is discouraged. Suggestions to bolster self-confidence and overcome feelings of inadequacy can be given during hypnosis.
It has been observed that alcoholics are good hypnotic subjects.14,26 An ego-building approach under hypnosis has been employed with frequent self-hypnosis sessions using reinforcement.6 Other investigators noted equivocal results,1,9,11,12 and still another found hypnosis to be of little value.8 Complete abstinence after cessation is usually emphasized,24 whereas some authorities allow only moderate drinking in a social setting.6 Switching to nonalcoholic beverages after one or two drinks has been recommended.6 The author believes that many alcoholics have a lowered resistance to alcohol, and this approach should not be employed for the hardcore alcoholic who has been “cured”; one or two drinks are enough to send him on a binge.
Hypnotherapy is used with autogenic training, conditioned reflex therapy, work therapy, and other measures in the Soviet Union. Group hypnosis and classical aversive conditioning are also employed by Soviet researchers in response to an increasing national incidence of alcoholism.16
Group Therapy
The success of Alcoholics Anonymous (A.A.) depends upon the same factors described in Chapter 35. The powerful group identification factor, which makes the sufferer feel accepted, and his intense desire to please the leader of the group or the person assigned to him (his sponsor) are additional factors. The group situation mobilizes the inherent competitiveness present in every individual and, through the strong support given by other members, his weak personality structure is bolstered. Finally, as a result of healthy motivation established by the emotional contagion, and alliance with a power greater than himself, the recovery forces of the individual are unleashed. Faith in a beneficient power means the difference between success and failure. The alcoholic has little or no reason to take issue with this new parental figure or to challenge his omnipotence. Through further friendly exhortations from former alcoholics, he often renounces his drinking habit. The author has a high regard for A.A.
Individual Hypnotherapy
Most problem drinkers are looking for a magical gesture and, because of their strong dependency strivings, attempt to “crawl into the lap” of the therapist. From the initial visit, they must be informed that this is a “do-it-yourself” program and that results are in direct proportion to the desire for recovery and the willingness to perfect their sensory-imagery conditioning technics. By using such measures, the therapist cannot get “out on a limb” or “lose face” with the patient.
It also is stressed that if the symptom returns, it can be controlled by autohypnosis; resistances are diminished whenever suggestions are self-originated. The therapist must not be too authoritative.
To avoid criticalness, the author states, “You will stop drinking as soon as you desire to, will you not? And it will be because you really want to do so down deep inside. I am only a friend who wishes to guide you as long as you need me.” This obviates the therapist's being placed in the role of a dominating parental figure.
Group Hypnotherapy
The author has found that the results in small groups are often better than with individual hypnotherapy. In addition to hypnosis, the technics include free discussion and expression of feelings, reeducation, reassurance, strong emotional support, and thorough explanations of the commonly encountered problems.
There are many rationalizations that alcoholics use to explain their drinking. They must recognize that dishonesty with themselves and with others, omnipotence, impulsiveness, guilt, shame, and the inability to establish durable relationships are related to the drinking. The manner in which tensions are displaced, self-abuse, the striving for perfection, and the need to manipulate others also should be pointed out.
When a permissive approach is employed that is directed toward these needs, guilt, anxiety, insecurity, and fear can be resolved, especially if the individual identifies with strong members of the group. The stronger the identification, the more will the alcoholic emulate those whom he admires. The important factor in group as well as in individual psychotherapy is giving the patient the feeling that the therapist really understands the patient's problems and is willing and able to help him. The greater ability to concentrate speeds up any type of psychotherapy. When group hypnotherapy is combined with decreasing doses of Antabuse medication, maximal improvement occurs. Wallerstein obtained 53 per cent improvement with Antabuse, 36 per cent with group hypnotherapy, 26 per cent with milieu therapy, and 24 per cent with conditioned-reflex treatment.42
Two-hour weekly sessions are held. Each one begins with a general discussion of alcoholism. Questions and answers pertaining to all aspects of drinking are dealt with in the first half hour. Then several former patients, who have been helped and who have returned to visit the group, cured, relate their experiences. They usually state that initially they could not believe that this kind of an approach would help them. Then, after observing improvement in other members, they were more motivated to obtain similar results. One or more grateful patients describe how they were taught hypnosis or autohypnosis and how through sensory-imagery conditioning they finally developed a profound disgust for alcohol (the technics outlined in the section below were used). In having a sufferer sincerely relate his feelings to the group, a considerable amount of hope rapidly develops, especially for the neophyte, the unsophisticated, or the disbeliever.
Those volunteers who are successfully hypnotized are given the appropriate suggestions for producing disgust and a strong aversion for drinking. Since a specific disgust to taste and smell will vary from patient to patient, it is wise to let each one pick these. In successive sessions, the technics of autohypnosis and sensory-imagery are inculcated into each person. The incidence of success is much higher where autohypnosis is employed. With this approach, the patient realizes that he must achieve the results through his own efforts. This is highly motivating and contributes to his self-esteem.
The medical management of the chronic alcoholic is not within the scope of this presentation. It involves a knowledge of the effects of long-term consumption of alcoholic beverages, including metabolic factors. The rehabilitation of the chronic alcoholic is tedious and requires painstaking attention, patience, and a mixture of empathy and firmness. At all costs, the therapist must not become too involved and must maintain a prestige position at all times.
Importance of Autohypnosis
It is not difficult for the alcoholic to practice autohypnosis. Frequently, however, he may procrastinate, saying, “I just can't find the time,” or “I don't feel up to it.” Here a careful step-by-step explanation should be given, stressing that the autosuggestions so necessary for his recovery should be under his control. This factor is of the utmost importance for establishing healthy motivation. Under autohypnosis, the patient can suggest when he thinks he will be able to substitute a soft beverage for the liquor. Through use of these measures, direct symptom removal is not employed. Instead, recovery is obtained by a weaning-off process in which the patient decides how and when to cut down on the number of drinks taken per day. It is also helpful to allow a choice of the type of beverage substitute that is to replace the liquor.
Importance of Posthypnotic Suggestions
Irrational fears of the patient that he will not be able to stop drinking can be reversed through posthypnotic suggestions directed to the possibility that maybe he will stop too abruptly. Other posthypnotic suggestions can be given to pick a date in the not-too-distant future when he will have reduced his drinks to one or two a day. It is suggested that he will be extremely worried as to whether he is going to be taking one drink a day or three drinks a day by the chosen date. Such extraverbal suggestions produce overreaction, with resultant improvement.
As in the treatment of obesity, posthypnotic suggestions are given that, if the patient is in doubt about taking a drink, he will imagine his therapist shaking his head in disapproval. When all these technics are employed with supportive psychotherapy consisting of rapport, ventilation of problems and skilful guidance, excellent results can be obtained in a high percentage of patients.
If a patient, who apparently is doing well, relapses or “falls off the wagon,” he is never censured or criticized. However, the question can be raised with him as to what the particular situation was for doing this and why he had to take 10 drinks—perhaps he could have gotten by with four drinks, or two drinks, or perhaps one drink. Also, what was he thinking about before he began drinking? These and other problems are fully discussed. It is important to emphasize that, with most chronic alcoholics, the ultimate therapeutic goal is directed toward total abstinence.
With greater maturation and growth of the personality, the alcoholic thinks more like an adult and eventually realizes that he no longer has the need to utilize harmful tension-allaying mechanisms to meet his life problems. Even after the problems responsible for the need to drink are made self-revealing to the patient, they are frequently of such magnitude that he feels there is no solution. Here it is imperative that one of two things be done: either the individual must be given the knowledge to make the proper decision as to what course he will adopt (and it should be emphasized that the decision must come from him and him alone), or, if he is unable to make a decision, he should walk away from the problem and stop using it for self-punishment.
The following verbalization is typical for the aversion treatment of alcoholism: “John, you are deeply relaxed. Listen to all my suggestions, as each one will be indelibly imprinted in your mind. You will not remember all these suggestions today, but eventually you will remember all of them. Each and every suggestion will be remembered over the coming weeks and months.
“If you really wish to stop drinking, think of the most disgusting, nauseating taste that you have ever had. Maybe a drink will taste like onions, rutabagas, parsnips, or whatever other food you dislike. That's right. You are beginning to taste something awful, are you not?” (“Yes.”) “Did you say it's turnips; is that what you said?” (“Yes.”) “Now, each time you even think of taking a drink, you are going to experience this taste of turnips … this vile, horrible taste of the turnips during the next few weeks and months. Each and every time you take a drink, you will associate it with the disgusting taste of turnips. Right now, this awful taste is getting more and more marked, is it not?” (“Yes.”)
“Now, think of the most putrid smell that you've experienced. Take your time and try to think of the most horrible stench that you've ever smelled. … Rotten eggs? Well, that's a good one. All right, now each and every time you hold a drink in your hand and smell it, you will think of rotten eggs … the horrible, violent, disgusting smell of rotten eggs. And each and every time you even think of taking a drink now, you are not only going to get the terrible taste of turnips, but also the smell of rotten eggs. This may not make itself apparent until you have said this to yourself over and over again, perhaps 50 or 100 times, under autohypnosis. Eventually you will associate this smell with the odor of liquor until you are sure that you really hate the sight, taste, and smell of a drink (sensory-imagery conditioning).
“John, the next thing I'd like to have you do is to recollect how horrible you felt after you had a lot of drinks last Saturday night, just as if you were doing it all over again (age regression). Remember the terrible feeling that you had in your stomach, and how you had to vomit? Recollect, if you will, that sickening feeling you had and how you trembled and shook all over and how weak you were, and the headache and the dizziness and all the other symptoms associated with your hangover. Recall all the details of that hangover and, if you really think about it, you will really become disgusted with drinking. Each and every time you even think of taking a drink, all of these positively awful tastes and smells will be etched in your mind. You can reexperience all of these sensations in a few minutes, even though the hangover lasted for several hours.
“I'm going to show you how this can be done by condensing (distorting) time. You know how when you're waiting for a cab on a cold, wet, rainy day and the cab is due in 2 minutes … it seems like 20 minutes. Or, conversely, when you're chatting with an old friend and a cab is due in 20 minutes, it seems like 2 minutes. And so, during the next 2 minutes, you are going to be able to experience all of the unpleasant, disgusting sensations associated with a half hour of the hangover that you had last Sunday morning. Fifteen minutes of actual time will seem like 1 minute of time. So, therefore, in 2 minutes by the clock, you will be able to relive all of the disgusting feelings that you experienced in approximately one half hour.” (Two minutes elapse, during which the individual screws up his mouth, begins to get sick, and has a tendency to vomit.) “Your time is now up. Wasn't that a horrible sensation? Now, each time when you have the desire to take a drink, you will reexperience the horrible sensations of that last hangover.
“Remember, this is your problem. If you wish to drink, it is your privilege. After all, as I mentioned, this is your mind and your body, and it's up to you to direct your own treatment. Over the next few weeks, you might raise the question as to exactly how much you have the need to drink. Do you need to drink 80 per cent of the time, or 50 per cent, or 10 per cent? Maybe 5 or 10 per cent will fulfill your needs. I'm sure that once you realize the need to drink, you should be able to recognize the deep-seated feelings responsible for the habit. Don't press or try to think of these reasons, but just rest assured that some of the reasons will become apparent to you in the near future.
“Now, John, perhaps you can step out of yourself, much as you would in a dream (depersonalization). Look at yourself standing at a bar, uncertain, wobbling, making a fool of yourself. Take another good look at yourself. Are you not disgusted with the terrible smell of liquor on your breath? Observe the sloppiness of your clothes. When you are sober, you are always very neat. Are you not disappointed with what you see?” (depersonalization often can be very effective in creating a disgusting self-image).
“Picture yourself at one of the drunken brawls where everybody is making a fool of himself. Is it not disgusting to see someone you respect sink lower and lower into utter insensibility and helplessness? I am interested in all your problems, and I want you to remember that any time you feel you need my help, regardless of where you are, I want you to please call me. If this is not possible, and if you are in doubt as to whether or not you should take that second or third drink, you will really see me standing beside you, shaking my head in disapproval (introjection of therapist).
“And now you can come out of this very nice state of relaxation, which is not sleep or unconsciousness and is not a trance. You can slowly open your eyes in the following manner: Number 1, say to yourself, ‘I will go deeper next time.’ Number 2, ‘I will follow all the suggestions that I am giving to myself to the best of my ability.’ Note that I said, ‘I am giving to myself,’ rather than ‘those given by the doctor.’ Three, ‘I will open my eyes. I will feel supremely confident that I can lick my problems.’
“You will feel, John, that you were the one who did it. Remember that. You were the one who was able to control your need to drink. Remember, the degree of success you achieve will be in direct proportion to the amount of effort you put forth. Practice makes perfect! Think of a foul-smelling, evil-tasting sensation every time you crave a drink. If you do this again and again, you will be able to break up this vicious habit.
“You need not feel guilty if you ‘fall off’ at any particular time. Progress is never in a straight line. It is characterized by a series of ups and downs. However, the long-term trend will ever be upward.
“You have a very powerful tool that is only as good as you use it. Use it well, sharpen it, and it will cut to the core of your problem. The manner in which you use it can be very helpful in this regard. A tape of this discussion with you is being recorded. It would be a good idea if you played it on your tape recorder every night. Then these suggestions will be deeply implanted again and again into your mind until they achieve a conditioned response. Whenever we hear a suggestion again and again, we eventually carry out the suggested act. You do have a great deal of confidence in yourself and you know that you can lick this problem in your own particular fashion.”
EXCESSIVE SMOKING
Excessive smoking is one of the commonest symptoms the hypnotherapist is asked to treat. Almost every chain smoker has at one time or another attempted to break the habit. Numerous authors have used hypnosis for smoking control.3,4,5,7,13,20,23, 29,31,33,37,38,41,45 One writer reviewed the current literature on smoking and was disappointed with the results.4 Spiegel utilized one 45-minute session, stressing an alert, self-renewing, vigilant sensitivity to new commitments, namely, that the patient stop injuring his body.37 These commitments consist, in essence, of the following: “For your body smoking is a poison! You need your body to live! You owe your body this respect and protection!” His results showed a 20 percent effectiveness. Dengrove, commenting on Spiegel's approach, notes the motivating effect of the fee and the striking relationship to operant conditioning and behavior modification.7 He also questions the value of the commitments requested by Spiegel. Another investigator noted that 90 of 121 of his patients resumed smoking within a month.33 It is believed that, in part, the covert factors present in the Spiegel method are the strong desire to stop smoking in our health-oriented society.45 Rose found that 50 per cent of his patients stopped smoking after a physical examination and three counseling sessions.36 Transcendental meditation also has been found helpful in reducing tension.
Kline reported that a 12-hour group therapy session, utilizing hypnosis and other technics, was successful for 88 percent of the participants.19 He contends that hypnosis, and particularly extended periods of hypnotherapy involving the reduction and control of deprivation behavior, offers a promise for relief of smoking habituation.
Nuland and Field,33 and Crasilneck and Hall5 obtained 60 and 82 per cent recovery rates respectively, using a personalized approach under hypnosis and follow-up by telephone. These results were not correlated with the depth of hypnosis. Kroger and Libbott advocated a holistic approach involving hypnosis, self-hypnosis, and treatment directed toward the patient who has the habit—understanding his emotional needs.23 Relapses were frequent, and there were no long-term follow-ups.
Watkins describes a five-session approach based upon the study of the motivations of each client.43 Specialized suggestions and tailored fantasies were directed toward removing rationalizations; reinforcement of the person's commitment to stop smoking was utilized. She used a number of technics combining a passive-concentration approach with behavior therapy. Those who did not stop appeared to be using smoking to control anger. Her results were excellent—67 per cent were not smoking at the end of 6 months. Kroger and Fezler have reviewed the behavior modification literature: in addition to aversive conditioning, desensitization, and self-control, a group of standardized images were added to increase motivation and unlearn the maladaptive smoking behavior.22 They also used cassette instructions for the latter. Stimulus control, self-punishment, and other operant procedures were employed, but not too effectively. The long-term results were only equivocal. Careful study reveals that all methods after long-term evaluation yield about equal results. Group therapy is no better than the didactic methods.
The following suggestions can be added to my approach, as described below: (1) have patients switch brands in gradual steps toward lower nicotine content, (2) have them inhale rapidly every 6 seconds, (3) reinforce the aversive suggestions, (4) employ recitation of the rationalizations to return to smoking and then analysis of what is wrong with the rationalizations. Withdrawal symptoms are reduced if the therapist stresses that increased oxygen intake will neutralize them.
Regardless of the approach employed, the hypnotherapist's responsibility in smoking control is to present the facts about smoking, to relate these facts to current health problems, to give every smoker a firm admonition to stop smoking, and to reinforce these by posthypnotic suggestions repeated during subsequent visits or by taped instructions. Long-term follow-up reinforcement by visits or phone calls is a powerful incentive to comply.
It is apparent from all foregoing studies that motivation is of prime importance. Presence of premonitory symptoms of heart, lung, and peripheral vascular disease provides additional powerful motivation. For such individuals, forceful instructions can be effective. Unfortunately, those who do not stop smoking label themselves as failures even though many can be helped. Moreover, many persons who are interested in hypnosis are looking for a magical, mystical cure—these are destined to fail.
The following is a sample verbalization of the posthypnotic suggestions that the author has used successfully on many smokers: “Use your imagination to curb your desire rather than your will. Therefore, each time you even think of smoking a cigarette, associate the pleasurable aroma and taste of a cigarette with the most horrible and awful smell and taste that you have ever experienced. Under autohypnosis and sensory-imagery conditioning you can convert your craving for a cigarette into an aversion. This will not happen immediately but, after you have given yourself a sufficient number of autosuggestions in this regard, you will notice that slowly and surely you will have less and less desire for cigarettes.
“Next, if you really wish to stop smoking, every time you puff on a cigarette, associate the taste and aroma of a cigarette with the most repugnant taste and odor that you have ever experienced. The craving will be converted into an aversion with continuous practice.
“You will agree that the best results are obtained if one has a goal. Hence, suggest smoking half as much during the next 2 weeks. Then cut down half as much again for the following 2 weeks until you are able to wean yourself off the habit. You can set the goal and arbitrary number of cigarettes to be smoked daily according to your needs and at your own pace.
“Since you are right-handed, would you mind holding the cigarette in your left hand and, instead of placing the cigarette in the right side of your mouth, which is customary for you, would you mind using the left hand for putting the cigarette in the left side of your mouth? You will, I am sure, find that if you follow these suggestions, smoking will be a chore.
“Would you mind holding the cigarette first between your thumb and little finger, then your thumb and ring finger, middle finger, or other fingers. By utilizing different combinations, you will soon find that smoking becomes rather inconvenient.
“If you really are interested in giving up this habit, allow several cigarette butts to remain in the ash tray until they develop a very stale odor. Then sniff this odoriferous ash tray at least once every hour. If you do this, you will easily develop a distaste for cigarettes. May I suggest that another ash tray with stale butts be placed on your night stand beside your bed just before retiring. When you no longer can bear the obnoxious smell, place the ash tray out in the hall, but do not empty the ash tray, as you should repeat this procedure the next night until every fresh cigarette reminds you of a stale one.
“After your smoking is reduced, you might consider the possibility of trading down to a more innocuous habit. How about substituting a peppermint Lifesaver for each cigarette that you do not smoke? You will find that, whenever the tip of your tongue is put into the hole of the Lifesaver, the same satisfaction will be obtained as if you had smoked a cigarette. If this is not feasible, you can use chewing gum or a dummy cigarette instead. You can hold the latter between your lips and imagine it's real.”
In addition to the above suggestions, one can stress the health and other beneficial factors related to abstinence. If the individual is a heavy smoker, he usually has his nails discolored by nicotine. One can, with tongue in cheek, point out that this discoloration occurs in the bronchial tubes, too; that the inside of the bronchial tubes actually “stinks” like the stale cigarettes. It is emphasized that all these suggestions, if given by the patient to himself, afford a distinct possibility that the habit can be broken because of his own efforts. Furthermore, it should be emphasized that all credit for breaking the habit belongs to him, since he really did it through his imagination. The posthypnotic suggestions are useful for symptom removal. About 40 per cent of the patients relapse. Therefore, it is advisable to reinforce the suggestions at least every week.
When the excessive chain smoking is a symptom of the underlying tension, the needs for the nervous tension must be eliminated. When hypnosis was used for symptom removal, the author has never seen the slightest harm. What is the difference between cessation of smoking through hypnosis and spontaneous remission? The author is not in accord with those who are continually pointing out the dangers of symptom removal. If these dangers are real, then proprietary products sold to stop smoking are also dangerous!
An ingenious method for smoking control has been described which uses a complicated, ritualistic 21-day approach.19 The “will” is not utilized, but rather an appeal on physical, cosmetic, personal, and financial grounds. Medications, such as antihistamines and barbitals, are used to control “withdrawal” symptoms.
INSOMNIA
Hypnosis effects improvement in acute cases of insomnia. Often a single session is effective in restoring the sleep cycle, particularly if autohypnosis has been taught on the initial visit. It can be suggested that the autohypnosis will merge with real sleep. The following posthypnotic suggestions are efficacious: “After you have established a deep state of autohypnosis, with each breath you will find yourself going deeper and deeper relaxed. And as your breathing gets slower, deeper and more regular, you will find yourself going into a deeper and deeper state of relaxation. And as you relax deeper, you will find that you will become drowsier and drowsier until you get sleepier and sleepier.”
Insomnia can take different forms and have many courses. Some insomniacs lay awake for hours before falling asleep. Others wake up and cannot fall asleep again. Early wakening with inability to fall asleep generally indicates the presence of a depressive reaction. None of these reactions poses a problem unless the individual is fatigued, tense, and anxious. If chronic, it can be debilitating, and the more the person worries about his sleeplessness, the more depressed he becomes. Pseudo-insomnia occurs in persons who think they do not sleep. This type responds to reassurance. Also, the older one gets, the less sleep one requires.
The physician should rule out brain disease and barbiturate addiction as causes for insomnia. Others have disturbances in their biological rhythms; they are nocturnal individuals. This type needs reprogramming to a more circadian rhythm. By far the most common type is the person who takes his worries to bed. Such individuals associate the bed with insomnia—a self-fulfilling prophecy. For these patients behavior therapy to recondition them to associate the bed with sleep often can be effective. Vigorous exercise, relaxation, meditation, and selfhypnosis are more effective than somnifacient drugs.
Chronic insomnia, however, is more difficult to treat. Many patients have deep-seated problems and the symptom cannot be alleviated unless the patient is able to recognize and deal objectively with these problems. When the tensions are decreased, the insomnia can be controlled. Here, too, the imagination plays an important role. Patients are instructed that the harder they try to fall asleep, the less chance they will have of doing so, and that lack of sleep seldom produces harm, but that worry wreaks more havoc than lack of sleep. Following the law of reverse effect, the posthypnotic suggestions must be directed toward the need to keep awake! The harder they try to remain awake, the more they will fall asleep. Adjunctive procedures such as regular hours for going to sleep, mild exercise to induce fatigue, hot drinks, and warm baths are helpful for promoting relaxation. Barbiturates and other drugs should not be removed at once but reduced gradually. Environmental factors such as noise must also be eradicated.
More specifically, hypnosis can be directed to symptom removal as follows: “At first you might consider the possibility of deliberately trying to keep awake; that is, do not try to fall asleep but, rather, imagine that you must stay awake as long as possible. Thus you can imagine that you are an airplane spotter and that it is necessary to screen all unusual sounds you hear. You will notice that it will become increasingly difficult to stay awake, and that sleep will gradually come over you.
“Next, sleep can be facilitated by ‘stepping out of yourself.’ In a dream you can see yourself performing all sorts of tasks, can you not? Thus, during hypnosis, you can also stand alongside the bed and see yourself there with your eyes closed. As you look at yourself, you can notice your breathing getting slower, deeper, and more regular, the rhythmic rise and fall of your chest, and the relaxed expression on your face. And as you keep looking at this image of yourself, you will become very, very relaxed. Very, very relaxed. As long as you keep your arms and legs in a nice, comfortable position, you will find that every muscle is relaxing more and more, and with every breath you will get very drowsy. And as you get very, very drowsy, you will find that even though your eyes remain tightly closed, you will get sleepier and sleepier.”
In general, one must minimize the importance of sleep and reverse the patient's fears by suggesting that he remain awake and that the harder he tries to keep awake, the deeper he will get. Also, one can use strong suggestions that the hypnotic relaxation will merge with true sleep. Where hypnosis is not successful, intensive psychotherapy is indicated.
NARCOTIC ADDICTION
Drug addiction involves many of the psychological factors that account for chronic alcoholism and obesity. In general, there are three types. In the first, the addict attempts to meet stressful situations with more equanimity through the use of drugs. In the second, individuals use drugs to give them a “lift.”
In the third, the addict requires drugs to help to overcome depressive reactions due to characterologic disorders.
Regardless of the method of addiction, drugs are utilized to provide approval from others, security, and self-esteem. Initially, though physiologic gratification is all important, emotional satisfaction plays an even larger role. Eventually physical cravings create a fear in the addict that he needs his drug in order to survive.
Addicts are usually unable to cope with or adjust to the demands of society. Many feel inadequate and inferior even though they present a façade of arrogance and confidence. They also manifest strong dependency strivings and succumb to peer pressures. Van Nuys posits a relationship between drug use and hypnotizability.39 However, this is not a causal one. Rather, as Josephine Hilgard has theorized, there may be a connection between hypnotizability and those she classifies as “mental space travelers”—those who seek excitement through adventures of the mind.15
Therapy should be directed toward restoration of self-confidence, elimination of despondency, induction of well-being, and, in all instances, rehabilitation to prevent recidivism. Most methods of psychiatric rehabilitation yield poor results, since addicts generally return to their old environment.
On the whole, the results with hypnosis in narcotic addiction have been poor. Many addicts have well-established, conditioned pain-pattern syndromes, and it is difficult for such persons to give up the drug even temporarily. Therapy is more likely to achieve results, if employed in an institution where withdrawal symptoms can be handled and where the addict can be kept under strict supervision. Even then, however, many relapse after release and return to their drug habits. Sedatives, hypnotics, and narcotics help to control withdrawal symptoms. Long-term effects of methadone therapy (for “controlled” addicts) are ineffective; one habit is merely traded for another. Furthermore, withdrawal from methadone is more difficult than from heroin.
Autohypnosis is helpful for withstanding disagreeable sensations produced by withdrawal. Posthypnotic suggestions and deep relaxation help to countercondition anxiety and allay nervousness and insomnia. Other posthypnotic suggestions of an aversive nature can often reduce the craving for the drug. Narcotic addicts show increased susceptibility to suggestion.40 However, lack of motivation, together with a weak personality structure, accounts for the poor results in most cases.
Behavior therapy and sensory-imagery conditioning in which the addict imagines that he is giving himself an injection or taking a drug by mouth while under autohypnosis often affords gratifying results.22When individuals can actually revivify the pleasurable effects afforded by the drug, withdrawal is accomplished more readily. In general, particular attention must be paid to the individual who has the addiction problem rather than to the symptom! Treatment by any method cannot be considered successful until craving has been abolished permanently. The methods for handling narcotic addicts by group psychotherapy under hypnosis have been described.10 Ludwig and co-workers use a very authoritative approach with narcotic addicts.28 Results of their study indicated that psychological factors played an important role in the narcotic drug experience and the drug abstinence state. A psychodynamic approach to understand the meaning of the symptom in the patient's psyche also has been stressed.6
Nelson and Nelson have described a method using three phases of therapy in drug detoxification:30,32
1. The motivational phase requires that primary motivation exists.
2. During the “physical withdrawal” phase, therapists work around the clock for 3 days. This intensive approach is designed to lessen, but not to alleviate, the experienced pain.
3. The “personality reconstruction” phase begins after discharge from the hospital and consists of “reprogramming” the individual for re-entry into society, including ego-strengthening, relief of tension, and counseling.
Other practitioners have treated heroin addiction with aversion therapy, relaxation training, and systematic desensitization.27,34,35 A classical aversive conditioning procedure, employing electric shock and verbal imaginal stimuli, was used to extinguish the intense cravings resulting from heroin addiction. Progressive relaxation replaced drug-induced relaxation. The systematic desensitization approach counteracted the profound anxiety instituted by the consummatory response of heroin addiction.
The original concept of a biological drive in the heroin addict—“tissue dependency”—can no longer be equated with addiction. The former is a neurophysiological state which follows cessation of the drug and is self-limited; here the brief use of drugs is indicated. If, on the other hand, the addiction is due to behavioral disorders characterized by a compulsive and overwhelming preoccupation with using the drug, then the attitudes must be altered by a sophisticated therapeutic approach wherein hypnosis and behavior modification can change the behavior, provided the patients are highly motivated.
Management of heroin addiction by substitution therapy, such as methadone maintenance, has not been scientifically validated. The treatment program may foster an iatrogenic drug dependency which is very often worse than the initial addiction. Any benefit derived from methadone maintenance is not solely from its “blocking effect,” but also from the interpersonal relationship and the potential for this human interaction to alter behavior. This applies to the abuse of drugs such as amphetamines, methaqualone, and barbiturates—these are more psychologically habituating than physically addicting. Success is increased if the tensions requiring the drug are identified and corrected.
Newton has used hypnorelaxation to relieve psychosomatic withdrawal symptoms in heroin addicts.* Three other procedures also were devised to deal directly with behavior relating to the use of drugs. One procedure consisted of having the hypnotized patient imagine himself using heroin and obtaining no effect from the fix. He was given posthypnotic suggestions to lead him to believe that the drug trip was of no value to him. Another posthypnotic suggestion was given that he remember this fantasied experience whenever the urge to have a fix occurred. A second procedure involved a hypnotic fantasy in which the patient's preparation for self-injection was paired with increasingly threatening stimuli, such as rats, spiders, and snakes. These aversive stimuli disappeared when the addict imagined himself completely rejecting the proposed drug experience. The final procedure dealt with hypnotically induced fantasies in which the addict imagined himself in situations that usually were resolved by injecting drugs. In these tenuous situations, the addicts imagined themselves declaring that they would not use heroin. This declaration during the imagery was immediately followed with a very rewarding and satisfying fantasy experience. The posthypnotic suggestion, in essence, was that whenever the patient found himself in these situations and had the urge to have a fix, he would imagine himself refusing the fix and then reward himself with the satisfying sequence.
The author firmly believes that no psychiatrist, regardless of his skill and experience and the particular therapy used, can manage a patient who takes drugs against the psychiatrist's prohibition and express orders. If the patient takes drugs which elevate or depress his moods, the problem becomes even more insoluble. Physicians who prescribe these drugs for other medical problems without obtaining a psychometric profile of the patient, or even determining if the patient is under psychiatric care, should be taken to task.
Every form of psychiatric help requires regular visits by the patient—to the degree that the psychiatrist determines and informs the patient. The willingness of the patient to cooperate can be determined by his meeting the schedule of appointments with the doctor. The psychiatrist attempting to help self-destructive patients often is faced with decisions which on one hand may have a short-term benefit and on the other may destroy the patient's trust in him, which is the essential ingredient necessary to continue therapy. The focus on a patient's rights has created a different perspective on consent to psychiatric hospitalization. Such a procedure often is difficult without the patient's informed consent.
Custodial care is not the end sought by psychiatrists. Such an objective suggests the elimination of hope for a functioning patient. We must accept the risks for allowing a patient who is functioning in his job or profession to continue to do so as an essential element in his road back to mental health.
REFERENCES
1. Abrams, S.: An evaluation of hypnosis in the treatment of alcoholics. Am. J. Psychiatry, 120:1160, 1964.
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6. __________: Clinical Hypnosis: Principles and Applications. New York, Grune & Stratton, 1975.
7. Dengrove, E.: A single-treatment method to stop smoking using ancillary self-hypnosis: discussion. Int. J. Clin. Exp. Hypn., 18:251, 1970.
8. Edwards, G.: Hypnosis in treatment of alcohol addiction: controlled trial, with an analysis of factors affecting outcome. Q.J. Stud. Alcohol, 27:221, 1966.
9. Feamster, J.H., and Brown, J.E.: Hypnotic aversion to alcohol: three-year follow-up of one patient. Am. J. Clin. Hypn., 6:164, 1963.
10. Fox, J.: The systematic use of hypnosis in individual and group psychotherapy. Int. J. Clin. Exp. Hypn., 8:109, 1960.
11. Fox, R.: Psychiatric aspects of alcoholism. Am. J. Psychother., 19:408, 1965.
12. Granone, F.: Hypnotism in the treatment of chronic alcoholism. J. Am. Inst. Hypn., 12:32, 1971.
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14. Hartman, B.J.: Hypnotic susceptibility in chronic alcoholics. J. Natl. Med. Assoc., 58:197, 1966.
15. Hilgard, J.R.: Personality and hypnotizability: inferences from case studies. In Hilgard, E.R. (ed): Hypnotic Susceptibility. New York, Harcourt, Brace and World, 1965.
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18. Johnston, E., and Donoghue, J.R.: Hypnosis and smoking: A review of the literature. Am. J. Clin. Hypn., 13:265, 1971.
19. King, A.: The Cigarette Habit. New York, Doubleday, 1959.
20. Kline, M.V.: The use of extended group hypnotherapy sessions in controlling cigarette habituation. Int. J. Clin. Exp. Hypn., 18:270, 1970.
21. Kroger, W.S.: The conditioned reflex treatment of alcoholism. J.A.M.A., 120:714, 1942.
22. Kroger, W.S., and Fezler, W.D.: Hypnosis and Behavior Modification. Philadelphia, J.B. Lippincott, 1976.
23. Kroger, W.S., and Libott, R.Y.: Thanks, Doctor, I've Stopped Smoking: A Modern Doctor-Patient Approach to Smoking Control. Springfield, Ill., Charles C Thomas, 1967.
24. Langen, D.: Modern hypnotic treatment of various forms of addiction, in particular, alcoholism. Br. J. Addict, 62:77, 1967.
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26. Lenox, J.R., and Bonny, H.: The hypnotizability of chronic alcoholics. Int. J. Clin. Exp. Hypn., 24:419, 1976.
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29. Miller, M.M.: Hypno-aversion treatment of nicotinism. J. Natl. Med. Assoc., 56:480, 1965.
30. __________: Treatment of chronic alcoholism by hypnotic aversion. J.A.M.A., 171:164, 1959.
31. Moses, F.M.: Treating the smoking habit by discussion and hypnosis. Dis. Nerv. Syst., 25:185, 1964.
32. Nelson, G.R., and Nelson, M.: The psychology of hypnotic drug detoxification. J. Am. Soc. Psychosomat. Dent. Med., 22:44, 1975.
33. Nuland, W., and Field, P.B.: Smoking and hypnosis: a systematic clinical approach. Int. J. Clin. Exp. Hypn., 18:290, 1970.
34. O'Brien, J.S., et al.: Treatment of heroin addiction with aversion therapy, relaxation training and systematic desensitization. Behav. Res. Ther., 10:77, 1972.
35. Raymond, M.J.: The treatment of addiction by aversion conditioning with apomorphine. Behav. Res. Ther., 1:287, 1964.
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38. Stein, C.A.: Displacement and reconditioning technique for compulsive smokers. Int. J. Clin. Exp. Hypn., 12:230, 1964.
39. Van Nuys, D.W.: Drug use and hypnotic susceptibility. Int. J. Clin. Exp. Hypn., 20:31, 1972.
40. Vogel, V.H.: Clinical studies of drug addiction: Suggestibility in narcotic addicts. Public Health Rep. Suppl., 127:1, 1937.
41. Von Dedenroth, T.E.: The use of hypnosis in 1000 cases of “tobaccomaniacs.” Am. J. Clin. Hypn., 3:194, 1968.
42. Wallerstein, R.S.: Hospital Treatment of Alcoholism. New York, Basic Books, 1958.
43. Watkins, H.H.: Hypnosis and smoking: a five session approach. Int. J. Clin. Exp. Hypn., 24:381, 1976.
44. Wolberg, L.: Medical Hypnosis. vol. 1. New York, Grune & Stratton, 1948.
45. Wright, M.E.: A single-treatment method to stop smoking using ancillary self-hypnosis: discussion. Int. J. Clin. Exp. Hypn., 18:261, 1970.
SUGGESTED READINGS
McCartney, J.L.: Hypnosis in treatment of narcotic addiction. Phi Chi Quart., 62:140, 1965.
Vogel, V.H.: Narcotics and Narcotic Addiction. Ed. 4. Springfield, Ill., Charles C. Thomas, 1954.
Wikler, A.: Some implications of conditioning theory for problems of drug abuse. Behav. Sci., 16:92, 1971.