HANDBOOK , _:: , of HYPNOTIC SUGGESTIONS AND METAPHORS This book is dedicated with deep love and affection to my children, Matthew, Erin, Christopher, and Mark FOREWORD Hypnotherapy is the application of hypnosis in a wide variety of medical and psychological disorders. Adequate training in psychotherapy is a prerequisite for practicing hypnosis, regardless of whether the clinician is a psychologist, physician, social worker, or dentist. In fact, training in psychotherapy and hypnotherapy is a never-ending process. A text of this magnitude offers both the neophyte and the experienced clinician a tremendous, comprehensive reference. After receiving initial classroom or workshop training, additional training comes through reading, self-study and self-experience. This book represents a beacon for those desiring additional training in treating clinical problems. Having this reference available will give the new practitioner a very secure feeling. This is a book for clinical practitioners. In fact, it will undoubtedly become the practical companion volume and supplement to comprehensive textbooks and courses on hypnosis. It provides the reader with the "how to" suggestions that therapists use with their patients. Rather than intellectually discussing the topic of hypnosis, this book gives therapists, physicians and dentists a sampling of what experienced clinicians actually say to their patients during hypnotic work. At last we have a book that helps answer the common query from our students: "But what do I say now that the patient is hypnotized?" Every student and clinician who uses hypnosis will want to have this invaluable and comprehensive desktop reference. It represents the largest 'collection of therapeutic suggestions and metaphors ever assembled, with contributions from over 1 00 of the world's finest hypnotherapists. For those interested in the theoretical and research aspects of hypnosis, there are numerous other volumes that may be found in libraries. In my opinion, we are very fortunate in having this new text in which something so complicated has been made so much more understandable. However, Dr. Hammond rightly emphasizes that this is not meant to be a cookbook of suggestions to be routinely used with certain problems . And simply the extensiveness of the suggestions he has compiled will tend to discourage anyone from mechanically applying the same paragraph of suggestions to everyone with a problem. His inclusion of empirical indications vii viii HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS and contraindications for modules of suggestions is also intended to facilitate thoughtful treatment planning and the individualization of treatment. What you will find here is a resource book from which you will be able to pick and choose suggestions that you clinically judge to be compatible with individual patients and with your own personal style of doing hypnosis. It is an eclectic book that models a wide range of styles of practice in clinical hypnosis. The tremendous breadth of suggestions will also serve as a stimulus to your creativity in preparing hypnotic suggestions and metaphors of your own. Chapter 2 will enhance your skills further through outlining the principles and guidelines for formulating successful hypnotic and posthypnotic suggestions. Suggestions included in the book concern dozens of clinical problems. There are chapters and sections of suggestions on such medical topics as pain, hypnoanesthesia and hypnotic preparation for surgery, burns, emergencies, gastrointestinal disorders, cancer, chemotherapy, dermatologic complaints, obesity, smoking and addictions, childbirth training, obstetrical and gynecologic applications, insomnia, autoimmune diseases, and hemophilia. Psychotherapists will find practical suggestions concerning habit disorders (e.g. , nailbiting, trichotillomania), anxiety and phobic disorders, sexual dysfunctions and relationship problems, concentration , academic performance, sports, egostrengthening to increase self-esteem and selfefficacy, posttraumatic stress disorders, multiple personality disorder, severely disturbed (e.g. , borderline, schizophrenic) patients, and other emotional disorders. A chapter on hypnosis with children includes such clinical topics as pain and hypnoanesthesia, dyslexia, stuttering, enuresis, Tourette syndrome, school phobia, and asthma. Dentists will find useful suggestions concerning bruxism, TMJ , anxiety and phobic responses, pain control, thumbsucking, vascular control and gagging. There are also suggestions to be found on facilitating age regression, age progression, and time distortion. Each chapter represents the epitome of clinical expertise extant in our field. This Handbook contains a wealth of original and previously unpublished suggestions that Dr. Hammond solicited from many of our most experienced hypnotherapists. In these pages you will also discover many of the finest suggestions that have appeared in books, chapters and journal articles over the last 30 years. For example, suggestions are included from throughout the back issues of the two most prestigious hypnosis journals in the world, the American Journal of Clinical Hypnosis and the International Journal of Clinical & Experimental Hypnosis. Dr. Hammond has done the work for us of reviewing tens of thousands of pages of books and journals, and then compiling in one place the practical clinical gems that he discovered. This book was a massive undertaking. Tasks of this kind require literally hundreds of hours of personal sacrifice and effort. Very few people possess this dedication and scholastic capability. The present text is literally Herculean in scope, volume and content. The book is also unique in that neither Dr. Hammond nor any of his contributors will receive royalties from its publication. The book was literally a labor of love by all those who FOREWORD ix have contributed. It was donated to and accepted as an official publication of the American Society of Clinical Hypnosis. All royalties from its sale will go to the American Society of Clinical Hypnosis to promote further research and workshop training in clinical hypnosis throughout the United States and Canada. Dr. Hammond is a master clinician of unusual breadth and talent who has become one of the giants in the field of clinical hypnosis. Part of his brilliance lies in the expertise that he has in integrating the practical contributions that are found in a great diversity of different orientations and approaches to hypnosis. Although he clearly makes scholarly and research contributions to the field, Dr. Hammond is primarily a clinician of the greatest magnitude, as exemplified by this text. Cory Hammond is one of the few people whom I know capable of authoring and compiling this type of text. People in the field will always be indebted for this yeoman challenge which he has completed in this magnificent presentation. His clinical breadth, extensive practical experience, and thorough knowledge of the field are truly reflected in this work. Dr. Hammond's book is destined to be a classic in the field that will be sought after for decades to come. It will rank as one of the greatest therapeutic contributions made in the fields of medicine, psychology, dentistry and allied fields. Harold B. Crasilneck, Ph.D. Past President, American Society of Clinical Hypnosis and the Society of Clinical and Experimental Hypnosis Clinical Professor of Psychiatry and Anesthesiology, University of Texas Health Sciences Center, Dallas CONTENTS Foreword by Harold B. Crasilneck vii 1. Introduction 1 The Underlying Therapeutic Philosophy: Integrative Hypnotherapy 2 The American Society of Clinical Hypnosis 4 Training Opportunities 5 Eligibility for ASCH Membership 8 Acknowledgments 9 2. Formulating Hypnotic and Posthypnotic Suggestions 11 , ., ,:. , Principles of Hypnotic Suggestion 1 1 Types of Hypnotic Suggestions 27 The Phrasing of Suggestions 38 The Process of Suggestions in Facilitating Phenomena 42 3. Hypnosis in Pain Management 45 INTRODUCTION 45 Techniques of Hypnotic Pain Management I Joseph Barber 50 • Altering the Quality of Discomfort: Example of Leg Pain I M. Erik Wright 52 • Transformation of Pain I William L. Golden, E. Thomas Dowd, and Fred Friedberg 53 • Erickson's Suggestions for Pain Control I Milton H. Erickson 54 • General Principles for Alleviating Persistent Pain I Ernest L. Rossi and David B. Cheek 56 • Religious Imagery of Universal Healing for EgoStrengthening and Pain I M. Erik Wright 58 • The "Sympathetic Ear" Technique with Chronic Pain I Barry S. Fogel 58 • Reactivation of Pain-Free Memories: An Example of Intensifying and Relieving Pain I M. Erik Wright 59 • Chronic Pain Syndrome I Richard B. Garver 61 • Hypnotically Elicited Mystical States in Treating Physical and Emotional Pain I Paul Sacerdote 63 • Active Control Strategy for Group Hypnotherapy with Chronic Pain I Timothy C. Toomey and Shirley xii HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS Sanders 66 • Pain Strategies by Hypnotizability Level I David Spiegel and Herbert Spiegel 67 • Reinterpreting Pain as Protection I Charles B. Mutter 68 • Splinting Technique for Pain Control I Charles B. Mutter 68 • Erickson's Interspersal Technique for Pain 68 • The Setting Sun Pain Metaphor I Alexander A. Levitan 71 • Mexican Food: Metaphor of the Body Adapting to Pain I D. Corydon Hammond 71 • Metaphor of Callous Formation I D. Corydon Hammond 71 • Suggestions for Patients with Chronic Pain I Lillian E. Fredericks 72 • Pain Reduction I Beata Jencks 72 • "Body Lights" Approach to Ameliorating Pain and Inflammation (Arthritis) I Ernest L. Rossi and David B. Cheek 75 • Suggestions with Postherpetic Neuralgia ("Shingles") I Diane Roberts Stoler 76 • Suggestions to Reduce Pain Following Hemorrhoidectomies I Ernest W. Werbel 77 • Suggestions for Pain Control I Don E. Gibbons 78 • Hypnosis for Migraine I Lillian E. Fredericks 80 • Suggestions with Migraine I J.A.D. Anderson, M. A. Basker, and R. Dalton 80 • Diminution Rather Than Elimination of Headache I Irving I. Secter 00 • Suggestion for Symptom Substitution I Gary R. Elkins 81 • The Progressive Anesthesia Induction-Deepening Technique I D. Corydon Hammond 81 4. Hypnoanesthesia and Preparation for Surgery 85 INTRODUCTION 85 Preparation for Surgery I Lillian E. Fredericks 90 • Suggestions for Anesthesia and Surgery I Bertha P. Rodger 91 • Hypnosis and the Anesthetist I John B. Corley 92 • Summary Steps for Preoperative Hypnosis to Facilitate Healing I Ernest L. Rossi and David B. Cheek 94 • Ericksonian Approaches in Anesthesiology I Bertha P. Rodger 94 • Examples of Preoperative Suggestions I Joseph Barber 98 • Preparation for Surgery I Sandra M. Sylvester 98 • Temperature Suggestion Following Chest/ Abdominal Surgery I D. Corydon Hammond 101 • Suggestions for Insertion of Needles or Short Procedures I Esther E. Bartlett 101 • Switching Off the Senses I Bertha P. Rodger 101 • Rapid Induction Analgesia I Joseph Barber 102 • Surgical and Obstetrical Analgesia I Ernest L. Rossi and David B. Cheek 106 • Techniques for Surgery I William S. Kroger 107 5. EgoStrengthening: Enhancing Esteem, SelfEfficacy, and Confidence INTRODUCTION EgoStrengthening I Moshe S. Torem 110 • An Example of Positive Suggestions for WellBeing I Sheryl C. Wilson and Theodore X. Barber 112 • Positive Suggestions for Effective Living I T. X. Barber 113 • Suggestions for Raising Self-Esteem I T. X. Barber 118 • Barnett's Yes-Set Method of EgoStrengthening I Edgar A. Barnett 120 • Ego-Enhancement: A Five-Step Approach I Harry E. Stanton 122 • Suggestions for Modifying Perfectionism I D. Corydon Hammond 124 • Suggestions Derived from RationalEmotive Therapy I Harry E. Stanton 126 • Suggestions for Raising Self-Esteem I Helen H. Watkins 127 • Suggestions to Facilitate Problem Solving I Don E. Gibbons 130 • The Serenity Place I D. Corydon Hammond 130 • CONTENTS xiii EgoStrengthening Suggestions I Richard B. Garver 132 • The Inevitability of Change I Robert C. Mashman 1 32 • Change Is Necessary for Comfort I Robert C. Mashman 133 • An Abstract Technique for EgoStrengthening I B. J. Gorman 133 • Learning to Feed Yourself: An Example of Age Regression to Experiences of Mastery I D. Corydon Hammond 1 35 • Ego Building I Joan Murray-Jobsis 136 • The Ugly Duckling Metaphor I Roy L. Rummel 1 39 • The Prominent Tree Metaphor I Alcid M. Pelletier 1 39 • The Seasons of the Year: A Metaphor of Growth I Lawrence R. Gindhart 140 • Confidence Building I H. E. Stanton 141 • Increasing Determination: The Snowball I H. E. Stanton 143 • Suggestions for Emotional Enrichment I Don E. Gibbons 143 • Stein's Clenched Fist Technique I D. Corydon Hammond 145 • Suggestions for EgoStrengthening I John Hartland 147 • Suggestions for SelfReinforcement I Don E. Gibbons 149 • Visualization of the Idealized Ego-Image I Maurice H. McDowell 149 • Cycle of Progress I Douglas M. Gregg 150 • A Brief EgoStrengthening Suggestion I William T. Reardon 1 5 1 • A Future-Oriented Suggestion I P. Oystragh 151 Anxiety, Phobias, and Dental Disorders 153 INTRODUCTION 153 Hypnosis with Anxiety 1 56 Progressive Relaxation Induction or Deepening Technique I D. Corydon Hammond 156 • Hypnotic Treatment Techniques with Anxiety I David Spiegel and Herbert Spiegel 157 • The Private Refuge I Selig Finkelstein 158 • Imagery Scenes Facilitating Relaxation I H. E. Stanton 1 59 • Island of Serenity I Edwin L. Stickney 1 59 • Deep, Meditative Trance: The Approach of Ainslie Meares, M.D. 1 60 • Methods of Relaxed Breathing I Beata Jencks 162 • The Autogenic Rag Doll I Beata Jencks 165 • Hypnotic Suggestion/Metaphor to Begin Reframing I Steven Gurgevich 167 • RationalEmotive Suggestions About Anxiety I Albert Ellis 1 68 • Stress Reduction Trance: A Naturalistic Ericksonian Approach I Eleanor S. Field 170 • The Closed Drawer Metaphor I Brian M. Alman 172 • He Who Hesitates Is Lost: A Metaphor for Decision-Making I Michael D. Yapko 173 • DeFusing Panic I Marlene E. Hunter 173 Hypnosis with Phobias 1 75 Paradigm for Flying Phobia I David Spiegel and Herbert Spiegel 175 • A Reframing Approach for Flight Phobia I Peter A. Bakal, M.D. 175 • Hypnosis with Phobic Reactions I Don E. Gibbons 177 • Suggestions for Simple and Social Phobias I Michael A. Haberman 177 • Example of Treating Phobic Anxiety with Individually Prepared Tapes I M. Erik Wright 180 • Treatment of Lack of Confidence and Stage Fright I David Waxman 180 • Overcoming Anxiety over Public Speaking I Don E. Gibbons 182 Suggestions in Dental Hypnosis 183 Suggestions with TMJ and Bruxism I Harold P . Golan 1 8 3 • Suggestions with TMJ I Ellis J. Neiburger 183 • Erickson's suggestions with Bruxism I Milton H. Erickson 184 • TMJ and Tension Heachaches I Dov Glazer 184 • Suggestions to Promote Dental Flossing I Maureen A. Kelly, xiv HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS Harlo R. McKinty, and Richard Carr 185 • Gagging I Harold P. Golan 185 • Imagery with Hypersensitive Gag Reflex I J. Henry Clarke and Stephen J. Persichetti 187 • Denture Problems and Gagging I Donald R. Beebe 188 • Suggestion with Gagging I Irving I. Seeler 188 • Gagging Suggestion I William T. Heron 188 • Control of Salivation I Irving I. Sector 189 • Dental Phobias and Fears I Louis L. Dubin 189 • Illustrative Suggestions with Tooth Extraction I Selig Finkelstein 191 • Dental Hypnosis I Victor Rausch 192 • Suggestions for Operative Hypnodontics I WilliamS. Kroger 193 • The Let's Pretend Game I Lawrence M. Staples 194 • Erickson's Approach with Bruxism in Children I Milton H. Erickson 195 • Use of Fantasy or Hallucination for Tongue Thrusting I Irving I. Seeler 195 • Suggestions with Tongue Thrusting I Donald J. Rosinski 196 7. Hypnosis with Cancer Patients 199 INTRODUCTION 199 Clinical Issues in Controlling Chemotherapy Side Effects I William H. Redd, Patricia H. Rosenberger's and Cobie S. Hendler 200 • Suggestions and Metaphors for Nausea I Alexander A. Levitan 201 • Suggestions for Chemotherapy Patients I Alexander A. Levitan 202 • Suggestions and Metaphors for Support and EgoStrengthening in Cancer Patients I Billie S. Strauss 203 • General Suggestions for Self-Healing I Joan Murray-Jobsis 203 • Hypnotic Suggestions with Cancer I Jeffrey Auerbach 204 • Hypnotic Suggestions with Cancer Patients I Harold B. Crasilneck and James A. Hall 205 • Imagery to Enhance the Control of the Physiological and Psychological "Side Effects" of Cancer Therapy I Simon W. Rosenberg 206 • Breast Cancer: Radiation Treatment and Recovery I Diane Roberts Stoler 209 • Hypnosis as an Adjunct to Chemotherapy in Cancer I Sidney Rosen 212 • Hypnotic Death Rehearsal / Alexander A. Levitan 215 8. Hypnosis with Medical Disorders 217 INTRODUCTION 217 Hypnosis with Dermatologic Disorders 222 Treatment of Pruritus I Michael J. Scott 222 • Erickson's Reframing Suggestion with Pruritus I Milton H. Erickson 223 • Suggestions for Itching I Beata Jencks 223 • Hypnotic Technique for Treating Warts I Harold B. Crasilneck and James A. Hall 223 • Suggestions for Warts [Modeled after Hartland] I Don E. Gibbons 224 • Suggestions for Vaginal Warts I Diane Roberts Stoler 225 • Suggestions with Condyloma Acuminatum (Genital Warts) I Dabney M. Ewin 226 • Suggestions for Immunodeficient Children with Warts I M. F. Tasini and Thomas P. Hackett 226 • Evoking Helpful Past Experiences and Medical Treatments: Example with Skin Rash I M. Erik Wright 226 • Suggestions with Pruritus I William S. Kroger and William D. Fezler 227 • Reducing Dermatologic Irritation I D. Corydon Hammond 228 CONTENTS XV Hypnosis with Burns and Emergencies 228 Suggestions with Burn Patients I Harold B. Crasilneck and James A. Hall 228 • Emergency Hypnosis for the Burned Patient I Dabney M. Ewin 229 • Hypnosis in Painful Burns I R. John Wakeman and Jerold Z. Kaplan 23 1 • Ideomotor Healing of Burn Injuries I Ernest L. Rossi and David B. Cheek 233 • Direct Suggestions in Emergencies with the Critically III I Ernest L. Rossi and David B. Cheek 233 • Suggestions for Use of Spontaneous Trances in Emergency Situations I M. Erik Wright 234 • Painless Wound Injection Through Use of a Two-finger Confusion Technique I Steven F. Bierman 236 Hypnosis for Healing, Psychosomatic Conditions and Autoimmune Diseases 238 General Approach to Physical Symptoms Caused by Stress I Carol P. Herbert 238 • Symphony Metaphor I Marlene E. Hunter 238 • Healing Imagery I Marlene E. Hunter 239 • Suggestions with Autoimmune Disease I Jeffrey Auerbach 241 • Prolonged Hypnosis in Psychosomatic Medicine I Kazuya Kuriyama 242 • Further Suggestions for Facilitating Prolonged Hypnosis I Stanislav Kratochvil 244 • Vascular Control Through Hypnosis I Emil G. Bishay and Chingmuh Lee 244 • Suggestion for Control of Bleeding I Milton H. Erickson 245 • Suggestions for Control of Upper Gastrointestinal Hemorrhage I Emil G. Bishay, Grant Stevens, and Chingmuh Lee 245 • Blood Perfusion Protocol I Lawrence Earle Moore 246 Hypnosis with Neurological and Ophthalmological Conditions 247 Teaching the Other Side of the Brain I Marlene E. Hunter 247 • Once Learned, Can Be Relearned I Marlene E. Hunter 248 • Hypnosis with Blepharospasm I Joseph K. Murphy and A. Kenneth Fuller 250 • Hypnotherapy for Lagophthalmos I Jean Holroyd and Ezra Maguen 25 1 • Suggestions for Involuntary Muscle Jerking I Valerie T. Stein 25 1 • Hypnosis with Bell's Palsy I Simon W. Chiasson 252 Hypnosis with Sleep Disorders 253 Suggestions with Sleep Disturbance I Richard B. Garver 253 • Suggestions with Sleep Disorders I Doris Gruenewald 253 • Visualization for Treating Insomnia I H. E. Stanton 254 • Hypnosis Techniques with Insomnia I David Spiegel and Herbert Spiegel 255 • Suggestions for Insomnia I Milton H. Erickson 255 • Snoring: A Disease of the Listener I Daniel A. Zelling 255 Miscellaneous Medical Applications 256 Hypnotic Techniques and Suggestions for Medical-Physical Complaints I Beata Jencks 256 • Paradoxical SelfHypnotic Assignment for Chronic Urinary Retention or "Bashful Bladder" I Gerald J. Mozdzierz 262 • Hypnosis in Postoperative Urinary Retention I Simon W. Chiasson 263 • Hypnotic Paradigm-Substitution with Hypochondriasis I Thomas Deiker and D. Kenneth Counts 264 • Suggestions with Asthma I Don E. Gibbons 265 • Suggestions for Prevention of Seasonal Allergies I Hans A. Abraham 265 • Erickson's Metaphor with Tinnitus I Milton H. Erickson 266 • Procedure with Difficulty Swallowing Pills I Irving I. Seeler 266 • Suggestion for Alleviating Hiccups I Gerald J. Mozdzierz 267 XVi HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS 9. Hypnosis in Obstetrics and Gynecology 269 INTRODUCTION 269 Obstetrical Hypnosis: Childbirth Training 27 1 Group Hypnosis Training in Obstetrics I Simon W. Chiasson 27 1 • Outline of Hypnotic Suggestions in Obstetrics I Bertha P. Rodger 273 • Suggestions for a Comfortable Delivery I Joseph Barber 275 • The Hypnoreflexogenous Technique in Obstetrics I A. Kenneth Fuller 277 • Childbirth Suggestions I Larry Goldmann 278 • Management of Antenatal Hypnotic Training I David Waxman 279 • Erickson's Childbirth Suggestions I Milton H. Erickson 281 • An Ericksonian Approach to Childbirth I Noelle M. Poncelet 282 • Childbirth Script I Diane Roberts Stoler 286 • Preparation for Obstetrical Labor I William S. Kroger 293 • Suggestions with Untrained Patients in Labor I Nicholas L. Rock, T. E. Shipley, and C. Campbell 296 Premature Labor, Miscarriage and Abortion 296 Hypnotic Relaxation Technique for Premature Labor I Haim Omer 296 • Use of Immediate Interventions to Uncover Emotional Factors in Pre-Abortion Conditions I David B. Cheek 299 • Treating the Trauma of Prospective Abortion I Helen H. Watkins 301 Hyperemesis Gravidarum and Miscellaneous Gynecologic Disorders 302 Hypnotic Intervention with Hyperemesis Gravidarum I Ralph V. August 302 • Control Of Hyperemesis I Larry Goldmann 303 • Suggestions for Hyperemesis I William T. Heron 304 • Progressive Anesthesia Technique for Hyperemesis Gravidarum I D. Corydon Hammond 305 • Suggestions for Hyperemesis I Harold B. Crasilneck and James A. Hall 305 • Suggestions for Hyperemesis Gravidarum I David Waxman 305 • Suggestions with Psychogenic Amenorrhea I WilliamS. Kroger 306 • Suggestions with Leukorrhea I F. H. Leckie 306 10. Hypnosis with Emotional and Psychiatric Disorders 309 INTRODUCTION 309 '-- Suggestive Techniques with Emotional Disorders 3 1 2 Hypnotherapeutic Technique for the Reduction o f Guilt: The Door of Forgiveness I Helen H. Watkins 3 12 • Dumping the "Rubbish" I H. E. Stanton 3 1 3 • The Red Balloon Technique I D. Corydon Hammond 3 1 3 • Edelstien's Fusion of Extremes Technique I D. Corydon Hammond 3 1 5 • Scenes for Facilitating Self-Understanding I H. E. Stanton 3 1 6 • Meeting an Inner Adviser I David E. Bresler 3 1 8 • Responsibility to a Fault: A Metaphor for Overresponsibility I Michael D. Yapko 320 • Different Parts: A Metaphor I Michael D. Yapko 321 • Enhancing Affective Experience and Its Expression I Daniel P. Brown and Erika Fromm 322 Hypnosis with Severely Disturbed Patients 324 Can Hypnosis Help Psychosis? I James R. Hodge 324 • Renurturing: Forming Positive Sense of Identity and Bonding I Joan Murray-Jobsis 326 • Suggestions for Creative Self-Mothering I Joan CONTENTS xvii Murray-Jobsis 328 • Hypnotherapeutic Techniques with Affective Instability I Louis N. Gruber 328 • Hypnotic Suggestions to Deter Suicide I James R. Hodge 330 • Hypnosis with Bipolar Affective Disorders I A. David Feinstein and R. Michael Morgan 332 , Hypnosis with PostTraumatic Stress Disorder and Multiple Personality Disorder 333 Emergency Room Suggestions for Physically or Sexually Assaulted Patients I Carol P. Herbert 333 • Hypnotic Suggestions with Rape Victims I Bruce Walter Ebert 334 • Saying Goodbye to the Abused Child: An Approach for Use with Victims of Child Abuse and Trauma I Ronald A. Havens 334 • Reframing Dreams in PTSD I Charles B. Mutter 335 • Suggestions and Metaphors for PostTraumatic Stress Disorder and Pain Control (in Spanish) I Marlene D. de Rios and Joyce K. Friedman 335 • A Fusion Ritual in Treating Multiple Personality I Richard P. Kluft 339 • Another Fusion Ritual / Richard P. Kluft 341 ,·r\ • Containing Dysphoria in MPD I Richard P. Kluft 342 • Modified EgoStrengthening for MPD I Moshe S. Torem 343 • Corporate Headquarters of the Mind I Donald A. Price 343 • Metaphors with Multiple Personality and Trauma Patients I D. Corydon Hammond 346 • A Projective Ideomotor Screening Procedure to Assist in Early Identification of Ritualistic Abuse Victims I D. Corydon Hammond 347 11. Hypnosis with Sexual Dysfunction and Relationship Problems 349 INTRODUCTION 349 Hypnotherapy and Sexual Dysfunction 354 The Master Control Room Technique I D. Corydon Hammond 354 • Illustrative Suggestions in Sex Therapy I Bernie Zilbergeld 356 • Hypnotherapy with Psychogenic Impotence I Harold B. Crasilneck 356 • Suggestions for Spectatoring and Sensate Focus I D. Corydon Hammond 358 • Suggestions for Facilitating Sexual Fantasy I D. Corydon Hammond 360 • Changes in Preference Metaphor I D. Corydon Hammond 361 • Metaphors for Going Out to Dinner and Back Scratching I D. Corydon Hammond 362 • Organ Transplant Metaphor I D. Corydon Hammond 363 • The Pee Shyness Metaphor for Sexual Dysfunction I D. Corydon Hammond 364 • Metaphoric Suggestions and Word Plays for Facilitating Lubrication I D. Corydon Hammond 364 • Suggestion for Ejaculatory Inhibition or Orgasmic Dysfunction I D. Corydon Hammond 365 • Suggestion for Erection or Lubrication I D. Corydon Hammond 366 • Suggestions for Impotence and Anorgasmia I Leo Alexander 366 • Suggestions for Induced Erotic Dreams I D. Corydon Hammond 367 • Suggestions with Sexual Dysfunctions I Don E. Gibbons 368 • Suggestions for Premature Ejaculation I Milton H. Erickson 370 Hypnotic Suggestions for Interpersonal Relationships 371 Hypnotic Ego-Assertive Retraining I David Waxman 37 1 • "Fruits & Vegetables": A Simple Metaphor for Understanding People Better I Gerald J. Mozdzierz 372 • Suggestions to Increase Interpersonal Effectiveness I Don E. Gibbons 373 • Suggestions for Difficulties in Interpersonal Situations I Kermit E. Parker, Jr. 374 • The Symbolic Imagery Letter xviii HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS Writing Technique I MarkS. Carich 374 • The Jazz Band Metaphor for Family Interaction I Philip Barker 375 • Golden Retriever Metaphor I D. Corydon Hammond 376 • The Pygmalion Metaphor I D. Corydon Hammond 377 12. Hypnosis with Obesity and Eating Disorders 379 INTRODUCTION 379 Hypnosis with Obesity 380 Examples of Suggestions for Weight Reduction I Sheryl C. Wilson and Theodore X. Barber 380 • Hypnotic Suggestions for Weight Control I T. X. Barber 383 • Hypnotic Strategies for Managing Cravings I D. Corydon Hammond 385 • Weight Control I David Spiegel and Herbert Spiegel 387 • Suggestions for Patients with Obesity Problems I Joan Murray-Jobsis 388 • Computer Metaphor for Obesity I Richard B. Garver 389 • Suggestions for Decreasing Food Intake I Harold B. Crasilneck and James A. Hall 390 • Historic Landmark Technique for Treating Obesity I William C. Wester, II 391 • Hypnosis in Weight Control I Herbert Mann 393 • Weight Control Suggestions I Harry E. Stanton 395 • Miscellaneous Suggestions for Weight Control I WilliamS. Kroger and William D. Fezler 395 • Further Suggestions for Management of Obesity I William S. Kroger 396 • Erickson's Suggestions with Obesity I Milton H. Erickson 397 • Negative Accentuation : Vivifying the Negative During Trance I M. Erik Wright 397 • Aversive Metaphor for Chocolate Eaters I Marvin Stock 399 • Symbolic Imagery: The Dial Box Shrinking Technique I Mark S. Carich 400 • The Attic of the Past I Eleanor S. Field 400 Treatment of Eating Disorders 402 Suggestions to Modify Body Attitude I Eric J. Van Denburg and Richard M. Kurtz 402 • Altering Body Image I Hans A. Abraham 402 • Suggestions for Increasing Food Intake I Harold B. Crasilneck and James A. Hall 403 • Suggestions for Presenting Symptoms in Anorexia Nervosa I Meir Gross 403 • Metaphors for Bulimia and Anorexia I Michael D. Yapko 405 13. Smoking, Addictions, and Habit Disorders 407 INTRODUCTION 407 Hypnosis with Smoking and Addictions 409 Smoking Suggestions I Joseph Barber 409 • Hypnotic Suggestions for Smoking Cessation I T. X. Barber 41 1 • Hypnosis and Smoking: A Five Session Approach I Helen H. Watkins 4 1 3 • Smoking Control I David Spiegel and Herbert Spiegel 416 • Suggestions for Smoking Cessation I Harold B. Crasilneck and James A. Hall 416 • Smoking Cessation I Richard B. Garver 417 • Suggestions Regarding Smoking I Steven Gurgevich 418 • Suggestions to Modify Smoking Behavior I Harry E. Stanton 419 • Suggestions Applicable for Smoking, Obesity and Other Addictive Behaviors I Doris Gruenewald 420 • Suggestions for Rational CONTENTS xix SelfTalk for Smoking and Other Addictions I D. Corydon Hammond 422 • Suggestions for Smoking Cessation I William C. Wester, II 422 • Aversive Metaphor for Smoking I Marvin Stock 423 • General Strategies for Overcoming Pleasure-Producing Habits I M. Erik Wright 425 • Illustrative Suggestions with Smokers I Paul Sacerdote 428 • A Posthypnotic Suggestion and Cue with Smokers I Brian M. Alman 429 Hypnosis with Habit Disorders 429 Hypnosis with Nailbiting I Harold B. Crasilneck and James A. Hall 429 • Erickson's Suggestions for Nailbiting I Milton H. Erickson 429 • Suggestions for Nailbiting I David Waxman 429 • Suggestions for Nailbiting I Don E. Gibbons 430 • Suggestions with Trichotillomania I Marianne Barabasz 43 1 • Suggestions for Scalp Sensitivity with Trichotillomania I T. J. Galski 43 1 14. Concentration, Academic Performance, and Athletic Performance 433 INTRODUCTION 433 Enhancing Academic Performance 436 Suggestions for Enhancing Academic Performance / Don E. Gibbons 436 • The Memory Bank I Douglas M. Gregg 437 • Academic Study Suggestions I Stanley Krippner 439 • Concentration Suggestions I William T. Reardon 440 • Suggestion for Concentration I Brian M. Alman 440 • Suggestions and Success Imagery for Study Problems I Jeannie Porter 440 • Suggestions for Studying, Concentration and Text Anxiety I Richard B. Garver 445 • Erickson's Suggestions for Facilitating Speed of Learning I Milton H. Erickson 446 • Alert Trance Suggestions for Concentration and Reading I E. R. Oetting 446 • Alert Self-Hypnosis Technique to Improve Reading Comprehension I David M. Wark 449 • Advanced Comprehension Suggestions for an Alert Trance I David M. Wark 450 • Improving Reading Speed by Hypnosis I Raymond W. Klauber 450 • Gorman's EgoStrengthening Technique Adapted for Reading I G. Gerald Koe 452 • Suggestions for Foreign Language Study I Don E. Gibbons 457 • Suggestions for Mathematics or Statistics Performance I Robert M. Anderson 458 • Examination Panic I Milton H. Erickson 459 • Suggestions for Concentration, Studying and Overcoming Test Anxiety I Alcid M. Pelletier 460 • Suggestions for Examination Phobia I David Waxman 461 Suggestions for Aesthetic Refinement 461 Suggestions for Artistic Expression I Don E. Gibbons 461 • Suggestions for Aesthetic Appreciation and Enjoyment I Don E. Gibbons 462 • Suggestions to Enhance Musical Performance I Don E. Gibbons 462 • Suggestions to Enhance Writing Ability I Don E. Gibbons 464 Enhancing Sports and Athletic Performance 465 Suggestions Used to Enhance Sport Performance I Keith P. Henschen 465 • Sports Performance Enhancement I Richard B. XX HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS Garver 466 • Metaphor for Athletics/Sports Competition I Richard R. Wooton 467 • Metaphor for Facilitating Cooperation and Teamwork in Athletics I Richard R. Wooton 469 • Suggestions for Concentration I Brian M. Alman 469 • A Cognitive-Hypnotic Approach to Athletic Performance with Weight Lifters I W. Lee Howard and James P. Reardon 470 • Suggestions for Sports Performance I Don E. Gibbons 47i • Endurance Suggestions with Distance Runners I J. Arthur Jackson, Gregory C. Gass, and E. M. Camp 472 15. Hypnotic Suggestions with Children 475 INTRODUCTION 475 Helping Parents See Specific Advantages in Child Hypnotherapy I G. Gail Gardner 477 • Hypnosis with Children I Daniel P. Kohen 480 Hypnosis with Pain 481 Hypnotic Procedure for Pain Relief I Valerie J. Wall 48 1 • Techniques of Hypnoanalgesia I Karen Olness and G. Gail Gardner 484 • Pediatric Wound Injection - Using a Visual Distraction Technique I Steven F. Bierman 486 • Examples of Suggestions for Use in Pediatric Emergencies I Daniel P. Kohen 488 Hypnosis with Enuresis 489 A Hypnotherapeutic Approach to Enuresis I Daniel P. Kohen 489 • Imagery with Bedwetting I H. E. Stanton 493 • Induction and Ocean Metaphor for Bedwetting I Valerie J. Wall 494 • Suggestions with Enuresis I Franz Baumann 496 • Erickson's Suggestions with Enuresis I Milton H. Erickson 497 • Enchanted Cottage Suggestions for Enuresis I Don E. Gibbons 497 Suggestions for Thumbsucking 498 Erickson's Suggestions for Thumbsucking I Milton H. Erickson 498 • Suggestions with a Four-Year-Old Thumbsucker I Lawrence M. Staples 499 Miscellaneous Pediatric Problems 499 Metaphor for a Boy with Behavioral Problems I Norma P. Barretta and Philip F. Barretta 499 • Hypnosis in the Treatment of Tourette Syndrome I David N. Zahm 501 • A New Hypnobehavioral Method for the Treatment of Children with Tourette's Disorder I Martin H. Young and Robert J. Montano 502 • Technique with Asthmatic Children I Harold B. Crasilneck and James A. Hall 504 • Suggestions with Dyslexia I Harold B. Crasilneck and James A. Hall 505 • Hypnotic Suggestions with Stuttering I Harold B. Crasilneck and James A. Hall 505 • Personalized Fairy Tales for Treating Childhood Insomnia I Elaine S. Levine 505 • Suggestions with School Phobia I David Waxman 506 • A Science Fiction-Based Imagery Technique I Gary R. Elkins and Bryan D. Carter 506 CONTENTS xxi t) 16. Time Reorientation: Age Regression, Age Progression, and Time Distortion 509 INTRODUCTION 509 Age Regression and Abreaction 5 1 8 Ideomotor Identification Followed by Partial Regression I D. Corydon Hammond 518 • Imagery Methods of Facilitating Age Regression I H. E. Stanton 519 • Improving the Quality of the Age Regression I Daniel P. Brown and Erika Fromm 519 • Suggestions to Facilitate Revivification I Eric Greenleaf 521 • Erickson's Confusional Method for Revivification I Milton H. Erickson 523 • Watkins' Affect or Somatic Bridge I John G. Watkins 523 • Facilitating a Full Abreaction I D. Corydon Hammond 524 • An Abreactive Technique I Richard P. Kluft 526 • A Vigorous Abreaction Technique I Richard P. Kluft 527 • The Fractionated Abreaction Technique I Richard P. Kluft 527 • The Slow Leak Technique I Richard P. Kluft 529 • Watkin's Silent Abreaction Technique I Helen H. Watkins 530 • Erickson's Age Regression Techniques I Milton H. Erickson 531 • Gradual Dissociated Release of Affect Technique I D. Corydon Hammond 534 • Sickness & Immunity Metaphors I D. Corydon Hammond 535 • Metaphor of an Injury, Scab, and Healing I D. Corydon Hammond 536 • Example of An Analytical Procedure for Reframing I E. A. Barnett 537 • Desensitization: An Example of Rapid and Repetitive Memory Evocation I M. Erik Wright 541 • Forensic Hypnosis Guidelines: The "Federal Model" I Richard B. Garver 542 Age Progression 543 Erickson's Time Projection Technique I D. Corydon Hammond 543 • Age Progression to Work Through Resistance I Richard B. Garver 545 • Suggestions Following Age Progression with Public Speaking I Don E. Gibbons 546 • Imagery of the End Result I Errol R. Korn and George J. Pratt 546 • Mental Rehearsal: The Protective Shield I Errol R. Korn and George J. Pratt 547 • Mental Rehearsal of Presentation and Sales Skills I Errol R. Korn and George J. Pratt 547 • Suggestions for Goal-Imagery I Alcid M. Pelletier 548 • End-Result Goal Imagery for Sales Productivity I Don E. Gibbons 549 • Erickson's Self-Suggestion Technique I D. Corydon Hammond 549 Time Distortion Training 55 1 Training Patients to Experience Time Distortion I Linn F. Cooper and Milton H. Erickson 551 • Summary of Suggested Steps in Time Distortion Training I D. Corydon Hammond 556 References 559 Credits 579 Name Index 587 Subject Index 592 INTRODUCTION T.ns IS A PRACTICAL resource book for clinicians. Although it is a large compilation of therapeutic suggestions and metaphors, I wish to emphasize from the outset that it is not intended as a "cookbook" of suggestions to be routinely used with various clinical problems. My own personal philosophy of hypnotherapy is to encourage therapists to individualize hypnotic suggestions to the unique personality, expectations, motivations and problems of the patient (Hammond, 1 988a) . In the introductions to chapters I have often provided a scholarly overview of relevant research because I believe that it is important for clinicians to be aware of this literature. But this volume is not intended as a thorough text of the field of hypnosis. Rather, it is first and foremost a practical reference for clinical practitioners who are already trained in the use of hypnosis and a practical companion volume to comprehensive textbooks (e.g., Crasilneck & Hall, 1 985; Hammond & Miller, in press; Watkins, 1 987; Weitzenhoffer, 1989; Wester & Smith, 1 984). The intent of this book is to provide clinicians with models of hypnotic suggestions and metaphors from seasoned hypnotherapists who have diverse approaches and styles. Verbalizations for hypnotic induction and deepening techniques have not been included because they may be found abundantly in the texts identified above, as well as in the American Society of Clinical Hypnosis course text, Hypnotic Induction and Suggestion (Hammond, 1988c). All too frequently we are only exposed to general descriptions of a therapeutic approach. As part of our training, we certainly need instruction in theory, history, assessment, guidelines and overall strategies. But if we are to function effectively as clinicians we also need exposure to the pragmatic nuts and bolts of what to say to patients. There is a deficit of such material in graduate education and students regularly complain that their training is not practical enough. This volume is designed to respond to that need and provide you with a look at what experienced clinicians actually tend to say to their patients during hypnotic work. You will find suggestions that are highly indirect, permissive and metaphoric, and ones that are also very direct, forceful and authoritative. I must admit to having occasionally included a suggestion that I, personally, 2 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS would probably not use with a patient, despite considering myself very eclectic and flexible. But there may be some readers who will appreciate and find certain of these same suggestions both helpful and compatible with their own style. As therapists we are as distinctive as our patients. It is hoped, therefore, that as you treat patients with specific problems you will find that you can pick and choose different paragraphs and modules of suggestions from various contributors and adapt them to your individual patient. The variety of suggestions will often provide you with alternative ways of communicating with a patient about a particular problem. We cannot always know for sure which ideas will produce the desired motivation. As Erickson (Rossi & Ryan, 1 985) said, "You provide a multiplicity of suggestions: the more suggestions that you give, and the more simply you give them, the greater the possibility of getting some of them accepted. Your task isn't to force a patient to accept suggestions. Your task is to present a sufficient number of suggestions so that he will willingly take this one and that one" (p. 213). In many ways hypnosis is the art of securing a patient's attention and then effectively communicating ideas that enhance motivation and change perceptions. There is nothing sacred about the phrasing of the suggestions in this volume. As Dr. Milton Erickson (Rossi & Ryan, 1 985) taught, "I want all of you to be willing to disagree with my wording, because it's right for me but it may be wrong for you" (p. 2 16). You will undoubtedly find interesting ideas and concepts that appeal to you in the suggestions of many different contributors. But ofttimes you will probably find yourself wanting to convey the same idea a little differently, in your own way or in a manner that you believe will be more appealing to a particular patient. This is as it should be. In fact, this was another reason for compiling this volume - my belief that it will serve to stimulate your creativity in preparing your own suggestions and metaphors. Alexander Hamilton once said, "Men give me some credit for genius, but all of the genius I have lies in this. When I have a subject in mind, I study it profoundly, day and night it is before me. I explore it in all its bearings. My mind becomes pervaded with it. The result is what some people call the fruits of genius, whereas it is in reality the fruits of study and labor. " Part of the genius that was attributed to our Society's founding President, Dr. Milton H. Erickson, stemmed from this same kind of hard work and study. His sophistication and polish evolved from his discipline in carefully writing and rewriting suggestions and thoughtfully planning treatment (Hammond, 1984a, 1 988b). He did this regularly for several decades of his life. Although this book will undoubtedly contain suggestions that you will find useful with patients or clients, it is also hoped that these materials will provide you with ideas and encouragement to thoughtfully prepare your own suggestions and metaphors. The Underlyi ng Therapeutic Philosophy: I ntegrative Hypnotherapy Certainly this edited work reflects some of my own philosophy of psychotherapy, which is one of broad spectrum, eclectic treatment. Reli- INTRODUCTION 3 ance on a limited range of methods and one approach appears to often be associated with inexperience as a therapist (Auerbach & Johnson, 1 977; Fey, 1958; Parloff, Waskow, & Wolfe, 1 978; Strupp, 1 955; Wogan & Norcross, 1 985). In fact, research has found that it is the most highly experienced therapists who ascribe to an eclectic approach (Norcross & Prochaska, 1982; Smith, 1 982), refusing to be limited by adherence to only one orientation. Currently 300Jo-540Jo of psychotherapists from various disciplines identify themselves as eclectic (Norcross, 1 986). It is my belief that not all patients need the same thing. Thus you will find a tremendous diversity in the suggestions represented in this book. In fact, when therapists tend to inflexibly use the same approach with all patients, there is evidence that destructive effects are much more likely to occur (Lieberman, Yalom, & Miles, 1 973). In the specialty area of hypnotherapy, we are beginning to witness an evolution similar to what has been seen in the broader field of psychotherapy where innumerable therapeutic schools and cults have sprung up. Various orientations to hypnosis have also begun to evolve. Unfortunately, we now see some clinicians who have begun to operate on the "one-truelight-assumption" that their specialized approach to hypnosis is the correct one. Similar to Erickson, I refuse to be limited by a unitary theory or orientation, either in psychotherapy or in my use of hypnosis. I value and encourage an openness to learning from all quarters. I am indebted to the work of many different master clinicians and hypnotherapists with highly - . �· divergent styles who have enriched my work in ways that would have never occurred if I limited myself to only one approach. Thus I identify my approach to hypnotherapy as Integrative Hypnotherapy (Hammond & Miller, in press) . This is an eclectic, multidimensional orientation that seeks to be comprehensive, incorporating methods from many hypnotic approaches. It is part of the emergent trend in psychotherapy, tracing its roots to pioneers like Thorne ( 1 967), Wolberg (1954, 1 967, 1 987), Lazarus ( 1 98 1), and more recently Beutler ( 1 983), Prochaska and DiClemente ( 1984), Norcross ( 1 986), and Hammond and Stanfield ( 1 977) . Depending upon the individual patient, direct, indirect, metaphoric, and insightoriented techniques may be employed to alter behavior, affect, physiologic processes, imagery, perceptions, cognitions, and the internal dialogue of patients. Hypnosis is used to explore preconscious and unconscious functions, resolve historical factors, and utilize -- unconscious resources. This method of working builds on the general philosophy of technical eclecticism (Lazarus, 1 98 1 ; Hammond & Stanfield, 1977), encouraging the prescriptive use of techniques according to indications and contraindications derived empirically and by experimental validation, rather relying on theories. Unfortunately, research on effectiveness is far too often lacking and experimentally validated criteria commonly do not exist on indications, contraindications and the matching of techniques with patient variables. Thus strategy and technique selection currently remain implicit and primarily guided by empirical evidence and clinical experience. Hypnotherapy, like psychotherapy, is still more of an art and only embryonic in scientific development. Tentative and yet systematic and explicit guidelines need to be published concerning strategy and technique 4 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS selection with different patients, and this process is currently under development (Hammond & Miller, in press). Stemming from this therapeutic philosophy, you will find that I have often included some suggestive guidelines and indications for the use of the hypnotic suggestions and metaphors that have been included in the book. I have indicated when these guidelines were mine. The titles and subtitles throughout the text are in most cases mine also. They have been provided to allow you to more easily identify "modules" of suggestions that have a different theme or focus . A necessary limitation of this book is that it focuses primarily on what we call suggestive hypnosis. Sometimes suggestive hypnosis is all that is needed to successfully treat a clinical problem. However, there are times when problems and symptoms are related to historical factors (e.g. , trauma) and/ or serve adaptive functions and purposes that are beyond conscious awareness. In these cases, delivering hypnotic suggestions and metaphors will be most effective following uncovering and age regression (abreactive) work. A comprehensive, integrative approach to hypnosis thus includes the use of exploratory and insightoriented hypnotic techniques. These interventions, however, are much more difficult to model in a limited amount of space and consequently are only rarely included in this book. These methods may be studied by consulting Hammond and Miller (in press), Rossi and Cheek ( 1 988), Brown and Fromm ( 1986), and Watkins (in press) . Finally, I wish t o emphasize that hypnosis i s often most effective when it is combined with other (nonhypnotic) interventions. Hypnosis is like any other medical or psychological technique or modality: it is not uniformly effective with all problems or all patients. Thus it is vitally important that we do not identify ourselves as "hypnotists," but rather as psychologists, physicians, dentists, social workers, marriage and family therapists, nurse anesthetists, etc. , who use hypnosis as one mode of intervention along with our other clinical tools. Furthermore, ethical practice requires that we only use hypnosis to treat problems that we are qualified to treat with nonhypnotic techniques. If one has not received advanced specialty training and supervision in practicing with children or in doing sex therapy, it seems ethically inappropriate to use hypnosis to work in these areas. Hypnosis training alone does not qualify us to work in subspecialty areas beyond our expertise. Similarly, merely learning a few hypnotic inductions and then seeking to apply suggestions gleaned from a volume like this is likewise deemed to be inappropriate. The reader is encouraged to seek specialty training and supervision in hypnosis from your local university or the American Society of Clinical Hypnosis workshops, and to study comprehensive textbooks. The American Society of Clinical Hypnosis PU RPOSE AND DESC RI PTION The American Society of Clinical Hypnosis (ASCH) was founded in 1 957, with Milton H. Erickson, M . D . , as the first president. Numbering INTRODUCTION 5 almost 4,000 members, the ASCH is a nonprofit professional organization. Its purpose is to establish and maintain the foremost society in North America of professionals in medicine, psychology and dentistry dedicated to informing the public about the therapeutic effects of hypnosis and educating qualified professionals in the use of hypnosis for the benefit of humanity and themselves. A central objective of the society is to provide and encourage educational programs to further, in every ethical way, the knowledge, understanding and acceptance of hypnosis as an important clinical tool. Thus, almost monthly, ASCH conducts beginning, intermediate and advanced training workshops at different locations throughout the United States and Canada, as well as an annual workshop. Approximately four dozen local Component Sections of the American Society of Clinical Hypnosis also provide . ' ' "· - ' ongoing professional interaction and educational programs. Another key purpose of the society is to stimulate research and encourage scientific publication in the field of clinical hypnosis. Thus we also sponsor an annual scientific meeting, held in conjunction with the annual workshops. The American Journal of Clinical Hypnosis is published quarterly by the society. In addition to the professional papers and book reviews, the journal also includes abstracts of the worldwide hypnosis literature. A comprehensive computer search of references to worldwide publications is also included in each issue of the Newsletter, which is published five times a year. The ASCH Education and Research Foundation was established to encourage and promote both education and research. Train i ng Opportunities REGIONAL WORKSHOPS Eight or nine regional workshops are held yearly in different cities throughout the United States and Canada. This training is available to licensed psychologists, physicians, dentists, social workers, marriage and family therapists, and masters degree level registered nurses with advanced subspecialty training and certification. Medical residents and doctoral students in medicine, dentistry and psychology are also eligible to attend. Students, residents, interns, ASCH members, and full-time faculty members are eligible for discounted registration rates. The regional workshops generally are conducted at three levels simultaneously: beginning, intermediate and advanced. A course text is available to participants and the workshops include the opportunity for several hours of supervised practice. The faculty is changed for each regional workshop, providing participants with models of a variety of styles of practice. Workshops generally begin Thursday evening and conclude at noon on Sunday. You may write for information at the address listed below. AN N UAL WORKSHOPS A N D SCI E NTI FIC M E ETI NG Held in late March or early April each year, the annual meeting consists of two and one-half days of workshops and a two-day scientific meeting. A 6 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS beginning and intermediate workshop is part of the program, and there is an extensive range of advanced workshop offerings. The 50-60 faculty members for the annual workshops include many of the finest teachers in the world. Professional papers in the scientific meeting cover a broad range of topics. AME RICAN JOU RNAL OF CLIN ICAL HYPNOSIS Published quarterly, the American Journal of Clinical Hypnosis contains both experimental and clinical papers, book reviews, and abstracts of worldwide hypnosis literature that is in English or has English abstracts. Yearly subscriptions are available for $30. Subscription and advertising inquiries should be sent to the Business Manager, ASCH, 2200 E . Devon Ave., Suite 291 , Des Plaines, IL. 600 1 8 , USA. VI DEOTAPE LIBRARY A N D AUDIOTAPES Dozens of audiotapes of past workshops and scientific meeting presentations are available for purchase to professionals. In addition, the ASCH Videotape Library contains over 80 high quality videotapes of recognized authorities in the field demonstrating techniques . These videotapes are available for rental to members or Component Sections of the society. BOOK SALES For the convenience of members and attendees at workshops, ASCH maintains an inventory of many of the most respected volumes on different aspects of clinical hypnosis. In addition, the following three publications are available exclusively from ASCH: 1 . Hypnotic Induction and Suggestion, edited by D. Corydon Hammond, Ph. D . , is the ASCH course text for beginning and intermediate level workshops . This 1 34-page monograph is highly practical in nature and ideally suited for use in courses and seminars . A free instructor's copy is included with each class order of 20 or more books. It includes: verbalizations for 1 2 induction techniques; principles of induction and suggestion; a checklist assessment instrument for individualizing hypnosis; over 20 deepening techniques; guidelines and questions for rapid unconscious exploration through ideomotor signaling; 19 strategies for managing resistant patients; an annotated bibliography describing the contents of 1 35 books on hypnosis; preparing the patient; phenomena of hypnosis; stages and depth of hypnosis; self-hypnosis; adverse reactions; hypnosis and children; types of suggestions; and hypnotizability scales . It is available from ASCH for $ 1 5 . 00/copy plus $2. 00 postage and handling. 2. The ASCH Manual for Self-Hypnosis, by D . Corydon Hammond, Ph.D. This 40-page manual is designed to provide your patients with the essential principles for using self-hypnosis. It will save you time in the INTRODUCTION 7 office, and patients who won't read a lengthy book will be willing to read this manual. Sections include: What is Hypnosis? Preparing for Self-Hypnosis; Preparing Hypnotic Suggestions; The Process of Self Hypnosis; Deepening Your Hypnotic State; Spectatoring and Dealing with Distractions; Imagination: The Catalyst for Change; Having a Dialogue with Your Symptom; The Council of Advisers Technique; The Inner Adviser Technique; Mental Rehearsal and Age Progression; Erickson's Method of Self-Hypnosis; References for Further Reading. The cost is $5.00 (plus $2.00 shipping and handling on single orders), and quantity discounts are available to encourage its use with your patients. 3 . Learning Clinical Hypnosis: An Educational Resources Compendium . "A unique, up-to-date volume on the methods and teaching of therapeutic hypnosis by D. Corydon Hammond and the acknowledged authorities of the American Society of Clinical Hypnosis. This is the standard reference text that belongs in the libraries of all medical, dental, and nursing schools, as well as graduate departments of Psychology and Social Work. Students and mature clinicians of all specialties will find an excellent orientation to the therapeutic art and leading edge of modern hypnosis right here! " Ernest L. Rossi, Ph.D. This 393-page volume includes 265 pages of practical handouts and summaries of clinical techniques, 28 handouts on induction and deepening techniques, and 34 inductions for children. It includes sections on: foundations of knowledge, an overview of modules for teaching hypnosis and model course outlines, numerous alternatives for teaching demonstrations, many experiential learning exercises, formulating hypnotic suggestions, methods of unconscious exploration, age regression, methods of egostrengthening, hypnotic strategies for pain management, specialized techniques and metaphors, resistance, and a comprehensive overview of commercially available audiovisual aids and resources. It is available for $37 .50 (add $3.50 for shipping and handling). COMPON E NT SECTIONS Approximately four dozen local component sections of ASCH provide support, professional interaction, and further training opportunities to members. Many component sections also allow masters degree practitioners membership status. Foreign affiliated societies offer still further opportunities for international exchange. THE ASCH N EWSLETT E R Published five times a year, the Newsletter provides members with timely information about latest developments in the field and training opportunities. Clinically relevant information is frequently included, as well as a current literature computer search update. 8 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS Eligibility for ASCH Membership To b e eligible for membership, the applicant must have: a. An M . D . , D.D.S., D.M.D. , D . O . or a Ph. D . , or an equivalent degree (e.g., Ed.D. or D.S.W.) with psychology as the major study. (Doctoral level social workers and doctoral level marriage and family therapists frequently meet these requirements); b. a doctorate from a university or college accredited by its appropriate regional accrediting body; c. a license to practice in the state or province; d. membership or eligibility for membership in a professional society consistent with his/her degree; e. 40 hours of appropriate professional training and experience in clinical or experimental hypnosis. To be eligible for associate membership, the applicant must have: a. An M.D . , D . D . S . , D.M.D., D.O. or a Ph. D . , or an equivalent degree (e.g. , Ed.D. or D . S .W.) with psychology as the major study; b. a doctorate from a university or college accredited by its appropriate regional accrediting body; c. a license to practice in the state or province; d. membership or eligibility for membership in a professional society consistent with his/her degree; e. an associate member shall have two years' time allotted for acquiring the prerequisite clinical experience and training for full membership requirements. To be eligible for student affiliate membership, the applicant must be: a. A full-time student with a minimum of 45 completed graduate semester hours or 60 completed graduate quarter hours; and shall be (1) enrolled in a graduate program in active pursuit of a doctorate in medicine (M.D. or D.O.) , dentistry or psychology, or (2) enrolled in a doctoral program where psychology is the major field of study; b. pursuing his/her doctoral degree at a university or college fully accredited by the appropriate regional accrediting body to give such a degree. For further information concerning membership, training, tapes or publications, please contact: The American Society of Clinical Hypnosis 2200 East Devon Ave. , Suite 291 Des Plaines, Illinois 6001 8 (312) 297-3317 All royalties from the sale of this book have been donated to the American Society of Clinical Hypnosis to promote further training and research in hypnosis. INTRODUCTION 9 Acknowledgments This book represents the compilation of many different people's styles and ways of working. Appreciation is extended to the dozens of master clinicians who freely contributed their work to ASCH for publication in this volume and in the 1 973 Handbook of Therapeutic Suggestions. The finest suggestions from the 1 973 volume have been retained in this book. Thanks are also in order to Dr. Louis Dubin, past president of the American Society of Clinical Hypnosis, and to my colleagues on the Executive Committee of ASCH for encouraging this massive undertaking. I am also appreciative for the assistance of Drs. Michael Yapko, Valerie Wall, and Daniel Kohen for reviewing and providing feedback on some of the original material that was submitted. Most of all, I appreciate the sacrifices of my loving wife and companion, Melanie, who provided encouragement, endured this project along with me, and thoughfully helped proofread this volume. � 2 FORMULATING HYP NOTIC AND POSTHYP NOTIC SUGGESTIONS IN THIS CHAPTER WE WILL overview the major principles and guidelines involved in formulating effective hypnotic suggestions. Afterwards, we will discuss different types of suggestions that may be constructed and how to phrase suggestions. Finally we will examine the process of how you may present a series of suggestions in order to production different hypnotic phenomena. Keep in mind that hypnotic suggestions may be directed toward behaviors, emotions, sensations and physiologic processes, cognition, imagery, and relationships (Hammond & Miller, in press; Hammond & Stanfield, 1 977). Suggestions may also focus on producing immediate responses within the hypnotic session or posthypnotic effects. Principles of H ypnotic Suggestion ESTABliSH RAPPO RT AND A COOPE RATIVE R E LATIONSH I P Establishing a relationship with the patient must always be considered the first and most vitally important prerequisite for suggestions to be effective. Relating to the patient in a warm, understanding, caring and respectful manner reduces defensiveness and creates the trusting kind of climate that is necessary for hypnosis to be maximally effective. Because hypnosis is a cooperative venture, rather than something we do to the patient, it is crucially important to devote time to the human relationship dimension and not to simply concentrate on technical expertise in hypnosis alone. CREATE POSITIVE EXPECTANCY Experienced hypnotherapists are probably more effective than new students, at least in part, because they act utterly expectant and confident that their suggestions will occur. This inspires confidence in patients. Act and speak confidently. 1 1 1 2 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS There are times, as we will discuss shortly, when it is wise to phrase suggestions in a more permissive and indirect way. Exercise caution, however, that you do not speak in such a laissez faire manner that you are perceived as lacking confidence. This is a mistake common among hypnotherapists with limited experience and confidence, or who are trying to be overly permissive. Be careful about using words such as "perhaps," "maybe," "can," or "might" (Brown & Fromm, 1 986) . For instance, listen to the lack of conviction and confidence conveyed by these suggestions : "One of your hands might begin feeling lighter." "Maybe (Perhaps) your hand can float up." "Perhaps a numbness will develop in your hand." Compare the difference when you change the words to "will" and "is." "One of your hands is beginning to get lighter, and will begin to float up, lighter and lighter." As we will discuss under the principle of successive approximations, you can be permissive concerning the time required to develop a response, and still convey confidence. It is important to make the distinction between being confident and authoritative versus authoritarian and dominating. T H E LAW O F REVE RS E D E FFECT The principle of reversed effect primarily applies to making suggestions to produce physiological effects. This "law" refers to the fact that the harder one consciously endeavors to do something, the more difficult it becomes to succeed. Have you ever tried to consciously will an erection or an orgasm? Or, how many times have you retired to bed too late and tried to help yourself to go to sleep, only to find yourself more wide awake? Just as we are unsuccessful at trying to will ourselves to perspire or salivate, we are generally unsuccessful in applying conscious willpower to produce therapeutic changes, especially physiologic changes. As you formulate suggestions, emphasize imagination and imagery rather than appealing to the conscious will. For example, instead of simply verbally suggesting that a hand is becoming numb, you may have patients imagine putting their hand into the snow or into an icy cold stream, while simultaneously suggesting anesthesia. Alternatively, seek to evoke memories and images of life experiences where the phenomenon was experienced in the past. For example: "And one of the things that you don't know that you know, is how to lose the ability to feel. (This is a confusional statement that creates a sense of wonderment.) And yet you've experienced that many times - like when you've fallen asleep on a hand or an arm, and awakened to find it numb, or like when you've gone to a dentist and had novocaine or lidocaine injected - and I'm sure you know what those numb, leathery sensations feel like, do you not?" (These are truisms that evoke memories of the desired phenomenon.) LAW O F CONCE NTRATE D ATTE NTION: RE PETITION OF SUGG ESTIONS This refers to the principle of repetition of suggestions. When we concentrate attention repeatedly on a goal or idea, it tends to be realized. FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 1 3 Thus, a classic principle in formulating important hypnotic suggestions is to repeat them several (e.g. , three or four) times. Repetition of suggestion may be accomplished through using somewhat synonymous words and phrases . However, one of Milton Erickson's (1 954/ 1 980) contributions to hypnosis was his model of giving both direct verbal suggestions and also using metaphoric examples as an indirect method of repeating suggestions. Thus, Erickson often told a metaphor or two to "seed" an idea. He would then make a bridging association, identifying the relevance of the stories to the patient's problem, and finally, he would offer the patient direct suggestions. TH E PRI NCI PLE OF SUCCESSIVE APPROXIMATIONS In formulating hypnotic and posthypnotic suggestions, it is essential to not expect your patients to immediately produce various hypnotic phenomena. As therapists we often err in the same way as our patients: we hold magical expectations that hypnosis will produce instant results. We, like our patients, often want immediate gratification. But most clients do not "leap tall buildings in a single bound. " Be patient as you seek to facilitate hypnotic phenomenon, and allow the client time to develop the desired response. It may be helpful, when responses are slow in coming, to mentally break the desired task down in your mind into intermediate steps to be facilitated. When you expect positive results, exude confidence, and are persistent in working to produce one the hypnotic phenomenon, the little bit of extra time will usually be rewarded. Adjust your pace to your patient's rate of response. Thus you will want to avoid the authoritarian suggestions reminiscent of lay hypnotists and stage hypnotists: "You will immediately . . . ," "In five minutes you will . . . ," "By the time you awaken your pain will be completely gone." Respect the individuality of your patient and realize that different persons will require more time to respond to a suggestion. When giving suggestions for new patients, where you are not yet aware of their response potentials, it is, therefore, desirable to phrase the suggestions in more a fail-safe and permissive manner (Erickson & Rossi, 1 979). We will discuss this further as we talk about different types of suggestions. We should add, however, that you can be permissive concerning time, and yet still convey a confidence that patient's will, in their own time, respond to the suggestions. Some of the following types of words are permissive concerning time, but still contain the implication that the patient will respond: "soon," "before long," "yet," "beginning to notice," "shortly," "in its own way." For example: "And do you begin to notice the tingling and numbness beginning yet?" "Soon you'll sense a lightness starting to develop in that hand. And you can begin to wonder just when you'll first sense a twitch and sensation of movement in one of the fingers. And that hand's becoming lighter. " THE LAW OF DOMI NANT E FFECT This principle states that stronger emotions tend to take precedence over weaker ones. Thus, once again, rather than appealing to the conscious will, 1 4 HANDBOOK O F HYPNOTIC SUGGESTIONS AND METAPHORS you will find it more effective to connect your suggestions to a dominant emotion. The famous defense attorney Clarence Darrow once described his prime courtroom strategy. He would seek to stir the emotions of the jury so that they wanted to decide the case his way, and then he would look for a technicality to give them to justify it. We as therapists may similarly be more influential by seeking to stir the emotions of patients and connect suggestions to them. It is my belief that this strategy is probably most effective with those patients who tend to emphasize their heart and emotions more than their intellect and rationality in decision-making. Related to this concept, you may at times seek to arouse an internal state of tension and anticipation in the patient that can be resolved only through producing the desired hypnotic response. T H E CARROT PRI NCIPLE As therapists we sometimes, in effect, try to push our patients from behind, toward a goal. But, like trying to push a mule toward our chosen destination, we find that some of our patients dig in their heels and resist our influence. Instead of pushing people from behind, we should be seeking to motivate them from in front, toward a goal. Therefore, as you formulate suggestions, interject comments about the patient's goals. 'J"'his principle encourages us to link the patient's motivations and goals with our suggestions, just as the Law of Dominant Effect encourages us to tie suggestions to strong emotions of the patient. By way of illustration, as part of a suggestion for deepening, you may state: "And you will sink deeper and deeper in the trance as that arm floats up toward your face, because you want to live to raise your children, and you want to become a nonsmoker." Along the same vein, when you work with a patient who gives more importance in his life to logic and reasoning (as contrasted with emotion), provide him with logical reasons (or even pseudo-rationales) for accepting your suggestions. T H E PRINCI PLE OF POSITIVE SUGG ESTION Rather than seeking to override existing motives or attitudes, create positive motivation and attitudes in your patients. This can sometimes be difficult to do, and in actuality, there is no research evidence to validate this principle. Thus you will notice that occasionally a contributor to this book resorts to a negative suggestion. Nonetheless, based on clinical wisdom, I recommend that whenever possible you should seek to change negative suggestions to positive ones. When this cannot be done, you may wish to precede the negative suggestion with an easily performed or accepted positive suggestion (Weitzenhoffer, 1989). By way of illustration, instead of suggesting to a weight control patient, "You will not be hungry," (an unlikely, and even undesirable proposition), you may suggest: "And you'll be surprised to discover, how really comfortable you will be, because you'll simply become so absorbed in the things you're doing, that time will go by very rapidly, and suddenly, to your FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 1 5 surprise, you realize that it's time for another meal." As another example, rather than suggesting, "You won't eat sweets or foods that are bad for you," you may suggest: "You will protect your body, treating it with kindness and respect, as if it were just like your precious, innocent little boy that you love, totally dependent upon your care and protection. You will protect your body, just as you protect and take care of your son." In talking to a child with a bedwetting problem, you talk about having a "dry bed" rather than about not wetting the bed. TH E PRI NCI PLE OF POSITIVE RE I N FORCEMENT \ Reinforce and compliment the patient both in and out of trance. "You're domg that very nicely." "Good. You're doing very well." "Umm hmm. That's right. And really enjoy the weightlessness of that hand, as it continues to float all the way up to your face." "You've worked very hard today, and I hope that your unconscious mmd will take a real pnde in how hypnotically talented you are, and in how much you've accomplished." As a further model of how you may compliment the hypnotized patient, note what Erickson (Erickson & Rossi, 1989) told a patient on two different occasions: "Also, after you awaken, I want you to have a very thorough appreciation of how very capably you have worked tonight." "I want you to know that I thank you for your generosity, your kindness, in permitting me to do things in my way. I appreciate it tremendously. It was very kind of you . . . "Social psychology research certainly suggests that compliments or praise �ill generally enhance patients' rapport and liking of us, and, therefore, their compliance to suggestions. Certain suggestions may also be reinforced nonverbally. For example, in facilitating levitation, limb heaviness, or glove anesthesia, the hypnotherapist may reinforce verbal suggestions through very lightly stroking the patient's arm or hand two or three times: "And as I stroke that hand, you'll notice how the anesthesia begins to spread and flow through that hand." Similarly, you may "prompt" a patient who is slow in developing levitation, gently using an upward stroking motion under the forearm during inhalations, or lightly lifting the fingertips. CREATING A N ACCE PTANCE O R YES-SET For many years human relations experts and sales people have known the importance of obtaining an initial "yes" response from someone you are trying to influence. A powerful orator will seek to immediately obtain affirmative responses from the audience to create an acceptance set mentally. As early at 1936, Dale Carnegie emphasized this principle, referring to it as "the secret of Socrates." "His method? Did he tell people they were wrong? On, no, not Socrates. He was far too adroit for that. His whole technique, now called the 'Socratic method,' was based upon getting a 'yes, yes' response. He asked questions with which his opponent would have to agree. He kept on winning one admission after another until he had an armful of yeses. He kept on asking questions until finally, almost 16 HANDBOOK O F HYPNOTIC SUGGESTIONS AND METAPHORS without realizing it, his opponent found himself embracing a conclusion that he would have bitterly denied a few minutes previously" (Carnegie, 1966, p. 144). One particular type of hypnotic suggestion is particularly effective at eliciting a "yes-set": truisms. The truism, which will be discussed more fully later, is an undeniable statement of fact. For instance, "All of us have had the experience of walking along on a cold, winter day, and feeling the cold against our skin." Using suggestions in the form of truisms creates an acceptance set. This may be enhanced even further by interacting with the hypnotized patient. For example, continuing with the suggestion we just gave: "And I'm sure you've felt how cold the winter wind can be against your skin, have you not?" Most patient's will nod their head "yes." If an overt response was not immediately forthcoming, you could simply add, "You can simply gently nod your head up and down for yes, and back and forth for no. And you can remember how cold the winter's wind can feel against your face, can you not?" (Following a nod for "yes":) "And you remember how you can see your breath, like fog, in the cold air, don't you? (Patient nods.) And the longer you walk with your face or your bare hands exposed to that cold air, the more numb they feel, don't they? And so your mind remembers what that feeling of numbness is like." This type of sequence of undeniable experiences, where patients think or nonverbally indicate, "Yes, yes, yes, yes," makes it more difficult for them to not continue responding affirmatively to the suggestions that follow. I NT E RACTIVE TRANCE A N D CON FI RM I NG T H E ACCE PTABI LITY OF SUGG ESTIONS It is common for new hypnotherapists to expect that the patient should basically remain in a silent and passive role, while the therapist assumes full responsibility for single-handedly formulating suggestions and controlling the patient's experience. This is an error. We observe students frequently suggesting various types of internal (e.g., imagery, regression) experiences without any idea whether the patient is actually experiencing what was suggested. You may involve the patient as an active participant in hypnotherapy in at least three ways. First, prior to hypnotic work, obtain patients' input and ideas about their interests, preferences, suggestions and the approach that they deem most likely to be effective. When your style of hypnotic work is congruent with the patient's expectations, you may anticipate a greater likelihood of success. Second, you may obtain nonverbal feedback from the patient in the form of head nods, ideomotor finger signals, or even levitation as a signal to monitor progress. This type of suggestion has been called the implied directive. After giving posthypnotic suggestions, for example, you may suggest: "And if your unconscious mind is willing to accept this idea [or, "all of these ideas"] , your 'yes' finger will float up to signal me." If a response is not forthcoming within the next 20 seconds or so, you may add, FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 17 "Or, if your unconscious mind isn't willing to accept all of these ideas, your 'no' finger can float up to signal me." In this manner you will be able to determine the acceptability of suggestions and whether resistance is present. Personally, I would rather know if there is resistance immediately so that we can work it through, rather than discovering it a week later. Neophyte hypnotists too often practice what we might call, "When I wish upon a star therapy" -giving hypnotic suggestions and then hoping that they will magically have an impact on and be accepted by the patient. It seems far more desirable to regularly track patient progress, the acceptability of your suggestions, and the success of internal therapeutic work. Thus, after giving a hypnotic or posthypnotic suggestion, you may ask the patient: "Would that be all right?" "Is that acceptable to you?" "Do you understand?" "Do you understand this clearly?" "And is that all right?" "Would you be willing to do that?" This was a common practice of Dr. Milton Erickson. Once a suggestion is accepted, it commits the patient to a course of change and therapeutic movement. The "unconscious" mind may also be consulted, as modeled two paragraphs above, to obtain a more involuntary commitment about the acceptability of suggestions. This is a regular practice in my therapeutic work. Once such confirmation is obtained, it is no longer necessary to be overly permissive or indirect in presenting suggestions to the patient. You have confirmed that resistance is not present, and you can, therefore, deliver the suggestions in a more positive, confident and forceful manner. Obtaining commitments in hypnosis, whether conscious or unconscious, is a powerful therapeutic tool for increasing the effectiveness of suggestions. The reason seems to be that most people experience an internal pressure and need to feel and look consistent. Considerable social psychological research indicates that when someone makes an initial commitment, he is subsequently more willing to accept ideas related to the prior commitment (Cialdini, 1988). In fact, obtaining any kind of commitment at all seems to increase the likelihood of accepting subsequent ideas. This is the basis for the well-known sales strategy referred to as the "foot-in-the-door technique." Sales people usually start with a small, often seemingly innocuous request, realizing that a domino effect will often result once the change process is under way. Once inertia has been overcome, further movement is much easier to obtain. This is also the basis for the "yes-set" that we have already discussed. Nonverbal responses may also be requested to determine when internal processes are being experienced or have been completed. Some examples will illustrate this process: "When you become aware of the numbness beginning to develop in your right hand, just gently nod your head up and down for yes." "And when your unconscious mind has identified a time in your past when you felt calm and confident, your 'yes' finger will float up to signal me." "And as you walk along in the mountains, the path will eventually lead you down by a creek or stream. And when you're walking along by that creek, just gently not your head up and down to signal me. " Other illustrations will be given later as we discuss the implied directive as a type of suggestion. 1 8 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS Let's model the manner in which nonverbal signaling might be used in exploratory or abreactive work. Suppose that we have a female patient who was a victim of incest as a child, and that you have had the patient regress to the age of four, relive the experience and abreact the feelings. Some therapists might just assume that feelings have been resolved at this point, and simply give some posthypnotic suggestions. However, following abreaction and reframing, I consider it a more careful and thoughtful approach to interact with the patient and check concerning the resolution and acceptance of suggestions: "And now that you've released all those old, outdated feelings, is your unconscious mind now willing to let go of all those old, out-of-date feelings, so that they'll no longer influence you?" If an ideomotor signal for "yes" is obtained, you can more confidently suggest: "You can now let go of all those old feelings of anger, and hurt, and fear, and guilt. Just let go of all those outdated feelings, and when your unconscious mind can sense you letting go of them, your 'yes' finger will float up again." (Following a positive response:) "That's right. And your unconscious mind can finish letting go of all those old feelings, so that you will now be free of the effects of that experience. It will no longer influence how you think, or act, or feel. And I want to ask, can your unconscious mind now sense that all men are not like your father?" (After a positive response:) Good. You can now understand that all men are not like your father. And do you realize that your husband is not like your father?" (Again, following a positive response:) That's right, you can now appreciate that all men are not like your father. And you will begin to see men as individuals now, perceiving them as distinct individuals. All men are not like your father, and your husband is not like your father. And you are free now; free to relate to men as individuals, and free to relate to your husband as an individual. And those events that we've worked through will no longer influence how you think or act or feel. You are free now." Finally, at times the patient may also be asked to verbally interact during hypnotic work. It is commonly believed that verbalizing "lightens" a hypnotic state, and, therefore, nonverbal signals often seem preferable. There are situations, however, when information is needed that cannot be conveniently conveyed through nonverbal ("yes" or "no") responses. When verbal interaction only occurs occasionally during hypnosis, it will not significantly alter the depth of trance. Furthermore, suggestions may be offered to minimize the "lightening" of the trance. For example, you may suggest: "You can speak in a hypnotic state, just as you can speak in the dreams of the night, without awakening. And remaining very deep in a hypnotic state, I want you to just verbally tell me, what are you experiencing right now?" Or, "And in a moment, I'm going to ask you to speak to me. And as you speak, simply the sound of your voice will take you into a deeper and deeper hypnotic state. So that as you speak, with every sound of your voice, and with every word that you speak, you'll go deeper and deeper into the trance." Sometimes interactive trance is useful during induction and deepening. You may simply ask the patient to occasionally describe what he is hearing FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 19 or seeing during an imagery experience. This allows you to tailor your input, rather than "operating blind." Similarly, in working to produce certain hypnotic phenomena, it may be useful to obtain interaction, and then accept and utilize whatever the patient offers you. T H E PRI NCI PLE OF TRANCE RATI FICATION In hypnosis it is vitally important to create a sense of positive expectancy in the patient. Trance ratification refers to the process of providing the patient with a convincer, that is, an experience or experiences that ratify for patients that they have been in an altered state of consciousness. It is interesting that sometimes even highly talented hypnotic subjects do not believe they have been hypnotized until they have a ratifying experience. Trance ratification is a basic, yet often neglected, hypnotic principle. Through eliciting various hypnotic phenomena, patients may come to realize that they have undiscovered potentials beyond their conscious capacities. This realization increases patients' sense of selfefficacy and confidence that they have the inner resources needed to change (Bandura, 1977). It is recommended, therefore, that you provide from time to time a trance ratification experience for your patients. For example, with a weight control patient, you might facilitate a glove anesthesia. Then, with the patient's permission, press on the hand with a sharp object, clamp a hemostat on the fleshy part of the hand below the little finger, or put a sterile needle through a fold of skin on the back of the hand. After inserting a needle or attaching a hemostat, ask your patient to open her eyes to briefly look at the hand. The suggestion may then be forcefully given: "I have had you do this to demonstrate to you the power of your own mind over your body. You have now witnessed the incredible power of your unconscious mind to control your feelings and your body. And you can know that, when your unconscious mind is so powerful that it can even control something as fundamental and basic as pain, that it can control anything having to do with your feelings and your body. You have far more potentials than you realize. And because of this power of your unconscious mind, your appetite and cravings will come under your control." Such an experience instills hope, belief and positive expectancy. Some of the following hypnotic experiences are recommended as having value for providing trance ratification: 1 . Glove anesthesia or analgesia. 2. Time distortion. 3 . Limb catalepsy. 4. Arm levitation. 5. Limb heaviness. 6. Amnesia. 7. Ideomotor signaling. 20 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS 8. Response to posthypnotic suggestion (e.g. , for an itch; to not be able to stand up). 9. Recall of forgotten or even insignificant memories. 10. Ideosensory phenomenon: warmth, taste, smell. 1 1 . Olfactory hallucination. EXAMPLE OF SUGGESTIONS FOR TRANCE RATI FICATION. As I have Stated, the production of hypnotic phenomena serve to convince patients that they are in an altered state. In addition, successful response to such suggestions also appears to increase the patient's subsequent depth of trance. In the following suggestions for the treatment of warts, Crasilneck and Hall (1985) model for us, in a single treatment procedure, the use of a wide variety of trance ratification procedures: ideosensory phenomenon (heat, coolness); arm levitation; eyelid heaviness; response to posthypnotic suggestions for eyelid catalepsy and limb rigidity; glove anesthesia; and olfactory hallucination. Please cup your right hand on your right knee . . . . That's it. . . . Now look at the knuckles of your hand and as you are doing so, your entire body will begin to relax thoroughly . . . . Pay no attention to other sounds . . . just concentrate on your right hand and my voice, realizing that nothing is beyond the power of your mind . . . and of the body. As I continue talking to you and as you continue staring at the back of your cupped hand, you will begin to notice things like the heat in the palm of your hand . . . and perhaps movement in one of the fingers . . . . As this occurs, slightly nod your head . . . yes . . . very good . . . and now you will notice that your hand is becoming very, very light . . . like a feather coming up toward your forehead . . . Good . . . Your hand starts to move upward . . . and as your hand continues to rise, keep looking at the back of your hand . . . but notice your eyelids are getting very heavy, very drowsy, and very relaxed . . . . Now when your hand touches your forehead . . . your eyes will be closed . . . you will be tremendously relaxed and capable of entering a deep level of trance. Your hand and arm comes up, up, up towards your forehead . . . . Now, your hand touches your forehead . . . your eyes are closed . . . . You can let your hand rest comfortably in your lap and normal sensation is returning to your right hand and arm . . . . Notice that your eyelids feel heavy . . . so heavy that even though you try to open your eyes for the moment . . . you can't. . . . Go ahead and try . . . but you cannot. . . . Try again . . . but the eyelids are shut tight. . . . Normal sensations return to the eyelids . . . . Now you will enter a much more sound and relaxed state . . . . Now I want you to raise your right hand . . . . That's it. . . . Extend it in front of you, and as I count to three, your arm will become rigid . . . hard . . . like a board soaked in water . . . like steel . . . so tight . . . so rigid . . . those muscles become steel. . . . One, tight . . . two . . . very rigid, and three, the whole arm, each finger . . . yes . . . become steel. . . . There . . . nothing can bend that arm or the fingers [as a further demonstration, at this point Crasilneck often has the patient use the other arm and feel the arm rigidity and their inability to bend it. Ed.] . . . showing you the power of your mind and body . . . . Now relax the arm and hand . . . . Normal sensation returns and still a much deeper and sounder state of relaxation. I now give you the hypnotic suggestion that your right hand will develop the feeling that a heavy thick glove is on your right hand . . . as your hand has FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 21 developed this sensation, move the forefinger o f the right hand . . . . Good . . . . Now you will note some pressure in the forefinger . . . a dull sensation of pressure . . . . Open your eyes . . . . Now you see that in reality I'm sticking your fmger severely with my nail file . . . but you are feeling nothing . . . correct? . . . Fine . . . . Normal sensation is returning to your hand . . . . I am now going to stimulate the middle finger. . . . As you feel this . . . nod your head, yes . . . . You see you pulled your hand back, which is an immediate and normal response. You are now aware of the tremendous control that your unconscious mind has over your body . . . . Now close your eyes again . . . . I now suggest that you can smell a pleasant odor of your choosing. . . . As you smell this, nod your head yes . . . . Good . . . . And now a very, very deep level of trance . . . . The pleasant odor leaves and still a more relaxed and deeper state of trance . . . . Nothing is beyond the power of the unconscious mind and these warts are going to leave completely and your skin will be void of them . . . . The area that I touch with this pencil . . . this area of warts now begins to feel very cool . . . cool . . . slightly cold . . . . As you feel this, nod your head . . . . Good . . . . Think the thought as I continue talking . . . . The area is cool. . . . The warts are going to leave . . . . The area is cool, and the warts will leave my body because of the power of my mind over my body . . . . Now just relax your thoughts . . . just pleasant, relaxed, serene thoughts. . . . Listen to me . . . my every word . . . These warts are gom g to leave. . . . We have demonstrated the control of your mind over your body, and these warts will be gone very shortly . . . . Your skin will feel slightly cool around the area of the warts for a day or so, and as the coolness fades, the warts will also begin to fade. And so, as I slowly count from ten to one, you will be fully awake . . . free from tension, tightness, stress and strain. These warts are going to fade out (pp. 374-375, reprinted with permission). TIMING OF SUGG ESTIONS AN D DEPTH OF TRANCE The timing of suggestions is something that is guided by clinical wisdom but which lacks research support at this time. Many leaders in the field have taught that you will have more impact by giving your most important suggestions last. Although depth of trance has been discounted as unimportant by some, many senior clinicians have believed that when suggestions are given in a deeper hypnotic state, they will have more influence. Erickson (Erickson & Rossi, 1974/1980) certainly believed that it was important to devote sufficient time to adequately produce certain hypnotic phenomena and he instructed Rossi in this regard. "Erickson rarely gives therapeutic suggestions until the trance has developed for at least 20 minutes, and this only after hours of previous hypnotic training" (p. 89). Erickson often treated patients in time extended sessions where the patient might be in hypnosis for hours, and a large proportion of his famous case reports involved work in deep trance. In fact, his widow informed me that his favorite paper that he ever wrote was his chapter on deep trance (Erickson, 1954/1980). It is my own personal belief that subjects often tend to be more responsive in deeper trances. 22 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS T H E PRI NCIPLE Of I NTERSPERSI NG A N D EM BEDDING SUGGESTIONS Suggestions may be subtly interspersed within stories, anecdotes, or "deepening" techniques. Words or phrases may be included, set apart by very brief pauses or changes in voice tone, that convey additional meanings and suggestions. For instance, I was working with a woman for both obesity and marital problems. She had a noxious habit of interrupting rather than listening during interactions. Therefore, the following suggestions were given (and recorded on cassette tape for use in self-hypnosis). Notice where commas indicate very brief pauses. "It will be interesting for you to learn to listen, to your body. And as you listen, to your body, you can notice how you feel satisfied. And rather than interrupting, the natural balance of things, you can listen respectfully to feelings, and sensations of your body, noticing how soon you feel comfortably full and contented. " Two problems were being addressed at once. Personally, I find it useful to brainstorm ideas and phrases that convey the desired suggestions, and then to consult a comprehensive thesaurus to identify additional synonyms. What words and phrases convey attitudes, perceptions, feelings or qualities that are desirable for the patient? Then I contemplate how these words and phrases may be interspersed within an analogy, example, metaphor, or deepening technique. You are encouraged to read Erickson's ( 1 966) example of the interspersal technique in the chapter on pain and to consult Erickson's collected papers ( 1980) for other masterful examples of this technique. E RICKSON'S PRI NCI PLES Of I N DIVI DUALIZATION AND UTI LIZATION Milton Erickson emphasized the need to individualize hypnotic procedures. But many lay hypnotists and even some legitimate professionals assume that hypnotic response is only a trait and that individualization is, therefore, unnecessary. Thus, they mass produce popularized self-hypnosis tapes, presenting everyone with the same induction and suggestions. There is limited evidence, however, suggesting that hypnosis may be more effective when it is individualized (Holroyd, 1 980; Nuland & Field, 1970) and takes into account the unique motivations, personality, interests and preferences of the patient. Furthermore, there is evidence in psychotherapy outcome research that failure to individualize therapy not only may result in poor outcome, but may be associated with psychological casualties (Lieberman, Yalom & Miles, 1 973). Therefore, I have many of my patients take home a paper and pencil checklist of life experiences, interest and values (Hammond, 1985, 1988a). The checklist rapidly provides information to use in individualizing the induction, metaphors and suggestions. As one example of individualization, we can determine by brief questioning (during or after hypnosis) which sensory modalities a patient is FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 23 primarily able to imagine (visual, auditory, kinesthetic, olfactory). We may then tailor the imagery that we suggest accordingly. I also recommend questioning your patients after an initial hypnotic experience to obtain their feedback about how you can make the experience even more effective. MYTH OF THE SUPE RIORITY OF INDIRECT SUGGESTIONS. As clinicians begin tO study hypnosis, they commonly ponder over the question, "Should I be direct or indirect in my approach?" In recent years this has become one of the most controversial areas in hypnosis, particularly among workshop presenters and non-research-oriented writers; therefore, we will examine in some detail the existing evidence. Some authors, particularly some of those identifying themselves as "Ericksonian," have assumed that indirect, permissive suggestions are always superior to direct suggestions. Some have even been so bold as to make statements like these: "Direct suggestion will bring only temporary relief, will intensify the transference relationship toward authority, and will increase repression of the conflict that led to the symptomatology" (Lankton & Lankton, 1 983, p. 1 50), and "An Ericksonian hypnotist strives to be artfully indirect in all suggestions and interventions" (Lankton & Lankton, 1 983, p . 25 1 ) . "He [Erickson] noticed that direct suggestions were useful only to the extent that clients knew what they wanted, were congruent about wanting to accomplish it, and had the resources necessary to change available and organized. Clients seeking therapy rarely meet these criteria" (Lankton, 1 985). Are indirect and permissive suggestions always superior? Alman (1983) experimentally tested this assumption and to his surprise found that response to direct versus indirect suggestions was normally distributed-some patients responded better to very direct suggestions, and others were more responsive to permissive, indirect suggestions. Very similarly, McConkey (1 984) found subjects were heterogeneous in their response to indirect suggestions - half were responsive to this type of suggestion and half were not. He speculated that "indirection may not be the clinically important notion as much as the creation of a motivational context where the overall suggestion is acceptable, e.g. by making the ideas congruent with other aims and hopes of the patient" (p. 3 1 2) . There have been some studies and uncontrolled case reports (Alman & Carney, 1 980; Barber, 1 977; Fricton & Roth, 1 985; Stone & Lundy, 1 985) that have reported superior effects for indirect suggestions, but several of these studies (e.g. , Barber, 1 977) had serious methodological flaws. The indirect condition that was used by Matthews, Bennett, Bean and Gallagher (1985), for example, was 340Jo longer than the direct condition, which appears to have accounted for the greater depth reported. In contrast to the studies claiming greater potency for indirect suggestions, many other studies have failed to find a difference in effectiveness (e.g., Lynn, Neufeld, & Matyi, 1 987; Matthews et a!. , 1 985; Murphy, 1988; Reyher & Wilson, 1 976; Spinhoven, Baak, Van Dyck, & Vermeulen, 1 988). For instance, Barber's ( 1977) superior results with indirect suggestions have 24 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS not been replicated with dental procedures (Gillett & Coe, 1 984), with foot surgery (Crowley, 1 980), obstetrical patients (Orner, Darnel, Silberman, Shuval, & Palti, 1 988) or with pain in paraplegic patients (Snow, 1 979). Furthermore, Van Gorp, Meyer and Dunbar ( 1 985) used his procedure with experimental pain and found that traditional hypnotic suggestions were significantly more effective than indirect suggestions. Still other studies have likewise found that direct suggestions produce better posthypnotic response (e.g. , Stone & Lundy, 1 985). Matthews and Mosher ( 1 988) entered their study anticipating a superior response with indirect suggestions, and expecting that it would decrease resistance as hypothesized by Erickson and Rossi ( 1 979). Subjects not only did not respond differently to either indirect inductions or indirect suggestions, but subjects receiving indirect suggestions were actually found to become more resistant! Lynn et al. ( 1 988) likewise did not find that resistance was minimized by using indirect suggestion. Further testing the "Ericksonian" belief that indirect suggestions are superior with resistant and more independent patients, Spinhoven et al. ( 1 988) examined the relationship of locus of control to preference for direct or indirect suggestions. Locus of control did not predict response to either direct or indirect approaches. Sense of involuntariness of response to suggestions has also been discovered to be the same for direct and indirect suggestions (Matthews et al. , 1985; Stone & Lundy, 1 985). Furthermore, Lynn et al. ( 1 988) actually found that sense of involuntariness and of subjective involvement was greater when direct suggestions were used. The later finding replicated the carefully controlled results of Lynn, Neufeld, and Matyi ( 1 987). Research (Matthews, Kirsch, & Mosher, 1 985) has now carefully examined the Bandler and Grinder ( 1 975) and Lankton and Lankton ( 1 983) contention that using two-level communication and interspersing suggestions in a confusing dual induction produces superior results. If anything, they found the opposite. Not only was a double induction not more effective than a traditional induction procedure, but when it was used as the initial induction experienced by a subject, it was less effective and appeared to have a negative impact on later hypnotic experiences. Even Erickson ( 1964) would have probably predicted this, however, since he designed confusional procedures for primary use with consciously motivated but unconsciously resistant subjects. So, let's return to our initial query, "Are indirect suggestions superior to direct hypnotic suggestions?" The weight of existing evidence clearly requires a response of "No." Indirect suggestions do not seem more effective than direct suggestions; in fact, direct suggestions may possess some advantages. Several studies (Alman, 1983; McConkey, 1984; Spinhoven et al. , 1988) seem to indicate that some individuals will respond better to each type of suggestion, but most people fall in the middle of the distribution and may well respond equally well to either type of suggestion. The furor of the past decade over the belief that "indirect is always better" is rather reminiscent of the extensive research literature that has now failed to replicate the creative, but nonetheless unfounded tenets of NLP. As FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 25 mental health professionals we may stand too ready to adopt unproven theories as truth. It is thus my recommendation, in the light of current evidence, that we i ' should keep our therapeutic options open and maintain the flexibility to use both direct and indirect suggestions. In light of the research, the debate over the preferability of one type of suggestion over the other may be "much ado about nothing." We are probably well advised to not spend so much time worrying about it. Erickson certainly felt free to use both highly directive and even authoritarian suggestions with some patients, and to use very permissive and indirect suggestions with others (Hammond, 1 984). We have no validated indications or contraindications for the type of suggestions to use. In fact, some of the widely accepted indications for when to use indirect suggestions (e.g. , with resistant and more independent subjects) that evolved from clinical beliefs may be nothing more than folklore, since they have not received research support thus far. Hypnosis like so much of psychotherapy - is still more art than science. We must therefore remain open and appropriately humble about what we actually know, rather than becoming prematurely entrenched in untested theories that may limit our options for intervention and learning. What I am going to express now is only my tentatively held clinical belief, which may or may not prove to be accurate. In my own clinical work I tend to be more direct, straightforward, and forceful in giving hypnotic suggestions under the following circumstances: 1 ) When a good therapeutic relationship and rapport have been established with the patient; (2) When the patient seems motivated and nonresistant; (3) When the patient seems able to accept direction and authority, or is more dependent and used to accepting authority; (4) When the patient seems more highly hypnotically talented and is in a deeper hypnotic state; (5) When I am familiar with the hypnotic talents and capacities of the patient and am thus aware of the hypnotic phenomena she or he can manifest; and (6) When, upon questioning the patient, I learn that he or she seems to prefer and respond more positively to a direct approach. (In other words, a "work sample" of how the patient responds to different styles of suggestion is probably more valid than drawing inferences from unsubstantiated "personality" characteristics.) UTILIZING PATIENT LANGUAGE PATTERNS. Another method for tailoring hypnosis to patients is to incorporate their idiosyncratic syntax and styles of speech into the suggestions you give. Listen for phrases and words that the patient tends to use. For instance, during the initial evaluation a patient with relationship problems described himself as "very intelligent," and indicated, "I have a lot of common sense." He also used the phrase, "Take my own destiny in my own hands ." The phrases and concepts of this patient were incorporated into the following suggestions : "Now you are an intelligent person, an astute person, who can very level-headedly size up situations. And you can begin to realize that you have even further mental resources, beyond your conscious intellect. Your unconscious mind is very perceptive, and within you there is 26 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS a great deal of intuitive common sense. Your unconscious mind perceives what needs to be done. And your unconscious mind will use these aptitudes, and will begin to give you spontaneous impressions about your relationships. As you interact with people, and as you observe other people interact, impressions, recognitions will spontaneously come into your mind, about what you do that's self-defeating in relationships. And you can trust that your unconscious mind has the common sense to recognize how you've been turning people off, without fully realizing it consciously. Your unconscious mind isn't about to let you just drift along, leaving your future to chance. It will bring images and impressions about your relationships into your mind, so that you can make intelligent decisions and changes. And rather than leaving your relationships to chance, you will find that you will begin to take your destiny into your own hands, realizing changes that need to be made." When we are able to incorporate the patient's own language into suggestions, the ideas may feel more compatible and congruent to the patient. We are literally speaking the patient's language and thus the suggestions may conform more to the patient's pattern of thinking and make a more profound and lasting impression. UTILIZATION. Another facet of individualization is Erickson's principle of utilization. Erickson used this term to convey the importance of utterly accepting whatever occurs with the patient, and then seeking to use, displace, and transform it. In hypnosis, this is essentially the parallel of using empathy and respect to establish rapport in psychotherapy. Thus if a patient yawns in a tired way, one may comment, "Have you ever noticed, how after a yawn, your whole body relaxes more deeply?" If a patient has some muscles jerk slightly in one leg during the process of induction, the therapist may say, "And you notice the little muscles jerk in your leg, which is a good sign that the tension is really flowing out of you, as your muscles relax." This intense observation and focus on the patient, in and of itself, creates rapport. But suggestions may then also reframe nonverbal behavior, making the attribution that it is evidence of hypnotic responsiveness. Patient behavior, even if it might be interpreted by some as problematic, is thus accepted and suggestions are connected to it. A new patient complained that, in hypnotic attempts with a previous therapist, he could only enter a light hypnotic state because his mind kept wandering. Therefore, the following suggestions were offered during the induction: "And as we continue, undoubtedly your mind will begin to wander to thinking about other things [accepting his "resistant" behavior] . And different images may run through your mind. And that's perfectly all right, because for the next little while, your conscious mind doesn't have to do anything of importance. Just allow your unconscious mind to wander in whatever way it wants, because the only thing that matters, is the activity of your unconscious mind." The patient went into a profound, deep trance and experienced spontaneous amnesia for almost the entire session. In individualizing hypnosis, you may also consider taking into account and utilizing the personality styles and needs of patients. In a highly competitive patient, for example, one might choose a dual levitation FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 27 induction, while suggesting an attitude of cunosity about which hand will reach the face first. You are encouraged to thoroughly study the literature on utilization (Erickson, 1959; Erickson, 1980; Erickson & Rossi, 1 979; Haley, 1973; Hammond, 1985). THE LAW OF PARSIMONY Finally, I wish to strongly encourage you to use the most parsimonious method and style of suggestion to accomplish the therapeutic task. Today, many hypnotists seem to be trying to make hypnosis much more complicated and difficult than it needs to be. This often stems from misinterpretations of Erickson's work (Hammond, 1984, 1 988b). Esoteric, multiply embedded metaphors and confusional techniques are unnecessary with most patients, are often perceived as condescending, and usually meet the therapist's needs far more than the patients . Types of Hypnotic Suggestions Many o f the types o f suggestions we will discuss were conceptualized by Erickson and Rossi (1979) . Some types were original with Erickson and some have been used for centuries. As I have indicated, there is no outcome research to suggest the superiority of any of these styles of suggestions. It is recommended, however, that you familiarize yourself with all of these types of suggestions to broaden your available repertoire for intervention. In general, almost every one of the 1 4 types of suggestion may be used to facilitate any of the hypnotic phenomena (catalepsy, levitation, amnesia, dissociation, anesthesia, hyperesthesia, ideosensory activities, positive or negative hallucinations, hypermnesia, age regression, age progression, time distortion, depersonalization, induced dreams). One way to refine your skills in using the various suggestion types is to practice writing out several suggestions of each type for facilitating each one of the different hypnotic phenomena. 1M PLICATION Implication is a difficult to define but important method of indirect suggestion. Rather than directly suggesting an effect, you may merely imply or assume that it will take place. For instance, in deepening a trance, you may ask, "What color are the flowers?" This implies and assumes that the patient is capable of visualizing. Similarly, a patient may be told, " When you're aware of noticing some of the sounds of nature around you, like the wind in the trees and the birds singing, just nod your head." This implies that the patient will be capable of auditory imagination; the only question is "when" he will notice the sounds, not "if' he will hear them. The hypnotherapist is well advised to be very cautious about the use of the words "if" and "try." "If your right hand is getting light, nod your 28 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS head," implies that the patient may fail to obtain the desired response. Instead you may ask, " Which one of your hands feels lighter?" This implies that one hand does, in fact, feel lighter. "You can begin to wonder which one of your hands your unconscious mind will cause to develop a lightness, and begin to float up?" This implies that one hand will lift. The question has been shifted from "will one lift," to "which one will lift . " Contrast the prehypnotic suggestion, "Well, let's try t o hypnotize you now," with the implications in the following suggestions by Erickson (Erickson & Rossi, 1975). "Would you like to go into trance now or later?" "Would you like to go into a trance standing up or sitting down?" "Would you like to experience a light, medium or deep trance?" "Which of you in this group would like to be first in experiencing a trance?" "Do you want to have your eyes open or closed when you experience trance?" (p. 1 52, emphasis added, reprinted with permission). These are therapeutic double binds, which will be elaborated in more detail later, but which change the question from "if" to "when" or "how." I have on occasion similarly asked a phobic patient, "Would you prefer that we get you over this problem with a rapid method that is more intense, or with a more gentle method that takes a little longer?" This offers the patient a double bind in that both alternatives are desirable and therapeutic, but it also assumes and implies that he will get better. "And the numbness will begin to spread slowly at first," implies that later it will eventually begin to spread more rapidly. "Don't go into a trance quite so rapidly," implies that the subject is already entering trance. "We won't do anything to get you over your problem today [implication: we will in the future] , but will simply give you the opportunity to experience hypnosis and see how soothing and calming it is" [implication: you will experience hypnosis] . Suggesting to a terminally ill or chronic schizophrenic patient that they send you a recipe when they return home implies that they will leave the hospital. "Have you ever been in a trance before," suggests through implication that they are about to enter a hypnotic state. Consider the implications of the following double bind suggestions of Erickson (Erickson & Rossi, 1975), "Do you want to get over that habit this week or next? That may seem too soon. Perhaps you'd like a longer period of time like three or four weeks. " "Before today's interview is over your unconscious mind will find a safe and constructive way of communicating something important to your conscious mind. And you really don't know how or when you will tell it. Now or later" (p. 1 53, reprinted with permission). Another example of using implication by changing "if" to "when" may be found in my suggestions for induced erotic dreams in the chapter on sexual dysfunction and relationship problems. Before moving on to discuss other types of suggestions, it may be instructive to listen to the words of Rossi (Erickson & Rossi, 1 975) as he described the work of a master hypnotherapist: Erickson does not always know beforehand which double bind or suggestion will be effective. He usually uses a buckshot approach of giving many suggestions but in such an innocuous manner (via implications, casualness, etc.) that the patient does FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 29 not recognize them. While watching Erickson offer a senes of double binds and suggestions, Rossi frequently had the impression of him as a sort of mental locksmith now gently trying this key and now that. He watches the patient intently and expectantly, always looking for the subtle changes of facial expression and body movement that provide an indication that the tumblers of the patient's mind have clicked; he has found a key that works much to his mutual delight with the patient. (p. 1 5 1) TRUISM A truism is a statement of fact that someone has experienced so often that they cannot deny it. These statements may be focused on motor, sensory, affective or cognitive processes, or on time. For example: "Most people enjoy the pleasant feeling of the warmth of the sun on their skin, as they walk along the beach. " TYPES O F PHRASING. The following types o f phrases are often used with a truism. "Most people . . . ; Everyone . . . ; You already know . . . ; You already know how to . . . ; Some people . . . ; Most of us . . . ; It is a very common experience to . . . ; Everybody . . . ; You've known all along how to . . . ; There was a time when you didn't . . . ; Sooner or later . . . ; Sooner or later, everyone . . . . ; In every culture . . . ; It gives everyone a sense of pleasure to . . . . " NOT KNOWI NG A N D NOT DOI NG Suggestions of this type facilitate unconscious responsiveness rather than conscious effort. They assist patients to not try too hard (in accord with the Law of Reversed Effect), encouraging autonomous responding and dissociation. Here is an example of this type of suggestion: "You don't have to think, or reply, or try to do anything at all. In fact, it isn't even necessary to listen carefully to what I'm saying, because your unconscious mind will just inevitably hear everything I'm saying, without any effort on your part at all." TYPES O F P H RASING. Some of the following phrases are commonly used with this type of suggestion: "You don't have to . . . ; It isn't necessary to . . . ; It isn't important . . . ; You don't need to . . . ; Without knowing it, you've . . . ; You don't need to be concerned if . . . ; Just allow it to happen . . . ; Without really trying, it will just happen all by itself . . . " COVERING All POSSI BI LITI ES OF RESPONSE Giving a suggestion that covers all the possible types of response that a patient may make is most valuable when you wish to focus patient responsiveness in a certain direction. This is a fail-safe approach because virtually any response is defined as successful and hypnotic. This is especially valuable when you don't know the patient well and are initially exploring his responsiveness and identifying his hypnotic talents. Here is an 30 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS example of this type of suggestion: "Shortly your right hand, or perhaps it will be your left hand, will begin to get light and lift up, or perhaps it may develop a heaviness and press down, or maybe it won't even move at all, I can't really be sure. But you can simply notice very carefully what begins to happen [implication] . Perhaps you'll notice something in your little finger, or maybe it will be in your index finger that you first sense a movement or sensation, I really don't know. But the most important thing isn't even how it begins to move, but just to become fully aware of what begins to happen to that hand. " QU ESTIONS Suggestions in the form of questions may be used to focus attention and awareness, stimulate associations, facilitate responsiveness, and to induce trance. This type of suggestion is particularly valuable when the question is one that cannot be answered by the conscious mind. Questions, however, should not be used in a rigid manner, but should utilize ongoing patient behavior. Each question, for example, may suggest an observable response. Questions are, again, a fail-safe approach that you will want to use when you do not yet know the responsiveness and hypnotic talents of your patient, or perhaps when you anticipate resistance. Be careful, however, to avoid asking questions that communicate a lack of confidence and doubt. It is counterproductive, for example, to ask, "Is your hand getting numb? " Several examples will illustrate this type of suggestion: "And the numbness, do you notice that beginning?" "And will that hand remain floating right there, or does it float up toward your face?'' "Can you enjoy relaxing and not having to remember?" "Do you begin to experience the numbness in the fingers, or on the back of the hand first, or does it spread out from your palm?" This type of suggestion, like the others we are discussing, may be used in producing any of the hypnotic phenomena, in induction or deepening, or as part of the treatment of almost any clinical problem. The following suggestions, reprinted with permission from Erickson and Rossi ( 1 979), demonstrate the use of questions in doing an eye fixation induction and a levitation induction. Ordinarily we would use this type of suggestion occasionally and not exclusively as it is done here for illustrative purposes. Would you like to find a spot you can look at comfortably? As you continue looking at that spot for a while, do your eyelids want to blink? Will those lids begin to blink together or separately? Slowly or quickly? Will they close all at once or flutter all by themselves first? Will those eyes close more and more as you get more and more comfortable? That's fine. Can those eyes remain closed as your comfort deepens like when you go to sleep? Can that comfort continue more and more so that you'd rather not even try to open your eyes? Or would you rather try and find you cannot? And how soon will you forget about them altogether because your unconscious wants to dream? (p . 29) Can you feel comfortable resting your hands gently on your thighs? [As therapist demonstrates.] That's right, without letting them touch each other. Can you let those hands rest ever so lightly so that the fingertips just barely touch your thighs? That's right. As they rest ever so lightly, do you notice how they tend to lift up a bit FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 3 1 all by themselves with each breath you take? Do they begin to lift even more lightly and easily by themselves as the rest of your body relaxes more and more? As that goes on, does one hand or the other or maybe both continue lifting even more? And does that hand stay up and continue lifting higher and higher, bit by bit, all by itself? Does the other hand want to catch up with it, or will the other hand relax in your lap? That's right. And does that hand continue lifting with these slight little jerking movements, or does the lifting get smoother and smoother as the hand continues upward toward your face? Does it move more quickly or slowly as it approaches your face with deepening comfort? Does it need to pause a bit before it finally touches your face so you'll know you are going into a trance? And it won't touch until your unconscious is really ready to let you go deeper, will it? And will your body automatically take a deeper breath when that hand touches your face as you really relax and experience yourself going deeper? That's right. And will you even bother to notice the deepening comfortable feeling when that hand slowly returns to your lap all by itself? And will your unconscious be in a dream by the time that hand comes to rest. (pp. 30-3 1) As you begin to experiment with using this type of suggestion, you may find the following format beneficial in helping you initially generate suggestions. Question Format For Suggestions: CAN YOU (R) . . DO YOU (R) . . . (they) AND WOULD YOU LIKE TO . notice sense feel (your) unconscious hear taste smell listen remember imagine see experience pay attention to wonder choose let your let yourself WILL (it; you) ARE YOU AWARE OF . CONTI NGENT SUGG ESTIONS Contingent suggestions connect the suggestion to an ongoing or inevitable behavior. This is a highly useful suggestion that has been used for well 32 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS over a hundred years. Contingent suggestions may be used with both suggestions given during hypnosis and with posthypnotic suggestions where a trigger or cue for the suggestion is identified. Here are some examples: "And as your hand lowers, you will find yourself going back to a time when ." "And when you feel the touch of his body in bed, you will be surprised at the flood of erotic, intimate memories that come to mind." Contingent suggestions are also closely related to the concept of "chaining" suggestions together, in a sense, making them contingent upon each other. It is commonly believed that suggestions may be made more effective by connecting them, as the following illustration demonstrates. [To a subject with an arm floating cataleptically:] "And as you become aware of the numbness beginning to develop in that hand, it will begin to float up even lighter toward your face, and your mind will begin drifting back through time to the beginning of that problem, and as the arm floats up higher, you drift further and further back through time." It is popularly believed that when two or more suggestions are linked together, it is more difficult to reject them. fYPES or PHRASING. You will find some of the following types of phrases are often a part of contingent suggestions: "And when . . . ; As . . . ; As soon as . . . " You will also often use the words "until" and "then" as part of contingent suggestions: "If then . " In using this type of suggestion to trigger posthypnotic behaviors (or feelings, or thoughts), you will also need to identify inevitable cues or triggers. For examples: lying down in bed; tying a shoelace; brushing your teeth; seeing your house; hearing a song. Contingent suggestions may also take the following forms: "While you you can " "When you please " "Don't until you " "You won't until " "Why don't you before you " "The closer you get to the more you can " "After you can " "As you feel you recognize " "The feeling of will allow you to " "And as occurs, may occur more than you'd expect. " "And when you . , you'll " As soon as: your arm feels numb you can no longer feel your legs your unconscious knows you have gone back in time to . . . THEN, your arm will lower. FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 33 THE IMPL I E D D I R ECTIVE The implied directive usually has three parts (Erickson & Rossi, 1 979): (I) a time-binding introduction; (2) an implied suggestion for an internal response that will take place inside the patient; and (3) a behavioral response that will signal when the internal response or suggestion has been accomplished. This type of suggestion is particularly used for tracking progress during hypnosis. FORMAT The implied directive often conforms to the format: "As soon as [the time binding introduction] your inner mind has identified the circumstances when that problem developed [the internal process that is desired] your 'yes' finger will float up" [the behavioral signal] . PHRASING Here are some illustrations, within the format that was just introduced, of how this type of suggestion may be phrased. "As soon as . . . (your entire hand feels very numb and anesthetized; you can no longer feel your legs; you can see ; that memory has faded from your conscious mind; you know ; your unconscious senses that your trance is deep enough to accomplish ) . . . then . . . (your arm will float down; your finger will lift; you will awaken). APPOSITION OF OPPOSITES ... This type of suggestion, probably originated by Erickson in the 1 930s, contains a balancing of opposites or polarities. For example: "As that right arm becomes more tense and rigid, the rest of your body becomes more and more relaxed." "As your right arm floats up, your left floats down." "As your forehead feels cooler, you'll feel your hands getting warmer ." In this type of suggestion, you may also mention or suggest a physical metaphor, and then a psychological one. PHRASING. In formulating this kind of suggestion, you may find it helpful to consider some of the following polarities or opposites: warmth coolness; tension - relaxation; anesthesia - hypersensitivity; wet - dry; floating - heaviness; light -heavy; full - empty; more - less; difficult (hard) - easy; older - younger. NEGATIVES TO DISCHARG E RESISTANCE Erickson (Erickson & Rossi, 1 979) believed that the use of negatives could serve as a "lightning rod" to discharge minor inhibitions and resistance. He had begun using this type of suggestion by the 1930s and he believed in its clinical utility, but thus far we have no experimental validation for its effectiveness . Nonetheless, this type of suggestion is commonly used by many clinicians. Some examples will illustrate this type of suggestion. 34 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS "You will, will you not?" "And you can, can you not?" "You can't stop it, can you?" "You can try, can't you?" "You do, don't you?" "And why not just allow that to occur?" "And you really don 't have to do until " "And you won't until " "You don't need to " " are you not?" " doesn't it? you?" T H E B I N D OF COMPARABLE ALTE RNATIVES This is a bind that appears to give a patient a free choice between two or more alternatives. However, both of the choices are essentially comparable and they will both lead the patient in the desired therapeutic direction. The choices offered in this type of suggestion may sound different, but are virtually the same, simply giving illusion of choice. Here are several examples of a bind of comparable alternatives. The first three examples actually model prehypnotic suggestions. I have identified the hypnotic phenomena that some of the suggestions seek to elicit. "Would you rather go into trance sitting up or lying back in the recliner?" "Would you prefer to go into a trance gradually or more rapidly?" "Would you rather go into a light trance, a medium trance, or a deep trance?" Levitation: "And perhaps your left arm, or maybe it will be your right arm that will float up toward your face. " Age Regression: "And you may remember a happy experience that happened when you were five years old, or perhaps you'd rather recall one from slightly later." Analgesia or Anesthesia: "You may choose to feel the pressure, or nothing at all. " Negative Hallucination: "You can just be aware of the sound o f my voice, or you can simply ignore everything else." Time Distortion: "Time may seem to pass quickly, or you may simply be unaware of its passing." Anesthesia: "Do you begin to experience the numbness more in the right hand, or in the left hand?" CONSCIOUS-U NCONSCIOUS DOU BLE B I N D This type o f suggestion seeks to utilize the patient's unconscious mind (or, depending upon one's theoretical frame of reference, uses the metaphor of the unconscious mind), bypassing conscious, learned limitations. Responses to this type of suggestion require patients to focus inwardly and initiate unconscious processes that are beyond their conscious control. In a double bind, behavioral possibilities outside the patient's usual range of conscious alternatives and voluntary responses are offered. Here are several examples: "And if your unconscious mind is ready for you to enter trance, your right hand will begin to get light and float up. If FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 3 5 your unconscious mind i s reluctant for you t o enter trance, your left hand will lift up." "And the unconscious mind can continue working on that problem and preparing you for our next session after you leave. And the really interesting, really curious thing, is that your conscious mind may or may not really be aware or even understand what's going on, depending on the preference of your unconscious mind. And as your unconscious mind is preparing you, and doing its work, your conscious will remain free to carry on all the many other things that you need to attend to each day." CON FU SIONAl SUGGESTIONS It is popularly believed that confusion will "depotentiate conscious mental sets" (Erickson & Rossi, 1979), allowing unconscious processes to occur more readily. Erickson ( 1964) believed that this type of suggestion was particularly indicated when a patient was consciously motivated but seemed unconsciously resistant to experiencing hypnosis. We will briefly introduce suggestions of this type. SHOCK AND sURPRISE Shock and surprise may be used to facilitate creative moments, stimulating the patient's unconscious mind to conduct an inner search and capturing the patient's attention. This may be done through interspersing certain shocking or surprising words and/ or through the use of strategically placed pauses. For instance, after leaving a patient's hand floating cataleptic, the facilitator may suggest: "And what that hand is going to do next will surprise you," while then waiting expectantly. This method may be used for a surprise reinduction of hypnosis in a patient recently realerted: "Are you awake? Are you sure? And what do you begin to notice about your eyes . . . as they begin to flutter . . . and get heavier . . . and close, all by themselves ." Another suggestion with a shock element would be to say, "It would be a disaster, if you didn't change directions, and arrived at where you are going." DOUBLE DISSOCIATION DOUBLE BIND This type Of suggestion may include various other types of suggestions, and creates overload and confusion, depotentiating conscious sets. Careful observation and noting of patient responses to the alternatives may alert you to the hypnotic talents and tendencies of the patient. This type of suggestion may take some of the following formats: "(In a moment) you can but (you don't need to; even though; when; without knowing) , or, you can (do the opposite) , but (or any of the other phrases above) Here are a few illustrative examples. "In a moment you can awaken as a person, but it isn't necessary for your body to awaken. Or, you can awaken along with your body, but without being aware of your body." "In a moment you will open your eyes, but you don't need to wake up; or you can come fully awake when you open your eyes, but without an awareness of what transpired while they were closed. " "You may choose not to remem- 36 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS ber, or you may choose just to forget, but choosing to forget is your choice in the same way as choosing not to remember that which you've chosen to forget." "As you remember to forget what it was that you were going to remember, you can just as easily forget what you were going to remember to forget." PHRASING FOR A DOUBLE DISSOCIATIVE CONSCIOUS-UNCONSCIOUS DOUBLE BIND This type of confusional suggestion may take the following format: "Your conscious mind , while (or, and, since, as, because, at the same time) your unconscious mind , or perhaps your unconscious mind , while your conscious mind ." Explained another way, the format may take either of two forms: (I) Conscious , unconscious , while (or, since) conscious unconscious ____ . (2) Unconscious , conscious while unconscious , conscious Here are some examples: "Your conscious mind may think about solutions, while your unconscious mind considers their implications, or perhaps your unconscious mind will generate some solutions, while your conscious mind wonders what the results may be." "Your conscious mind may remember the details of those events, while your unconscious mind perceives the feelings, or your unconscious mind may recall what happened, while your conscious mind is only aware of strong feelings and not the reason for them." "Your conscious mind may be aware of the time available to complete the test, while your unconscious mind seems to have all the time it needs, or, your conscious mind may enjoy a relaxed pace without concern for time, while your unconscious monitors the time you have left and the speed of your work." "And when you open your eyes you can consciously see your mother sitting in front of you while your unconscious mind is aware of your feelings toward her, or perhaps your unconscious mind will hold the image of her while your conscious mind is encompassed in the feelings you have about her." Do not be concerned if confusional suggestions initially seem overwhelming and too complex to master. They are by definition confusing, and are probably the least important type of suggestions to become skillful in using. I NTE RSPE RSAL OF SUGG ESTIONS A N D METAPHORS This refers to bringing up topics and using words or phrases that "seed" ideas, focus attention, and indirectly influence the patient. Metaphors or anecdotes may serve to illustrate a point or tag a memory, to indirectly suggest or model solutions, to foster self-reflection and insight, to increase positive expectancy or motivation, to bypass resistance, to reframe or redefine a problem, and to intersperse suggestions while bypassing defenses (Zeig, 1980). Metaphors may be used, just like hypnotic suggestions in general, to facilitate behavioral, affective or cognitive-perceptual changes. By way of illustration, you may describe to a patient the process, following an injury, of a scab forming for protection, while natural and FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 37 internal healing processes take place. A scar may remain later, perhaps as a small reminder of a hurt, long ago, but which doesn't have to remain painful. This metaphor may be used to communicate ideas to a patient who has experienced trauma, incest, rape, or divorce. Metaphors are another way of conveying suggestions, and they may be of particular value as a method of accomplishing repetition of suggestion without using identical words or phrases. When metaphors are delivered prior to giving more straightforward suggestions, this process has been popularly referred to as "seeding" an idea. We may think about three basic styles of metaphors. Some hypnotherapists tell metaphoric stories out of their background of experience for example, concerning previous patients or personal experiences. Another type of metaphor is the truism metaphor. These metaphors are commonly about nature or types of life experiences that are so universal that the patient cannot deny them. They thus establish a yes-or acceptance-set in the patient. Several of these types of metaphors that I use may be found in the sections of this book on sexual dysfunction and trauma. Finally, some therapists (e.g., Lankton & Lankton, 1983; Gordon, 1 978) make up metaphoric stories to fit a patient situation, often seeking to create characters and components that are parallel to aspects of the patient's circumstance. My personal preference is clearly to utilize the first two types of metaphors, but no research exists to indicate that one is more effective than another. Making up stories seems to me, however, the opposite of therapist genuineness or authenticity - qualities which are consistently found to be important "nonspecific" factors in successful therapy and relationships (Hammond, Hepworth, & Smith, 1977; Truax & Carkhuff, 1 967). Making up tales of the "once upon a time" variety may also seem condescending and, therefore, offensive to some patients. The use, and particularly the overuse, of such stories may thus run the risk of impairing the therapeutic alliance with the patient. Erickson, who usually serves as the model for those who emphasize a metaphoric orientation to hypnosis, seems to have almost always used the first two types of metaphors. Furthermore, close colleagues who actually observed his therapy, as well as patients, have emphasized that metaphors were only occasionally used by him (Hammond, 1 984). In fact, metaphors were estimated to represent no more than 200Jo of Erickson's hypnotic work (Hammond, 1 988b). Metaphors have their place in our therapeutic armamentarium, but we must keep a balanced perspective and realize that therapy is more than storytelling. A metaphoric story may be introduced by simply saying, "And let me give you an example," or "You may remember," or "Can you remember a time when . . . ?" Also, and importantly, metaphors do not always have to be long and involved to make an important point. Consider, for example, this brief metaphor by Barker ( 1 985): "Fleming's discovery of penicillin was serendipitous. He was working in his laboratory with some disease-causing bacteria. These were growing on a culture plate which became contaminated by a mold. Some investigators would probably have thrown the contami- 38 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS nated plate out, but Fleming took a look at it and noticed that the bacteria were dying where the mold was growing. This proved to be due to a substance produced by the mold, later named penicillin. So things should not always be taken at their face value" {p. 1 05 , reprinted with permission). This metaphor makes a point, albeit briefly. You will have an opportunity to review a variety of metaphoric styles in the chapters that follow and to determine the extent of your comfort with them. If you are particularly interested in refining this type of suggestion, you may wish to consult authors who have emphasized metaphors {Barker, 1985; Lankton & Lankton, 1 989; Mills & Crowley, 1986; Witztum, Van der Hart, & Friedman, 1 988; Zeig, 1 980). You should also consult the section on Erickson's Interspersal Technique in the chapter on pain. SYM BOLIC A N D METAPHORIC IMAG E RY The term suggestions usually refers to verbal statements. The effects of imagery seem so powerfully in hypnosis, however, that it is my belief that we should acknowledge suggestions for imagery as a category of suggestion. The Law of Reversed Effect is a principle that encourages the use of imagery, particularly to bring about physiologic effects. For instance, having patients imagine what their pain looks like and then modify the imagery may produce analgesic relief. Imagining an agitated acid stomach and then modifying the imagery to images {and sounds, sensations and smells) of cool comfort often reduces gastric secretions. Imagery modification is a powerful hypnotic technique. Symbolic imagery may also be used to treat emotional problems, as you will see illustrated in the Silent Abreaction technique and others later in the book. Finally, metaphoric imagery should also be noted. A patient's situation or idiosyncratic speech often suggests metaphoric imagery experiences. For instance, a patient may say, "I feel like I'm in a cave," or "I'm blocked and I don't know how to get past it," or "I'm trapped. " Suggesting that the patient imagine himself in such a circumstance may be a valuable therapeutic method of evoking deeper emotions, clarifying situations, and facilitating the working through of conflicts. The Phrasing of Suggestions Hypnosis i s essentially a refined way o f communicating with a patient who is in a state of concentration. Becoming proficient with hypnosis requires that you master a new way of speaking and communicating, a hypnotic "patter." For this reason, as you study and watch hypnosis demonstrations, you are encouraged to write down phrases and suggestions that appeal to you. You will find it valuable to tape record workshops and demonstrations and subsequently study the language and phrasing of suggestions . Some writers and teachers have emphasized the concept of going into a trance oneself, and simply "trusting the unconscious" to formulate sugges- FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 39 tions and conduct hypnotherapy. This admonition stems from Erickson's discussing a particularly fascinating case where he did precisely this. However, before we can trust that something brilliant will flow out of our unconscious mind, we have to put something into it! After 40 years of experience in compulsively writing, rewriting and carefully preparing suggestions (Hammond, 1 984, 1 988b), Erickson could certainly trust his unconscious mind to spontaneously contribute suggestions and ideas for intervention. This is the case with all experienced clinicians. Rollo May ( 1958) once said: "The therapist's situation is like that of the artist who has spent many years of disciplined study learning technique; but he knows that if specific thoughts of technique preoccupy him when he actually is in the process of painting, he has at that moment lost his vision . . . " (p. 85, emphasis added). After thorough, careful study of the technique of hypnosis and of fort?ulating suggestions, you will increasingly find that you can trust yourself to innovate spontaneously. In fact, as you progress you will undoubtedly be delighted with some of the creative and valuable suggestions that flow into your mind. However, the concept of "trusting the unconscious" should not be used to justify sloppy clinical work and a lack of thoughtful preparation or treatment planning. I want to encourage you to invest considerable time in writing out suggestions and metaphors. Take concepts and ideas in this book that appeal to you and rewrite them and make them your own. Carefully consider where to put pauses and painstakingly examine the implications of your suggestions. Tape record your hypnotic work and listen afterwards to what you are actually saying and implying. This kind of thorough study and preparation is crucial to becoming skilled at the art of hypnosis. It is my experience that many of the most highly polished hypnotherapists who seem to be "silver tongued" simply have the appearance of spontaneity. In most cases they have actually spent many long hours carefully formulating the suggestions and metaphors they use, and have then, in many cases, committed them to memory. This was certainly the case with Erickson, who for many years compulsively wrote and rewrote suggestions and metaphors to use with patients. RHYTHM AND PAUSES Most experienced practitioners speak with a rhythm and cadence when they do hypnosis, essentially speaking in phrases. This seems to encourage hypnotic response. A common error among new students is that they will tend to speak continuously, in a lecturing or conversational manner, without pauses. It not only seems beneficial to speak in a rhythmic manner, but during the process of induction it is helpful to gradually slow down the rate at which you are speaking. Thus you will speak slower and in a more relaxed manner as the induction proceeds. There is an exception, however. Occasionally you may be working with an obsessional or resistant patient who is overanalytical of everything you say. With this type of patient it may be helpful, at least with important suggestions, to speak more rapidly so that they have less time to pick apart or resist suggestions. 40 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS EXAMPLES OF I NTRODUCTORY HYPNOTIC P H RASI N G I n an effort to speed up your learning process, I will provide you with a list of many types of introductory phrases that are often used by hypnotherapists, particularly those with a more "Ericksonian" orientation. Repeated study of these phrases and the types of suggestions identified above will undoubtedly assist you to become smoother in your delivery of inductions and suggestions . It may be helpful to tape record these phrases and listen to them repeatedly. This will assist you in internalizing this new way of speaking. And you can wonder . . . Can you notice . . . ? And you can be pleased . . . And you begin to wonder when . . . With your permission . . . Now I'd like you to have a new experience . . . . In a way that meets your needs. I want you to enjoy this experience. And you will be surprised at . . . Now of course I don't know for sure what you're experiencing. But perhaps you're . . . It's going to be a pleasure to . . . And I'd like to have you discover . . . Perhaps even taking a special kind of enjoyment (in your ability to) . . . And sooner or later, I don't know just when . . . And I wonder if it will surprise you when . . . I wonder if you'll be curious, as you notice . . . You already know how to . . . Perhaps you wouldn't mind noticing . . . I would like you to discover something . . . One of the things I'd like you to discover is . . . And I want you to notice something that's happening to you. At first . . . , but later . . . Have you begun to notice that yet? And I think you're going to enjoy being surprised that . And I want you to notice something that's happening to you. I wonder if you'll enjoy how naturally, how easily . I wonder if you'd like to enjoy . . . I wonder if you'll be surprised to discover that . . . And I wonder if you'll be curious about the fact that you . . . Perhaps noticing . . . Perhaps beginning to notice . . . And maybe you'll enjoy noticing . . . I wonder if you've ever noticed . . . Maybe it will surprise you to notice that . . . I'd like you to let yourself become more and more aware of . . . FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 4 1 I'd like you to begin allowing . . . And your unconscious mind can enable you to . I wonder if you'll decide to . . . or . . . In all probability . . . Very likely . . . And would you be willing to experience . . ? You don't need to be concerned if . . . It's so nice to know . . . And do you notice the beginning of . . . ? It may be that you'll enjoy . . . At times like this, some people enjoy . . . One of the first things you can become aware of is . . . And it appears that already . . . Give yourself the opportunity (to see if) . . Perhaps sooner than you expect . And if you wish . . . And you can wonder what . . . And, in an interesting way, you'll discover . And its very rewarding to know that . . . And, Chris, you know better than anyone that . . . It's very positive and comforting to know . . . You'll be fascinated and feel a strong compulsion to . . . And that will probably remind you of other experiences, and other feelings you've had. I would like you to appreciate the fact that . . . I wonder if you'll be reminded . . . I wonder if you'll be pleased to notice . . . . . . by just noticing. I wonder if you've ever noticed . . . And while you wonder that, I want you to discover that . . . I'd like you to begin allowing . . . What's important, is the ability of your mind to . . . I want to remind you of something that you probably already know, which is . . . And as that occurs, you really can't help but notice . . . So that it's almost as if . . . Almost as if . . . Almost as though . . . Kind of like . . . And that's just fine . . . And that's all right . . . That's okay. All that really matters . . . All that's really important . . . I don't know if you're aware of these changes, and it doesn't really matter. I wonder if you'll be interested, in learning how, to . . . It may be that you're already aware of . . . The really important thing is just to be fully aware of . . . 42 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS The Process of Suggestions in Facilitati ng Phenomena I have adapted and modified (Brown & Fromm, 1 986) eight steps that may be useful in conceptualizing how to structure a series of hypnotic suggestions that are designed to produce one of the hypnotic phenomenon. 1 . Focusing Attention. It is recommended that a sequence of suggestions begin with something that captures or focuses the patient's attention. This may be done indirectly by simply speaking in a manner that compels or captures attention. For example, "Something is beginning to happen to one of your hands, but you don't know what it is yet." Such a suggestion creates a sense of wonderment, depotentiating conscious mental sets and focusing attention through evoking curiosity. After all, how often does anyone say something like that to most people? Attention may also be focused through a more direct suggestion. For example, in the case of formulating suggestions to facilitate arm levitation, one may say: "Concentrate on the sensations in your hands." Another illustration of a straightforward directive to focus attention prior to giving more important suggestions is to say, "I want the deepest part of your unconscious mind to listen very carefully. And when the deepest part of your mind is fully listening, your 'yes' finger can float up to signal me." Erickson often said, very simply, "Now I want you to listen very carefully." 2. Enhancing A wareness of Immediate Experience. Particularly when seeking to facilitate an immediate action or sensory hypnotic phenomenon (e.g., ideomotor or ideosensory activity, anesthesia), it can be valuable to increase the patient's awareness of his or her current experience. As a next step in arm levitation, for example, one may continue: "And you can simply tell me, which hand feels lighter?" or, "And notice the texture of your slacks, and the sensations that you notice in your fingers ." This step, popularly referred to as "pacing," does not suggest an activity or experience, but simply points out or seeks to increase current awareness. 3 . Noting and Accepting Any New Aspect of the Experience or Leading the Subject. Next, a suggestion is given to create an expectation and anticipation of a new experience. The therapist will now have an opportunity to note the patient's response to suggestion. Several suggestions will illustrate this step: "And one of your hands will begin to feel lighter than the other." "And a lightness will begin to develop in one of your hands. [pause] And you'll begin to notice a tendency to movement in one hand. And then a finger will begin to twitch or move, [pause] and then to float up." "You will begin to notice a numbness and anesthesia beginning to develop in your right hand. And when you notice the anesthesia beginning, just nod your head to let me know. [If no response is forthcoming, after 20 seconds, further suggestions may be given:] And I don't know if you'll begin to notice the numbness in your fingers, FORMULATING HYPNOTIC AND POSTHYPNOTIC SUGGESTIONS 43 or your palm or on the back of the hand first. But when you notice the numbness beginning, just nod your head. [If necessary, after another 30 second pause, you may ask:] Do you notice the numbness yet?" 4. Introducing the Immediate (Process) Goal of the Suggestion. The behavioral response or desired goal for the near future is next noted to the patient. "And as that lightness increases, soon that entire hand and arm will begin to float up, off your lap" [the immediate goal] . "And notice how that numbness begins to flow and spread through that entire hand ["that" is dissociative language, in contrast to saying "your hand."] . Before long that entire hand will become very numb, and leathery, and anesthetic. And when that entire hand feels very numb and anesthetized, just nod your head to let me know. " 5 . Repetition of Suggestion and Reinforcing Partial Responses. I t is often important to be patient in seeking to obtain a hypnotic response. Use repetition of suggestion focusing on the intermediate responses that are needed to produce the full response you desire. "And that hand is getting lighter and lighter [said during inhalations] , lifting, lifting, that's right [reinforcing a small twitching movement] . And that index finger twitches and lifts [further reinforcing the partial response to suggestion] , and the other fingers will develop a lightness also, almost as if large helium balloons were being attached to each fingertip and the wrist with strings." Naturally, more significant responses to suggestion are also deserving of reinforcement. "That's right, and up it comes. And you can really enjoy the way it's effortlessly floating up. " 6. Encouraging Dissociation and Involuntary Response. As the suggestive sequence continues, as modeled under step 4, it is important to shift to using dissociative language that will encourage a feeling of automatism and of responding involuntarily. For example: "And the hand is lifting; it's floating up, lighter and lighter. And just allow that hand to continue floating up all by itself, at its own pace and speed." The following suggestions illustrate this process in producing glove anesthesia: "Notice, with a sense of curiosity, how that numbness and anesthesia begin to flow and spread, all through that hand. Spreading and flowing in its own way, without really trying, just allowing it to happen." 7 . Building Anticipation and Expectation . Occasionally in the process of giving suggestions to facilitate a phenomenon, it is helpful to create expectancy and build a sense of anticipation of a response that will soon occur. For instance: "And soon you'll become aware of the tendency to movement, and first one finger, and then another, will begin to develop a lightness. And before long you'll sense a finger twitch or move, and then it will begin to lift." "And something's beginning to happen to one of your hands, and soon you 'll become aware of what it is." 8. Accepting the Patient's Pace of Response. Adjust to the patient's rate of response, whether it is rapid or slow. Begin by "pacing" the behavioral response, adjusting, accepting and commenting on it. Then, suggestions may be introduced to accelerate or slow down ("lead") the speed of response. When a levitation is beginning to occur very slowly, for example, be patient and continue to focus on and reinforce small, 44 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS minimal movements. Later, leading suggestions may be given. For instance, "And now it's as if some other force begins to push or pull that arm up. As if there's a large helium balloon under the palm, or attached with strings to each fingertip and to the wrist, and that hand and arm will begin to float up more rapidly, lighter and lighter [as the therapist very lightly strokes up the underside of the forearm, or very gently lifts the fingertips while the patient is inhaling . ] . " HAN DLI NG FAI LU RE TO RESPOND TO SUGG ESTIONS What do you do when there is no response to a suggestion? One option is to be accepting (e.g., saying "That's all right.") and then simply move on to something else, possibly with the suggestion that they will respond more fully next time. But perhaps the best strategy that I have discovered is to interact with the patient in trance. You may ask , "Remaining deep in trance, just tell me verbally, what are you experiencing? " You may discover that your suggestion was not clear to the patient or that he misinterpreted the suggestion. On the other hand, you may discover that some type of response has occurred that may then be accepted and utilized for therapeutic gain. For instance, after failing to obtain an ideomotor signal in response to suggestions, the inquiry may reveal that the patient feels a sensation in one finger, but that "it doesn't seem to want to float up." This may be accepted and utilized in the following manner: "That's just fine. Many people experience sensations instead of feeling a finger move. So whenever your unconscious mind creates a distinct sensation in that finger, it can represent a signal of 'yes,' you can then voluntarily lift it up to let me know. " Be open to patient feedback when you make inquiries. You may learn something you need to modify, change or suggest to facilitate a successful response. Also, remember to be patient and reinforcing of partial responses. It is also vitally important to accept that many patients seem to be natively talented at experiencing certain phenomenon, and may have difficulty experiencing others. It may be interpreted in this way to the patient, as a normal phenomenon, and this reduces perceptions of failure. � 3 HYPNOSIS IN PAIN MANAGEMENT INTRODUCTION Evaluation and Assessment of Pain ETHICAL PRACTICE requires that we have the technical knowledge to adequately evaluate patient needs. This means that the nonphysician treating pain patients must become familiar with medical evaluation and treatment alternatives. Pain patients should be required to obtain a physical examination and appropriate diagnostic studies prior to psychological intervention. Similarly, it is vital for physicians and dentists to learn to evaluate more than the biophysical aspects of pain. Particularly with chronic pain patients, multidimensional assessment is required (Hammond & Stanfield, 1977), taking into account the physical-sensory, behavioral, affective, interpersonal-environmental, and cognitive (and adaptive function) components of the pain experience. Interview evaluation may include: a description of the pain; history of the pain and whether it is acute or chronic; prior treatments, surgeries and medications and their effects; the impact of the pain problem on relationships, vocation, leisure activities, sexual activity, etc. ; level of premorbid functioning; potential benefits of the pain ("If I could magically take away your pain today, how would your life be different? What would you be able to do that you can't do now?"); antecedents (environmental, temporal, emotional, cognitive) associated with exacerbation and improvement of pain; and level of depression. We must remain aware that lifestyle variables such as bruxism, postural habits (e.g., from lengthy telephone use and video games) , and environmental chemicals (Hall, 1980) may all contribute to pain problems. Last year a 53-year-old female patient consulted me with a 40-year history of severe, daily migraines. She had undergone almost every kind of medical 45 46 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS and dental evaluation. But during the first interview it became apparent that her migraine headaches were usually present upon awakening in the mornings. Although she had no evidence of tooth abrasion from grinding, I asked her to consciously relax her jaw before retiring during the next week. The next week she had four migraines instead of seven. She was then taught self-hypnosis with suggestions for bruxism. The following week she only experienced one mild headache and she reported that it was the most comfortable week in 40 years! Her relief has continued. Despite the many intensive medical and dental evaluations, this behavioral factor that is responsive to hypnotic intervention had been overlooked. Other cases may be cited, however, in which medical causes for pain were discovered that required medical treatment, not hypnosis. For instance, a large proportion of the women referred to me for the psychological treatment of dyspareunia (pain with intercourse) are said by their gynecologists to have no organic pathology. Experience has taught, however, that most gynecologists (who usually happen to be men) have not learned to do a detailed enough pelvic examination to identify organic causes of dyspareunia (Abarbanel, 1 978; Kaplan, 1983). In my practice, when we have a specially trained gynecologist evaluate these patients, we find organic causes for dyspareunia in 700J'o-800J'o of the cases. The message is that we must not neglect thorough medical or j)sycholo_gical (behaYimal�s;ognitive, environ.:eyal��t�n with pain patients. Pain is a complex disorder. 1::;' - -- - __, _ ........ � -----� - --- OBTAI N I NG A S E N SORY DESCRIPTION OF TH E PAI N Hypnotherapy with pain is facilitated by a detailed description o f the following sensory aspects of the pain: ( 1 ) thermal sensations (e.g. , degree of heat versus cold); (2) kinesthetic sensations and pressure aspects of the pain (e.g. , dull, sharp, binding, itching, heavy, twisting, drilling, penetrating, stabbing, pounding); and (3) imagery of the pain (size, shape, color, texture, sound). One method for doing this is to obtain a detailed verbal description of the sensory components of the pain. This may be done in an interview in a manner that establishes rapport with the patient and leaves him or her feeling empathically understood. For example, I typically ask the patient to tell me which of the following adjectives describes an aspect of their pain: Aching, beating, binding, biting, burning, caustic, cool, corroding, cramping, crushing, cutting, drilling, dull, flashing, flickering, gnawmg, grinding, gripping, heavy, hot, itching, lacerating, nagging, nauseating, numb, penetrating, piercing, pinching, pounding, pulsing, rasping, searing, sharp, shooting, smarting, spasming, splitting, squeezing, stabbing, stinging, tearing, throbbing, tingling, twisting. A detailed sensory description of the pain not only establishes rapport but also, more importantly, provides you with clues that may be valuable if techniques are used for replacement or substitution of sensations or for hypnotic reinterpretation of the pain experience. In addition, many of the pain descriptors listed above suggest imagery to both patient and therapist that may subsequently be used with the technique of imagery modification. HYPNOSIS IN PAIN MANAGEMENT 47 The qualitative aspects of pain may also be assessed through paper and pencil instruments such as the McGill Pain Questionnaire (Melzack, 1 975) and the Low Back Pain Questionnaire (Leavitt, Garron, Whisler, & Sheinkop, 1978). It may likewise be enlightening to have patients draw their pain or at least to imagine in hypnosis what their pain looks like. Drawings may usefully assess the location of pain and will naturally also suggest images for later modification during hypnosis. Drawings to determine location of pain may particularly be facilitated by giving the patient a page with a line drawing of the front and back of the body, with instructions to identify or shade areas where pain is experienced. OUTli N E OF HYPNOTIC STRATEGI ES A N D TECHNIQUES FOR MANAG I NG PAI N In this chapter you will find a large number o f hypnotic techniques discussed and modeled for you. You may find the following conceptualization of major hypnotic pain control strategies and the techniques that fall under these strategies to be useful in understanding these methods. I. Unconscious Exploration to Enhance Insight or Resolve Conflict A. Ideomotor Signaling B. The Inner Adviser Technique C. Guided Imagery D. Hypnoprojective Techniques II. Creating Anesthesia or Analgesia A. Direct or Indirect Suggestion B. Imagery and Imagery Modification C. Ideomotor Turnoff of Pain D. Gradual Diminution of Pain E. Interspersal Technique and Use of Metaphors F. The Clenched Fist Technique G. Increasing and Decreasing Pain III. Cognitive-Perceptual Alteration of Pain A. Body Dissociation B. Symptom Substitution C. Displacement of Pain D. Replacement or Substitution of Sensations E. Reinterpretation of Sensations F. Unconscious Exploration of Function or Meaning of Pain G. Amnesia H . Time Distortion I. Massive Time Dissociation J. Increasing Pain Tolerance 1 . Posthypnotic Suggestions for Internal Dialogue 2. Mental Rehearsal of Coping with Triggers and Pain 3. Desensitization to Triggers that Exacerbate Pain K. The Inner Adviser Technique (to explore meaning and triggers of pain) 48 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS IV. Decreasing Awareness of Pain (Distraction Techniques) A. Time Dissociation B . Imagining Pleasant Scenes and Fantasies C. Absorption in Thoughts D . External Distraction Through Enhanced Awareness of the Environment E. Eliciting Mystical Experiences STRATEGY AND TECHNIQUE SE LECTION How does one select which one of the strategies to use? My personal preference is to first determine with a technique from strategy I (e.g., ideomotor exploration) that an unconscious dynamic or past event is not a part of the problem. This can generally be assessed in one part of a single session, although if factors are uncovered they may require an interview or two to resolve. One problem with conventional pain assessment strategies (e.g., Karoly & Jensen, 1 987) is that they neglect the possible role of unconscious variables as a potential cause of a pain problem. There are occasions when a pain problem, or part of a pain problem, may be associated with past trauma (e.g., incest) or serve unconscious purposes (e.g., for self-punishment). We may hypothesize that this may particularly be the case when the cause of the pain is unknown and cannot be causally related to any pathophysiologic process, where the pain seems more intense than would ordinarily be anticipated, and/or when pain lasts longer than is appropriate. Hypnotherapy for pain should include a brief routine check (e.g., with ideomotor signaling) to determine if unconscious factors contribute to the problem (Hammond & Cheek, 1 98 8 ; Rossi & Cheek, 1 988). When it has been determined that psychological and unconscious factors do not play a role in the problem, suggestive hypnosis may then be introduced. Thus it is next recommended that you determine whether strategy II techniques (e.g. , suggestions for anesthesia, ideomotor turnoff of pain, imagery modification) are successful in alleviating or managing the distress. When these more straightforward techniques are not entirely effective, we may then experiment with the more complex techniques that fall under strategies III and IV. These techniques will be particularly beneficial when pain is chronic and where several pain sites are identified. Certain techniques (e.g. , time dissociation, imagining pleasant scenes) are primarily useful with patients who can be inactive, at least for segments of the day. For instance, if a patient is imagining a future or past time when they were not in pain, this inward absorption precludes simultaneous interaction with people or the performance of vocational tasks. When working with more difficult, chronic pain patients who have several sites or types of pain, you may also find it helpful to begin by working with their least difficult or intense problem first. Begin with the problem where you anticipate the highest probability of success. Successful management of one pain area or problem will enhance patient selfefficacy and their belief that success may be anticipated with other problems (areas) as well. Success breeds success. When time permits, it is also valuable to determine the hypnotic pain management techniques that the patient is most skilled in using and which HYPNOSIS IN PAIN MANAGEMENT 49 techniques are most potent for them individually. You will probably find it most helpful initially to demonstrate pain control techniques to manage acute pain that is therapist-induced; for example, begin by creating glove anesthesia to block pain that is induced through the use of a hemostat or nail file. There are a variety of suggestive hypnotic strategies for pain management that will be reviewed in the first part of this chapter. In successfully controlling organic pain, however, it is extremely important to have frequent reinforcement sessions early in treatment. In particular, it has been recommended (Crasilneck & Hall, 1 985) that we should reinforce pain control as quickly as possible after the patient becomes aware of the return of pain. Thus, in the first 24-hour period it may be necessary to see the patient several times (e.g., every four hours) and self-hypnosis should be learned as rapidly as possible. We should also not neglect the role of egostrengthening as part of hypnotic work with chronic pain patients. Patients with chronic pain customarily also develop feelings of low self-esteem and self-worth that may be responsive to hypnotic suggestion. Furthermore, self-hypnosis provides such patients with an active self-management strategy that can return some sense of control and mastery to their lives . Most of our patients are not capable of creating a complete anesthesia and removing all of their pain through hypnosis. However, even for those patients who are this hypnotically talented, we should only remove all pain in a small number of conditions: ( 1 ) dental anesthesia; (2) childbirth; (3) terminal illness (e.g., cancer pain); (4) when hypnosis is being used for surgical anesthesia; (5) phantom limb pain; and (6) possibly for treating shingles or arthritis attacks (Crasilneck & Hall, 1 985). In other cases, we must remain cautious to leave some "signal" pain so that the patient will not mjure himself and so that pain from the development of new symptoms or a worsening of the patient's condition will be perceived and reported. Very importantly, as clinicians treating pain we must assume a realistic posture concerning the role of hypnosis . Hypnosis is like any other medical or psychological technique: it is not effective with every patient. Some patients obtain tremendous pain relief with hypnosis; others find it clearly helpful but are in need of still other methods of relief; some find that it reduces the affective components of pain (Price & Barber, 1 987), making the sensory pain more tolerable; and some patients receive no benefit from hypnosis. Consequently we must also be familiar with nonhypnotic treatment options such as medications, nerve blocks and trigger point injections, physical therapy, transcutaneous electrical nerve stimulation (TENS), and biofeedback. When it comes to the treatment of pain, the hypnotherapist should not work in a vacuum. A multidisciplinary team is ideal, and mterdisciplinary cooperation is vitally important. CHAPTER OVE RVI EW The first part of this chapter will introduce you to a variety of hypnotic techniques for pain management and models of verbalizations for these techniques. Later, suggestions specific to several conditions such as migraine, arthritis, cancer and shingles will be presented. 50 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS Tech niq ues of Hypnotic Pain quently enable a patient to tolerate some Management persistent feeling in the area but not to suffer from it. A sensation of stabbing pain joseph Barber, Ph . D . may be substituted with a sensation of vi Los Angeles, Cal!forn1a bration, for example: " The stabbing needles might become, in a surprising way, some Though there are many ways of conceptualhow more dull, not quite so very hot, so izing techniques of hypnotic pain management, that, at some point in the future, maybe in and while different clinicians will certainly two minutes, maybe in two hours, you can apply techniques differently, it is helpful to notice the peculiar buzzing, or vibrating consider four basic methods of achieving hypfeeling of the blunt, warm needles." For notic pain control: some patients, substitution is easier when the substituted feeling is not thoroughly 1 . Analgesia or anesthesia can be created in the pleasant; a burning neuralgic pain may behypnotized individual by simply suggesting come an irritating itch, for instance, or a that the perceptio_n._of pain is changing, -1s tickle; a patient who needs for some reason diminishing, or-that is becoming to continue to be aware of the stimulus of numb, so that the pain is gradually disapthe pain, for instance, may be better with pearing. It may be easier for a patient to this technique. notice growing comfort rather than dimin3 . Displacement of the locus of pain to anishing pain; thus a specific feeling of comother area of the body, or, sometimes, to an fort such as that associated with anesthesia area outside the body, can again provide an can be suggested specifically, for example: opportunity for the patient to continue ex "You may remember the feeling of anesperiencing the sensations, but in a less vulthesia from the past, and begin already nerable, less painful area. The choice of the imagining that such numbing comfort is area is usually based on its lesser psychologbeginning, just barely, to become more and ical vulnerability, and suggestions can leave more apparent." Alternatively, the patient the choice to the patient; for example: "As can be given a specific focus to notice you continue to pay careful attention to the diminishing pain. For instance, it may be discomfort in your abdomen, let me know helpful to ask the patient, before treatment, when you first begin to notice the very slight to rate his or her pain on a scale from 0 to movement of that feeling . . . . That's right, 10, "0" representing no pain at all, and " 1 0" now just notice, as the movement continues, representing the most pain imaginable. (Pain perhaps a circular way, to increase . . . zs tients can rate their pain quite reliably, as it moving clockwise, or counterclock Sternbach [ 1982] describes.) Following inwise? . . . That's fine, now just continue to duction, the hypnotized patient may be be curious as you notice how the feeling can told, "Earlier, you were able to rate your continue to move, in an ever-increasing pain, using numbers. I'd like you to look spiral, moving round and round your abdoup, in the corner of your mind, right now, men, and notice which leg it begins to move and notice what number you see, and notice into . . . " and so on, as the feeling is sugthat number beginning to change." Further gested to move into a limb, perhaps even to suggestions can be given for associating the center in a single toe or finger, or to move number with the perception of pain, and for outside the body altogether. perceiving progressively diminishing magni4. Dissociation of awareness can be created tude of the numbers. when the patient does not need to be very 2. Substitution of a painful sensation by a functional (e.g. , during a medical or dental different, less painful sensation can fre-procedure) or when some condition renders HYPNOSIS IN PAIN MANAGEMENT 5 1 the patient virtually immobile (e.g. , during you might, more quickly than you expect, begin the last stages of a terminal illness). The to have the impression of a lovely white swan, patient can be taught simply to begin to gliding along, the graceful long curve of its psychologically experience himself or herneck reminding you very, very distinctly of a self as in another time, place, or state, as in "2." Or is it that, seeing a "2," you are reminded a vivid daydream. For instance, one can of a swan. And not only reminded of a swan, suggest that the patient experience himself but, somehow, begin to feel almost as if you, or herself as floating, and that "your mind, too, are gliding gently along, the smoothness your awareness, can just float easily outside and grace more and more a part of your your body, and move over by the window, awareness . . . . And any time that you want to so you can watch the world outside . . . " or feel more comfortable than you do, all you one can suggest that the patient float outhave to do is look up in the corner of your mind side the room, and travel to any place he or and see the number you feel. And the number she would enjoy. you feel is the number you see, and the number you see is the number you feel. And then just watch . . . just watch, as the numbers, and your feelings, begin to change. And a beautiful EXAMPLE OF SUGGESTIONS FOR swan, or is it only the coolness of a "2," is so DECREASING NUMB E RS TO CREATE very much more easy to live with, is it not? COMFORT [The patient was thus given a posthypnotic suggestion for coping with future pain. How A while ago, you were able to very accurately ever, in order not to lead the patient to expect rate your pain, using a number from 0 to 10. too much from this new experience, no sugges Any time in the future that you would like to tion was given for complete pain relief (no "0" feel more comfortable, you can do so. All you was suggested, for instance), and further cauhave to do is to look up in the corner of your tion was added:] mind, and notice what number is associated Now, I really don't know you very well, and with the level of pain you feel. Then, just you certainly don't know me well yet at all . . . watch . . . just watch as the number begins to so I really don't know how much relief you can change. I don't know exactly what that will be expect, really expect, to feel when you leave my like. Maybe it will begin to quite slowly fade office. It may be that sometime later today, and from your visual awareness, and as it does so a I really don't know what time, maybe 1 0:30 this smaller number will begin to emerge from the morning, or maybe just one second after noon, background. For instance, if you feel and see or maybe 6: 1 8 this evening . . . I really cannot an "8," you may begin to notice the lines of the say what time it will be . . . I cannot predict the "8" begin to fade, and "7" will become more future . . . but maybe it would be interesting to apparent. Or maybe the curves of the "8" will you, or even enjoyable for you, to notice, at begin to straighten and relax, and become more some time later today, but I don't know what like the angles of the "7 ," until, after a while, time exactly, to just suddenly notice how much the angularity of the "7" will take on the more comfortable you feel than you thought graceful curves of the "6. " And maybe the "6" you might. But I don't know what to expect. I'd will, like the pages of a calendar in a movie, be be really very surprised if you left here feeling blown by the wind, off into the darkness, much relief; I wouldn't be very surprised to leaving a "5." And maybe the "5" will begin to later find out that you felt better later today. open, ever so gradually, and the line at the top But listen . . . even if you feel better late today, will fade until you notice that there is no longer either later this morning, or this afternoon, or really a "5" there but rather a "4." Or, maybe even tonight, just before getting ready for bed, some numbers will be skipped altogether, and there is no reason to assume that this has 52 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS anything at all to do with anything you and I your eyes closed, your body relaxing more and may have done today. There is really no need to more with each breath you take. Whatever know how or why something happens in order relief you might feel, either now, or later today, to enjoy the fact of it. So there is no reason at or tomorrow morning when it's time for you to all to assume any cause in particular. In fact, awaken, that relief is j ust something that hapwhatever relief you feel may be so very pleaspens, and I don't know why, and I don't know ing, so very enjoyable to you, you may not even how. You may have some idea about it, either care why it happens. while it's happening, or just after you discover [The purpose of such suggestions was to feeling better, or maybe next month or next obviate any expectations the patient may have year. I don't know. After all, time is not only had about my own expectations, as well as any relative, but it is sometimes very confusing. doubts the patient may have had about the Your mom is going to drive you home today, efficacy of hypnosis, and to diffuse issues of and when she does, while she is driving, and control or power which might have otherwise while you sort of daydream about what I've inhibited relief.] said to you, while this is happening, it is today, and you know what day this is. But tomorrow, today will be yesterday, and tomorrow will be I LLUST RATIVE DI SSOCIATIVE today, and what was once today will be just SUGG ESTIONS WITH A RESISTANT that much farther in the past of your comfort, C H RONIC PAI N PATI E NT your relief, your hopes, your curiosity about what can be done for you, and better yet, what I wonder, even as you continue to lie on the you might do for yourself. Now, as I leave the treatment table, if you would enjoy rememroom, I want you to take whatever time you bering some time, long ago, when you didn't need to get up, after your mind has cleared and hurt very much. Or maybe you can remember your eyes have opened, to get up, get your what it was like when the nerve block stopped clothes on, go find your mom and do whatever the pain. That was really a great experience, else is necessary to get yourself gone to the and, though it might happen again, I really comfort of your home. The receptionist will doubt that it could happen today. In fact, if make an appointment for you to see me in a few you do feel better later today, on your way days, and when I see you again, I will be really home, after you get home, while you're standeager, really curious, to hear you tell me about ing in the kitchen, or just as you're getting into the things you've been wondering about. Goodyour bed, it is unlikely that it is the result of bye. anything we've done for you today. We're just getting to know you, and it seems unlikely that someone with a problem as complex as yours is going to experience much relief today, or, even Alteri ng the Quality of if you do, it is probably just a lucky break, j ust Discomfort: Exam ple of a fluke. Who knows how much comfort you can have? I don't. Well, at least I don't know leg Pain for sure. I'm sure you can have some relief. Who couldn't. But just how much is really as M . Erik Wright, M . D., Ph . D. unclear to me as it is to you. I don't know you, I don't understand you, I don't feel your pain, The following illustration shows how guided I don't really understand your pain, so it would imagery can be used to assuage discomfort by be really dumb for me to stand here and tell you reinterpreting its nature. It is taken from a case that you're going to feel better today just where it was important for the intensity of pain because you're lying there listening to me with to become tolerable so that healing could be HYPNOSIS IN PAIN MANAGEMENT 5 3 facilitated. Trance induction had already taken Transformation of Pain place. The therapist continued: You have described this pain in your leg shin W i l l iam L . Golden, as being sharp and piercing, like a knife point E. Thomas Dowd , and sticking into the bone . . . A very distressing Fred Fried berg and uncomfortable experience . . . It would become more tolerable if this sudden, intense, In physical transformation of pain, the pain sharp pain were replaced by a pain that did not is moved to a part of the body that is less come so unexpectedly, that gave you time to central to the individual's activities or to a adjust yourself so that when it occurred, even if location that is so ridiculous that the person is the new pain were not exactly comfortable . . . . enabled to treat it in a humorous fashion, thus [The therapist begins to develop imagined making it easier to view the pain in a more conditions for modifying the pain:] Now visudetached manner. For example, lower-back alize the left leg as being covered by thick layers pain could be transferred to the big toe, where of cotton . . . going around and around that it interferes less with daily activities. Or a part of the leg where the pain is most often headache could be moved to the little finger of experienced . . . See this cotton secured to your the right hand or, more humorously, the left leg so that it won't slip off . . . The cotton is so earlobe. This procedure is especially valuable in thick and matted that nothing would be able to cases of chronic, intractable, benign pain, pierce through it, no matter how sharp it might where there is often a need to retain the pain for be . . . [The therapist paces the process accordpsychological reasons. The client is thus not ing to cues from the client:] Signal with your asked to give up the pain, but only to transform finger when you see this clearly . . . Good . . . it. Often it is helpful to ask clients where they [The therapist continues building painwould like to move their pain, in order to reducing imagery:] Now see a sharp knife involve them in the process. thrusting at the cotton layers, but it absolutely Physical transformation of pain is accomcannot penetrate through the cotton protecplished as follows. After the subject is placed in tion . . . You may sense the pressure transa trance, he or she is instructed to touch the mitted through the cotton . . . It may feel like a painful part of the body with (usually) the right dull pain, but it is mostly pressure and you are hand and to transfer the pain to another part of much better able to stand the amount of disthe body by touching it with that hand. If comfort . . . When you have reached the tolerdesired, suggestions can also be made for a ance level for this dull pain, see the knife being reduction of the pain in the new location. An withdrawn from the cotton batting . . . The instruction such as the following could be used: pressure is relieved, and the dull pain drops immediately. . . . You can slowly allow your right hand to move so [The therapist gives control to the client for that it touches your back at the most painful pain reduction and healing:] Now that your spot. . . . As it touches your back, you can be aware body does not have to prepare for the shock of of the painful sensations flowmg from your back the sharp pain, you will be able to use that mto your hand . . . . Now slowly allow your hand to spared energy to speed up the healing promove toward your left shoulder, feeling the pain lessen as It does so . . . . As your hand touches your cess . . . When the pain recurs, you can graduleft shoulder, you can feel the pain move to your ally build up the thickness of the cotton wadshoulder, but somewhat less than before. Now reding so that the pressure becomes more move your hand and let it slowly drop to your lap, tolerable and the dull pain continues to derelaxing as it goes. crease. In time, you may feel only a sensitive area on the skin as the healing underneath Pain can also be transformed into other sensacontinues. tions, and this procedure is likewise useful 54 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS in cases of chronic, psychogenic pain. In addi TRU ISMS FOR D EVELOPING tion, the signaling function of pain is retained, AN EST H ESIAS while the suffering and incapacitation associated with it are reduced. For example, sugges Erickson discussed "the tremendous amount tions can be given that the individual will of learning you have acquired during your experience an itching, tingling, or warm sensalifetime of experience in developing anesthesias tion in the place of and at the site of the pain throughout your entire body. For example, as rather than the pain itself. To some extent, this you sit and listen to me now, you've forgotten technique is based on the common observation the shoes on your feet . . . and now you can that the label we attach to something might in feel them; you've forgotten the glasses on your part determine how we respond to it (a rose by nose . . . and now you can feel them; you've another name might not smell as sweet), beforgotten the collar around your neck . . . and cause the meaning of an event or object is now you can feel it . . . You listen to an partly a function of its name. For example, we entertaining lecture, and you forget about the might respond quite differently to a behavior hardness of the chairs. But if it happens to be a labeled aggressive than to one labeled forthvery boring lecture, your chair feels so utterly right, although the actual behavior could be the uncomfortable. You sense those things. We've same in both cases . The client might be inall had tremendous experience in developing structed as follows: anesthesias in all parts of our bodies" (Erickson, 1 985, p . 228). "So how did you get As you pay close attention to the sensations in that anesthesia for the shoes on your feet? Not your back [the location of the pain] , you can become because there is a drug put into the nerve; not aware of a feeling of warmth, it will gradually because you were told to have the anesthesia; replace all other feelings so that all you feel in that but because in your lifelong learning you have area is warmth. And you can allow that feeling o f acquired the automatic ability to turn off senwarmth t o remain for a s long as you have need of it. sations and to turn them on again" (Erickson, 1 986, p. 120). E rickson's Suggestions for ANTICI PATION AND UTI LIZI NG T H E Pain Control U NCONSCIOUS A number of things may develop, some of M i lton H. E ri c kson, M . D . which I have not mentioned. I hope you will notice and appreciate them, and then fit them into the goal that you wish to achieve. And I'd I NTRODUCTION like to have you interested in the way these unexpected things can fit into the goal you wish These practical suggestions were compiled to achieve (Erickson, 1 985, p . 1 80). from throughout the published papers and lectures of Dr. Erickson. They have been compiled according to technique. Although sometimes RE PLACEME NT, SU BSTITUTION OR Erickson simply describes a technique, often his R E I NTE RPRETATION OF SE NSATIONS actual suggestions are provided. I believe that many of these suggestions will provide you with You tell your patients in the trance state to a valuable model for many of the more complex think over their pain. Maybe they can't cut out methods that we must occasionally resort to the nagging quality of the pain, but maybe they when more straightforward techniques are not can cut the burning quality; maybe they can cut successful. (Ed. ) out the heavy quality. Or maybe they can keep HYPNOSIS IN PAIN MANAGEMENT 55 the heavy, dull aspect of the pain, and lose the patient's subjective experience of pain is going burning, the cutting, the lancinating, shooting to lessen that pain . . . " (Erickson, 1 983, p . qualities of the pain. And what have you done? 228). You have asked your patients to take the total And I explained to her with profound apolexperience of pain and to fragment it into a ogies that even though I had relieved the pain of variety of sensations; and as surely as your her cancer by this numbness, I would have to patients fragment their pain, . . . they have confess that I was going to be an absolute reduced it (Erickson, 1 986, p . 8 1 ) . failure in one regard. I would not be able to remove the pain from the site of the surgical ALTERATION O F SENSATIONS. You have aching scar. Instead of removing absolutely all of the pains in your legs that distress you very greatly; pain, the best, the very best, that I could do you are suffering from arthritis. But if you will would be to leave the scar area with an annoyexamine those sensations, you will find, pering, disagreeable, great-big-mosquito-like feelhaps, a feeling of warmth; perhaps a feeling of ing. It would be something awfully annoying; coolness; perhaps a feeling of coldness; and something she would feel helpless about; somenow how about extending some of those sensathing she would wish would stop. But it would tions? (Erickson, 1 986, p. 1 04). be endurable, and I impressed that point on I asked my patient to tell me whether I should Cathy's mind. It took me four hours to accomtake care of the cutting pain next - or should it plish everything (Erickson, 1 983, p. 1 72). be the burning pain, or the hard, cold pain, or the lancinating pain? What does the patient do in response to such a question? He immediately DISPLACEME NT OF PAI N divides his pain experience, psychologically, into a great variety of separate kinds of Now, you've got cancer pain. Why not have pain . . . (Erickson, 1983, p. 223). another kind of pain also? Why not have pain There are certain transformations that can be out here in your hand? You have cancer pain in brought about here. You know how that first your body. It is very, very troublesome; it is mouthful of dessert tastes so very good? And very, very threatening; it is going to kill you. even the second mouthful still tastes good; but You know that. You wouldn't mind any by the time you reach the sixty-sixth mouthful, amount of pain out here in your hand, because it doesn't taste so good. You have lost the liking that wouldn't kill you. It is the pain in your for it, and the taste of the dessert has changed torso that is going to kill you, and if you only in some peculiar way. It hasn't become bad; it had pain out here you could stand any has just "died out" in flavor. Now, as you pay amount. " You can teach your pain to displace attention to these various sensations in your the pain from the torso out into the hand where body that you have described to me, I would it is gladly experienced, because it has lost its like you to name the particular sensation that threatening quality. (Erickson, 1 986, pp. 80-you want me to work on first (Erickson, 1 983, 8 1 ) . pp. 225-226). I want to know if that grinding pain is a rapid grinding pain or a slow grinding pain. Or, I can suggest an addition to the grinding: "If you will AMN ESIA FOR PAI N just pay attention to that grinding pain you will notice that it is a slow grinding pain." I have One o f the ways o f dealing with unpleasant added my own adjective of slow to the patient's sensations is to forget them - like when you go grinding pain, and if the patient does not accept to the movies and get all absorbed in the slow I can slip over to rapid grinding pain. suspenseful drama on screen, and meanwhile Why? Because anything that I do to alter the you forget about your headache. You may not 56 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS remember until three days later that you had a because [the left hand] was the only hand that headache when you went into the cinema was left to write with! . . . What was my tech (Erickson, 1983, p . 226). nique? I set up a body disorientation by teaching the patient to get very confused about the site of the pain, about the part of the body G RADUAL DIMIN UTION OF PAI N involved in the pain, and about the direction of the pain. You disorient the patient to the point I can't take away all o f your pain. That is where he simply does not know which side is asking too much of me; it is asking too much of which, and then you provide him with the your body. And if you lose I percent of that orientation that you want for him. If you can pain you would still have 99 percent of it left; move the pain to a place in the body where you wouldn't notice the loss of I percent, but it there is no organic cause for it, then you are in would still be a loss of I percent. You could lose a position to produce hypnotic anesthesia for 5 percent of that pain. You wouldn't notice the the pain at its actual site. You move the paloss of 5 percent, because you would still have tient's subjective experience of the pain to the 95 percent of the pain; but you would still have wrong area, bodily, because you can correct it a loss of 5 percent. Now you could lose 1 0 more easily there; the patient has little resispercent of the pain, but that really wouldn't be tance to accepting suggestions in the healthy noticeable because you would still have 90 area (Erickson, 1 983, p . 235). percent of it; but you nevertheless would have a loss of 1 0 percent of your pain. [You continue to diminish the pain - down to 85 percent, 80 PAI N M ETAPHOR percent, 75, 70, 65, 60,and so on. Then you say:] You might even lose 80 percent of your . . . You can also cut down organic pain by pain, but I don't think that is quite reasonable, minimizing your response to it. You see, in yet. I would be willing to settle for a loss of 75 organic pain situations you have neurosynapses percent. [And the patient is going to agree with that are transmitting the pain. Through hypyou, regretfully. Then:] What is the difference nosis you can spread those synapses apart - like between 75 and 80 percent, and sooner or later sparks jumping a gap - until you have your you can lose 80 percent, and maybe 85 percent; synapses spread so wide apart that you get a but first, let us settle for 80 (Erickson, I983, p . jumping of the thing. At that point a certain 236). maximal pain stimulation is necessary in order for the person to sense the pain (Erickson, 1 985, p. 26). DISORIE NTATION AND CON FUSION TECH N IQUE WITH PAI N "Let us see, is that pain in your right leg, or General Pri nci ples for your left leg? . . . Let us see, which is your left leg and which is your right leg?" And you can Alleviating Persistent Pain get as confused as you get the child confused on Ernest L. Rossi , P h . D . and this subject of where the pain is, and which leg is which. "And now is it on the outside side of David B . Cheek, M . D . your leg, or is it on the inside side of your leg?" Mal1bu, Cal1forn1a, and Santa Barbara, Cal1forn 1a . . . I discussed rightness and leftness, and centrality and dextrality, and so on, until the Therapy for persistent pain states must be girl was so confused that she thought this hand elastic and must conform to the understandings was her right hand [her left hand] , and this and needs of the patient and the patient's hand was her left hand [her right hand] - relatives. Often it must also fit into the needs HYPNOSIS IN PAIN MANAGEMENT 57 and understandings of prior medical and surknow how to turn pain off by first learning gical attendants in whom the patient has conhow to turn it on. (Prior experience with tinued faith. It is best judgment to listen careuncontrolled fear of uncontrolled pain, a fully to what the patient thinks can be done and fear of the unknown.) what he or she expects the hypnotherapist to 8. As soon as the patient has developed conuse as an approach to the problem. The patient fidence in being able to turn the pain on and is often in a hypnoidal state during the first off, it is helpful to have him select a cue moments of interview and may have insights of word or thought which will automatically utmost value to impart. If the therapist can turn off the pain. This is rehearsed several weather the initial critical interview and can times in the office, but the patient is told to have free rein, these are the general steps which avoid trying it on his own until the instruchave proven helpful: tor knows it is going to be successful. (There are several implications to this bit of in1 . Be sure the patient is unconsciously willing struction. Most important is the implied to be helped. confidence that such a day will come. Next 2. Discover when and what caused the illness in importance is the warning that simple or pain to be important in the very beginexperiences in the office setting do not inning [through ideomotor signaling] . This dicate that the task is now finished.) may relate to the distress of another person 9. A pseudoorientation into the future is rather than to a personal experience with requested and the patient is asked to have pain. the yes finger lift when he is forward to the 3. Determine the first moment at which the time when there is good health and total patient experienced the pain. Discover freedom from pain. (Refusal to select a whether the patient was awake or asleep at time may indicate discouragement or resisthe time. (Sleep means either natural sleep tance which have not previously been apor a period of unconsciousness as from parent. Acceptance of a date commitment chemoanesthesia.) reinforces the other placebo elements of 4. Discover what reinforced the importance optimistic hope.) of that initial pain. This may have been the 10. Train the patient carefully with autostatement of a doctor or the consternation hypnosis induction and simple use of brief of relatives at the time of initial illness or periods for complete relaxation. This injury. should be restricted to three minutes, at the 5. Ask if the patient now, at the time of most, from onset of a medium trance to the interview, believes cure is possible. Orient moment when the eyes feel like opening. tc the moment when this conclusion was The author insists that the patient stick to drawn, regardless of the answer. Points of the time limits rather than drifting off into origin are significant whether optimistic or natural sleep or prolonged reverie. If too pessimistic. much time is lost during these exercises, the 6. Have the patient turn off all pain at an patient will tend to discredit results and will unconscious level and have a yes finger lift give up the rehearsals as a needless waste of when this has been accomplished. Ask for time. The two-or three-minute exercises a verbal report when it is known conshould be repeated after each meal and at sciously that all pain is gone. bed time, four times a day. This is no more 7. Ask the patient to turn the pain back on time than might be taken in smoking five again but to make it twice as strong as it cigarettes during the day. was at first. The patient may balk at this until it is made clear that the pain will It may suffice to make office appointments for again be turned off, and that it is helpful to one hour once a week if the patient is first seen 58 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS during an interval of relative comfort. If the for healing and for relief from pain . . . You patient is in severe pain, the author usually must let yourself come closer to its essential arranges for admission to the hospital for a meaning . . . Forgiveness and love are parts of period of two or three days . This separates the this universal healing spirit . . . that release the patient from unrecognized triggering stimuli at inner tensions . . . free your body and your home, permits more than one visit a day if spirit from pain . . . Let your thoughts focus necessary, and allows use of pain-relieving upon your feelings of forgiveness and love . . . drugs to augment effects of suggestion. Forgiving yourself . . . forgiving others . . . releasing the stresses within yourself that generate tension through anger, hatred, resentment . . . And as the spirit of forgiveness grows within Religious I magery of U niversal you . . . these tensions are released . . . open H ealing for EgoStrengthening ing up the healing life forces . . . permitting and Pain you to connect with the love of others and love of self . . . and love of God . . . As you open M . Eri k Wright, M . D . , Ph . D . up to this healing love . . . the awareness of the pain becomes distant . . . moving further and further away . . . diminishing in importance I NTRODUCTION and in consequence . . . as the healing love flows through you . . . . It is commonly believed that anger, resentment and guilt take up a great deal of energy COMMENTARY. Those who identify themselves and may inhibit healing, as well as causing with a particular religious group may invoke emotional turmoil. In fact, some research significant hypnotherapeutic images associated (Pennebaker, Kiecolt-Glaser, & Glaser, 1 988) with their deep religious convictions. The client implies that releasing such feelings may prois encouraged to activate religious imagery that duce both immediate and long-lasting effects will evoke the most intense religious involveon immune function. ment, including religious ecstasy, with a conse In Wright's technique, you may also use quent distancing from the ongoing pain experiideomotor signals to have patients indicate ence. The procedures may not only emphasize when they feel they can forgive themselves. relief from pain but also may provide consid They may be asked to identify specific individerable religious solace for the individual. uals they need to forgive, and to work inwardly on forgiving them and even praying for them, giving a signal when they feel they have let go of their negative feelings and resentments toward The "Sympathetic Ear" the person. It may then be suggested that they Tech n ique with Chronic Pain visualize the empty spaces where the guilt and resentment were, and imagine them being filled Barry S . Fogel, M . D . with love. It may be further suggested that they Provtdence, Rhode Island sense and feel the energy, which was wrapped up in keeping the resentment and guilt inside, being released and becoming available for heal I NTRODUCTION ing. (Ed.) Comprehensive approaches to the management of chronic pain attempt to reduce psycho SUGGESTIONS logical rewards for pain behavior, of which secondary gains are a part. Commonly used There is a deep universal healing spirit within methods include environmental manipulation you and in the world that you can draw upon in an inpatient setting, marital and family HYPNOSIS IN PAIN MANAGEMENT 59 therapy to reduce interpersonal rewards for have to say - thoughts, feelings, complaints, pain behavior in important relationships, forideas . . . . It wants to listen, and listens with mal instruction in alternate coping skills, and perfect attention, without fatigue or judgment. insightoriented psychotherapy. Tell the ear all that concerns you now . . . . When a clinician is presented with an unre Each day take time to put yourself in a trance stricted invitation from a patient to treat pain and talk to the sympathetic ear. As you talk to by whatever means are necessary, the clinician the sympathetic ear, you feel your concerns are often will opt for some combination of the fully and completely heard. above methods to deal with the operant aspects of pain; hypnosis might be used to directly reduce the intensity of the pain or to promote relaxation. However, the patient specifically Reactivation of Pain-Free requesting hypnotherapy of pain may be open to hypnosis, yet be relatively resistant to the Memories: An Example of introduction of other management approaches, I ntensifying and Relieving Pain particularly if they appear to be costly or to require the involvement of other individuals. M . E r i k Wri ght, M . D . , Ph . D . The seeker of self-hypnosis may be seeking individual mastery of the situation, through a mutative technique or experience, rather than I NT RODUCTION seeking a program which requires ongoing submission to environmental manipulation sug Another approach to pain control is based on gested by another person. With patients who the following premises: People typically retain have settled upon hypnosis as their treatment of memories of a pain-free period in their lives, choice for psychological or ideological reasons, with its concomitant physical and emotional it may be useful for the therapist to use hypfeelings of well being. A persistent pain experinosis itself to promote a cognitive restructuring ence, however, can submerge these memories . that may mitigate the effect of secondary gain The psychotherapeutic premise is rhat clients in sustaining pain behavior . Following such a who can recall these and intensify their chronic restructuring, the patient may initiate a discuspain can also learn to diminish that pain persion of secondary gain with the therapist, elimception, even to the point of eliminating it. The inating the need for the therapist to confront imagery invoked during hypnotic trance is the patient, possibly intensifying resistance or based on this premise. The therapeutic process even leading to a defection from treatment. can proceed along the following lines. Once the issue of secondary gain can be comfortably discussed directly, the therapist has the option of blending hypnosis with indi I LLUST RATIVE SUGGESTIONS vidual psychotherapy . . . , or making use of behavioral or family therapy techniques to di Therapist: You are familiar with your own rectly reduce the operant reinforcers of the signal for entering trance . . . So give yourself patient's pain behavior. your signal to relax . . . to let yourself go all over . . . to feel yourself becoming light and free . . . Take the time you need to bring about TH E "SYMPATH ETIC liST E N E R" a most comfortable feeling of calm and quiet SELFHYPNOTIC ASSIGNM E N T ness within yourself . . . of the freeing up within yourself of muscle tension and inner [Following hypnotic induction and deepentension . . . Raise your right index finger when ing] Imagine a sympathetic listener, a sympayou have reached that point . . . [The client thetic ear . The ear is eager to hear whatever you does so shortly.] Fine . . . . 60 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS From what you have told me . . . you know is okay . . . [The therapist reassures the client:] that there was a time in your life when you felt No matter how intense the pain may bewell - physically, emotionally, and in every come . . . you will be able to manage it . . . other way . . . when you knew what it meant to Observe what images are in your mind as the feel glad to be alive . . . when your body funcpain begins . . . Tell me what you are thinking tioned easily and freely . . . [The therapist of . . . what you are feeling . . . [Pain intensiseeks permission to proceed:] Let's check with fication is suggested:] Let this pain become the inner part of your mind to see if it will be stronger and more intense . . . Feel it in all its okay to go back to that time . . . to let the typical ways . . . Let the part that is with me in awareness of what it felt like to feel well return the here and now describe it, while the part that to you . . . Would the inner part of the mind is going through the pain episode feels it in all use the finger signals in the way it has used its usual intensity . . . If you wish, now make them in the past? [The client lifts finger.] The that even more stressful than the usual experi "yes" finger went up slowly but definitely and ence . . . This is a bad episode . . . [Pain modremained up . . . Okay . . . . eration begins:] When you have the full aware[The therapist invites age retrogression in ness of pain . . . start the turnoff . . . [Pain is recalling wellness:] Drift yourself back through supplanted with well being:] Let the inner well time to before the pain was part of your being flow into your body and clear out the life . . . before the pain was in the picture . . . pain sensations . . . quietness, calmness, the [Observer-participant dissociation is suggestmuscles letting go . . . turning off the pain . . . ed: ] Let part of you continue to remain with me leaving it in the past . . . the images o f relief in the here and now, while the other part of you filling you. . . . .., goes back in time . . . Going back . . . going [Posthypnotic suggestions are offered:] The back . . . going back . . . When you are at that conscious part of your mind and the inner part good time . . . let me know by your right index of your mind will remember the importance of finger . . . [The therapist encourages elaborawhat has just taken place . . . Not only were tion of the feeling of well being:] Describe you able to permit the pain to flow into your yourself . . . Tell how you feel in each part of body in its very typical way, but you were also your body . . . how it feels to feel good . . . able to clear the body of this pain, to have relief Enjoy every moment of this feeling of well replace it and the well being feeling come being . . . Let every cell of the body restore the back . . . [Homework is suggested:] This is an awareness of this capacity to feel well, which is exercise that you will practice in between the part of that cell but which has been submerged pain episodes . . . Your skill at shutting off by stress feelings . . . This feeling is still a part pain will increase . . . and then you will find of you . . . Nourish it . . . bring in colors . . . yourself shutting off pain right in the early sounds . . . or any other sensations you wish to stages of your pain episodes . . . You will bring strengthen that feeling . . . Let yourself feel the pain into limits of feasibility that permit very comfortable . . . Now count from one to you to go on with your life . . . You can turn it five slowly . . . and let all the psychological off more and more as you gain confidence, and time take place that will revive these feelings of your life will expand once again . . . . well being strongly in your mind . . . signal when you reach the count of five . . . [Soon the CONCLU D I NG COMME NTARY client signals.] [The therapist seeks permission for the pain In the reactivation model illustrated above, experience:] Is the inner part of your mind three phases are evident: the reactivation of ready to move up in time to the beginning of a pain-free memories, the reactivation and intentypical pain episode? . . . [The client responds sification of the chronic pain, and then the with the finger signal.] The "yes" finger says it quieting of the pain experience. HYPNOSIS IN PAIN MANAGEMENT 6 1 Chronic Pain Syndrome these that are more acceptable to you." [See the section on cancer patients below for further Richard B . Garver, Ed . D . suggestions about reinterpreting sensations .] San Anton1o, Texas It is important, first, to help newly referred GATE CONTROL TH EORY M ETAPHOR chronic pain patients to understand why they have been referred by a physician who determined that conventional medical treatment re "The more sensations that your unconscious sources have been exhausted. In fact, the pamind has options to produce, the more likely tient has often been told, "There is nothing these other sensations are to occur. Your unmore I can do for you; you have to learn to live conscious mind can relax all the nerve and muscle fibers with the pain." Although it is not meant to be in the area of your body where so, this is often a negative suggestion. there is tension or pain. It can also interrupt the I let patients know that I believe they are in pathways which travel from the site of the pain, that they feel the pain, and that they are injury, to the spinal cord, up the back of the not seeing me because they are crazy or imagspinal cord, through the brain stem and into the ining things. But, I indicate that I am here to pain reception area. There are many, many help them to change this pain pattern and that gates which these pain impulses must pass pain is a behavior like all other sorts of behavthrough, and your unconscious mind can close iors, and that we learn behaviors that are both many of these gates, reducing the number of productive and non-productive. Pain is somenerve impulses that will finally reach the pain times a productive behavior when it protects us, reception area, and so, you simply will be aware but when it is reinforced and perpetuated by of less pain." negative emotions such as anxiety and fear, it becomes self-perpetuating. Pain produces negative emotions . Negative emotions produce ten CONTROL SWITCH VISUALIZATION sion, and tension produces more pain. I also indicate that there is within the unconscious "Your unconscious mind can also help you mind an established program of pain, which is visualize this pain reception area, perhaps as a reinforced by many things (primary and seccompartment or a lighted room. When there is ondary gain), and this memory of pain adds to a lot of pain being reported there, the light can the perceived pain. be very, very bright; but you have a rheostat, a One of the first things that I do is to have dimmer switch, which you can turn down. As patients produce a glove anesthesia and help you turn the light down, dimmer and dimmer, them understand that they are really doing this, you will experience less and less pain. Perhaps not I. They have produced this analgesic effect you will even want to rate it on a scale of 1 to in their hand. This, of course, can be trans10, with 1 0 being the most pain that you would ferred to the affected areas. Other useful pain ever be in. And the number that you feel will be metaphors and suggestions follow. the number you can see in your mind and in this pain reception area. If you feel an 8, you will SUGGESTIONS REI NTE RPRETI NG PAI N see an 8 . So the number you feel is the number SENSATIONS you see, and the number you see is the number you feel. So see the number 7, and the number "You will experience other sensations that are 6. As you lower the numbers, you will lower the more acceptable than pain, perhaps a gentle pain. Remember the number you feel is the coolness or warmth, a lightness or heaviness, number you see, the number you see is the tingling, even numbness, or any combination of number you feel." 62 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS TIME DISTORTION ical diagnosis . My emphasis with all of these pain patients is to emphasize and reinforce the "Your unconscious mind can also distort fact that they are gaining more and more time. You can tell your unconscious mind that control of the pain, and that the pain is less and the time that you feel pain will be perceived as less in control of them. the shortest amount of time. Perhaps an hour can even be like a minute, and the time of comfort can be much longer. So, whenever you H EADAC H E PAI N do feel pain, you know that it will be over a very short period of time." I use more relaxation o f the nerve and muscle fibers in the area of the pain for tension headaches, and have found cooling the head and DISSOCIATION Of PAI N warming the hands useful for migraine headache pain. To help patients learn this feeling of "Also, if you like, you can leave the pain here cooling the head and warming the hands, I tell and you can go somewhere else. You can leave them to actually put themselves in that situayour pain here, and go somewhere else where tion, to imagine putting ice packs around the you are comfortable, and you can stay there for head, and to place their hands in warm water any amount of time that you would like. And, and memorize the sensations. Self-hypnosis will while you are gone, nothing will strengthen thereby enable them to reproduce this at anyour pain; and so perhaps it will grow weaker other time. and weaker, and by the time you return, there will be very little, if any, pain left at all." SUGGESTIONS WITH CAN C E R PAT I E NTS COM PUTE R PROG RAMMING � METAPHOR Many of the same pain strategies apply with pain patients. However, for coping with the The computer metaphor of programming out side effects of chemotherapy or radiotherapy, I all pain-related behaviors and programming in suggest that the unconscious mind will potenall comfort and control-related behaviors is a tiate the therapeutic effects of all treatment and useful one. All the behavior that the patient minimize the adverse side effects . It is suggested associates with pain will be programmed out, that, in fact, "you can experience any number and all behaviors that the patient associates of different sensations instead of nausea or with being comfortable and in control, both pain. A feeling of tingling, which often accomphysically and emotionally, will be propanies nausea, is one that you can focus on, grammed in. A very good posthypnotic cue can and you will experience more tingling than also be used to reinforce this so that while the nausea." patient is in a normal waking state he may use Some other very specific posthypnotic suga cue such as touching his right ear, which tells gestions are also helpful. First, an environhis unconscious mind to program in that posimental cue is established, for example, that tive comfortable behavior. If the situation he is when the patient enters the hospital or the in produces pain, tension or discomfort, he can treatment room or smells a particular odor, touch his left shoulder, which is the unconthat will produce another effect (or several scious cue for the unconscious mind to reother effects) rather than any uncomfortable member to program that behavior out. The effects or sensations. A second very valuable exception to this, of course, is to always remind suggestion is to establish a symptom awareness the patient that the unconscious mind will allow cue that is always present. It is suggested, "If him to have pain that will keep him safe from you begin to feel even the slightest effect of an injury, or that might prove beneficial for med-unwanted symptom, whether that be pain or HYPNOSIS IN PAIN MANAGEMENT 63 nausea, that will be a feedback cue to the ods seem contraindicated, or should at least be unconscious mind, to instead produce other used with utmost caution, with borderline or behavior, other sensations that are acceptable." psychotic patients. Elicitation of mystical states This is very important because the symptoms will be useful primarily with deep trance subwill often be there in one form or another jects and with patients who are judged to have unless all suggestions work perfectly, which the capacity and security to temporarily susthey often won't. But, if the symptom occurs, pend reality. Sacerdote primarily used these the patient usually expects more of that symptechniques after having a couple of hypnotic tom. It is very valuable when the symptom can sessions with patients to determine their hypbe used instead to produce other sensations notic talent and to provide them with experiwhich are more comfortable. ences in primary process thinking through The third suggestion is for a physical action guided imagery and the use of induced dreams. cue. For example, by touching the forefinger (Ed. ) and thumb together or touching the right ear, that will signal the unconscious mind to produce another sensation rather than the un I NTRODUCTION wanted symptom. I tell the patient that this is very much like pushing the play button on a For the purpose of this paper, mystical states tape recorder so that the tape that you want are defined and operationally described as played will begin to run. The physical action states of ecstasy, rapture, and trance. The cue is the play button on that recorder. experiencing subject finds himself perceptually, emotionally, and cognitively immersed in oceanic, universal feelings; i.e., in direct intuitive or supernatural communion with the universe Hypnotically Elicited Mystical or with a superior being. Visual (lights, colors, States in Treating Physical and shapes), auditory (music), olfactory, and other Emotional Pain sensations are often part of the experience, but the mystical states bypass ordinary sensory Pau l Sacerdote, M . D. , Ph . D . perceptions and logical understanding. Therefore, they cannot easily be described in terms of Rtverdale, New York everyday reality. They are, by definition, ineffable - beyond verbal expression. In spite of IN DICATIONS AND these "inborn" difficulties of communication, CONTRA I N DICATIONS patients usually attempt and partially succeed in giving some ideas of perceptual, emotional, Sacerdote, expanding on the work of Fogel, and cognitive experiences which can only be Hoffer and Aaronson, provides us with two described as mystical. unique perceptual change techniques for elic As this is a clinical paper, no useful purpose iting mystical states. These methods are inwould be served by attempting to catalogue tended for patients suffering with protracted or hypnotically elicited, mystical experiences recurrent physical pain and with accompanying along Fischer's (1971) continuum in his interemotional pain (anxiety, depression). They may esting "A cartography of the ecstatic and medhold particular value for patients with severe itative states: The experimental and experiential chronic pain problems, for example, from feature of a perception-hallucination contincancer and migraine. It is recommended that uum are considered." (Incidentally, this cartogthese techniques only be used by highly experiraphy does not include hypnotic states ! ) Nor enced hypnotherapists, after establishing a would the methods which I am about to detrusting rapport with the patient, with patients scribe or my patients' experiences be clarified if without severe psychopathology. These methI were to spell them out in terms of Zen 64 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS Buddhist or other religious or philosophical ination" or "expansion" of space elicited terminology. comparable alterations of perception, emotion, I find it of some use, however, to accept mood, and cognition. These changes were dra Aaronson's (197 1 ) distinctions between an matically illustrated by one S through drawings "introvertive mystical experience" and an and paintings of the same scene, seen under "extrovertive mystical experience." The former different posthypnotically suggested time conculminates in the subjective experience of ditions or space conditions. "nothingness" - the absolute void. The latter I have found it feasible to apply the above tends to expand the person's awareness to unobservations to the clinical area. The patient's limited, universal experiences. To facilitate conscious and subconscious needs, as well as introvertive mystical experiences, Aaronson our own understanding of such needs and our ( 197 1 ) developed a progression of deepening ability to follow and to guide him, determine verbalizations aimed at guiding trained Ss into the results: a schizophrenic-like experience, or a abandoning identification of the senses, relin "conversion" occurrence, or a mystical state. quishing ego-identification, and dispensing For instance, an exceiient S and superb student with usual logical categories of distinction. To became belligerently paranoiac when she achieve extrovertive mystical states, he used emerged from hypnosis; the opening of her eyes techniques aimed at expanding the ego across was the cue for the posthypnotic suggestion barriers of space and time. that, "upon coming out of hypnosis, distances The techniques which I have evolved and will would seem very short, people and objects describe were inspired by the original observawould be close, clear, and distinct." Upon tions and experiments conducted by Fogel and opening her eyes to this radically changed Hoffer ( 1 962), and by the more recent experispace, she had felt terribly closed-in and threatments of Aaronson ( 1 968). In Fogel and ened. The same student was given the posthyp Hoffer's experiment, a talented and well trained notic suggestion that, upon opening her eyes, S was led into deep hypnosis and made to listen she would find herself in a gently expanding to an oscillator with the belief that its speed was space, with people and objects shining in marconstant. When, unknown to her, the speed velous luminosity. Upon emerging from hypnowas progressively increased, S became progressis, she seemed to radiate ethereal serenity. She sively more manic. When the speed was gradulater described her experience as soothingly ally decreased, depression set in, until, at unreal, ineffable, without end or beginning, a speeds near zero, she retreated into a catatonic wonderful universe without problems. state. This experiment suggested that a person's behavior, mood, emotion, and cognition can be altered very radically through basic manipula SUGG E STIVE VE RBALIZATIONS tions of the dimensions of time. Aaronson ( 1 968) gave to his trained, deep I will give some of the verbalizations which I hypnotic Ss various posthypnotic suggestions. currently utilize. It should be kept in mind that For instance, posthypnotic suggestions of a these are modifiable according to the patient's "restricted present" generally produced evicapabilities, needs, responses, and degree of dence of depression; suggestions of total abhypnotic talent and training. Transference and sence of the present elicited a schizophrenic-like countertransference obviously play an imporcatatonic state. On the other hand, posthyptant role. notic suggestions of "expanded" time - especially expanded present and expanded future I NTROVERTIVE MYSTICAL EXPE RIENCES. Usually the led his Ss to experiences of supreme serenity, patient has been previously induced to a meduring which the strictures and anxieties condium level of hypnosis by my method of "renected with passage of time disappeared. Simversed hand levitation," which is based largely ilar suggestions involving "restriction" or "elim-on concentrated attention with detachment. HYPNOSIS IN PAIN MANAGEMENT 65 The reversed hand levitation has generally the yond it another chain of mountains . . . and then advantage, when compared with traditional levbeyond, more and more valleys and more and more itation, of implicitly suggesting relaxation, mountains and plains, and rivers, and lakes and deepening, and "letting go" (Sacerdote, 1 970). oceans extending and expanding further and further The patient who has responded well to preout in every direction to receding horizons . . . . As vious inductions will already be able to experithe view continues to expand, your ears rejoice in the natural music of the wind, the rustling of grasses and ence dissociative phenomena and deep relaxleaves and tree branches, the singing of birds, the ation. When there is evidence for both, I chirping of crickets, the tolling of bells; your nostrils repeatedly, patiently, and monotonously sugsmell all the fragrances of the trees, and the grasses, gest: and the flowers . . . and your eyes watch in wonderment the continuously "expanding" view of the ex Now, as every word travels from my lips to your panding future . . . . ears to reach your brain, your body progressively enjoys more and more complete relaxation in every muscle and cell; and your mind delights in calm, WHY A N D HOW S HOULD MYSTICAL clear, peaceful serenity . . . . You are now sur STATES H E LP TO RELI EVE PAI N ? rounded by a soothing atmosphere of absolute calmness . . . , protected from danger, disturbance, and fear. And while relaxation and peaceful serenity The idea o f eliciting extrovertive mystical penetrate deeper and deeper to every cell of your states came to me while I was dealing with body, we are safely surrounded in every direction by advanced cancer patients; they were raked with wider and wider transparent, concentric spheres of pain, beyond the reach of any further palliative luminous serenity, of cheerful calmness . . . [The treatment. I was familiar with the effects that transparency which I explicitly mention communithe perception of expanded present, expanded cates to the patient that he can see and be seen; that future, and expanded space could have on the he is not emotionally isolated.] You are safely mood and reality perceptions of normal indibathing and comfortably breathing in the center of viduals. It seemed worthwhile to see if patients these transparent spheres, while luminous calmness in pain, guided into symbolic, multisensory all around you penetrates even more deeply within your body and permeates your mind . . . . All volunimagery, could be led to experience perceptions tary and involuntary reactions and responses graduof expanding time and space. Such experiences ally fade and disappear. . . . Little by little, you might "free" them from the limits of time, from become free of fears, of anxieties, of thinking, of the restrictions of activity; death itself could feeling. become merely the completion of life, rather than an event to be feared. In the expanded EXTROVERTIVE MYSTICAl EXPERIENCES. The patient present and future, people and objects could who has similarly been led to a state of inappear to the patients as bathed in luminous creasing dissociation and body relaxation is reflections. Synesthesias of colors, music, and first guided by me through an imaginary climb fragrances would further distance them from to the top of a symbolic mountain: the "reality" of pain, desperate illness, dependency, and depression. Mystical states could Now finally you are at the top and you are able to enable the patient to deal in entirely new ways look towards the sunny side of the mountain . . . . with problems of guilt and punishment, of life You notice the blue of the sky and the brightness of and death. They might also encourage him to the sun. You enjoy the warmth of the sunshine on come to terms with these problems on a philoyour shoulders and your back, on your arms and sophical or theological basis. hands, on your legs and feet. You breathe in slowly and deeply the clean, pure, cool air . . . . In front of The other approach, leading to "introvertive" your eyes under the quiet blue sky you see the mystical experiences, is based upon progresbeautiful green valley; and beyond the valley a sively deeper states of muscular relaxation and picturesque chain of mountains . . . and beyond that increasing psychological calm and serenity. The first chain, you distinguish another valley; and be-gradual restrictions of perceptions and re- 66 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS sponses suggested to the patient are also sym Patients were given the following suggestions bolized for him with the image of his body fully following the hypnotic induction: relaxed at the quiet center of concentric, luminous, serene spheres of wider and wider radius. Allow yourselves to imagine a scene of comfort Thus, a kind of sensory and emotional isolation and relaxation. A place where you can feel really is established which, in itself, can facilitate secure and peaceful. You may see yourself alone or psychological and physiological dissociation of with another person or in a familiar or unfamiliar the loci of pathology from the thalamic and place. Let the scene present itself to you and allow cortical centers of pain perception. yourself to see, smell, hear, touch, or taste anything of special interest to you. After a time, as you continue to experience your special place, with your eyes remaining closed, we will ask you to describe your scene to the rest of the group . You will retain a Active Control Strategy for clear image of your special scene and will be able to Grou p Hypnotherapy with recall it with ease anytime you like, especially when Chronic Pain you begin to experience the onset of any pain . . . . Ti mothy C . Toomey, Ph . D . and E NCOU RAG E M E NT OF IMAGES AN D S h i rley Sanders, Ph . D . FANTAS I E S THAT EMPHASIZE CHOICE Chapel Hill, North Carolma AND ALTE RNATIVES I NTRODUCTION As a common feeling elicited from the chronic pain patients in the group was that of The following strategies and suggestions were being "locked in" and overwhelmed by the pain, used in a group hypnotherapy treatment format the use of a technique that emphasized choices for working with chronic pain patients. Aland alternatives seemed important. Thus, pathough only five subjects were used, the treattients were encouraged to have a dream while in ment was successful in reducing pain levels. trance of two roads, one leading to health, the (Ed. ) other to sickness and disability. They were asked to image both roads, to describe thetp., to image choosing the road to health and what PRODUCTION OF PLEASANT, that entailed. Patients were given the following RELAXI N G IMAGES AN D FANTASI E S suggestion: Patients were encouraged to produce images You are able to experience yourself at an intersecof relaxation and comfort and to share these tion and can clearly see two paths leading from with the group . The responses frequently infamiliar to unfamiliar terrain. You know that both volved simple images of scenes which the paof these paths are meant for your steps alone. One of tients reported when encouraged by the therathese paths is a healthy path and contains clues and pists and other group members. In contrast directions for your recovery. While on this path with traditional relaxation procedures which some of you may experience a particular image or vision which is a clue to your healing and recovery. impose a technique on the patient, the thera Allow yourself to be open to such an image. The pists strove to employ the utilization methods other path is a sickness path and has sights and signs described by Erickson (1959) which emphasize of the future should you choose this direction. Allow starting where the patient is and gaining yourself to ask questions of any one you meet along gradual control over the symptom to demonboth of these paths . After a time, we will ask each of strate that change is possible. you to share your j ourney with the rest of the group. HYPNOSIS IN PAIN MANAGEMENT 67 Frequently the "healthy path" generated images E NCOU RAG E M E NT OF PRACTICE AN D of people, activity, and interesting sights and ACTIVE EMPLOYME NT OF COPI NG sounds. The "sickness path" was usually dark, STRATEGIES dreary, and isolated. While in trance, patients were encouraged to attend to the characteristic In addition t o incorporation i n the patient's features of the healthy road as a way of obschedule of a time period each day for relaxing taining cues for restoration - including people and enjoying pleasant images following selfor activities they may have forgotten or neinduction of an hypnotic trance state, patients glected during their illness . were encouraged to make active use of coping strategies during periods of pain or when they DETERMI NATION OF SIGNALS O R needed an extra boost to accomplish a difficult CUES ASSOCIATE D WITH ONSET O F task. They were encouraged to view novel or SEVE RE PAI N difficult tasks, e.g. , a new exercise-activity program or taking a plane trip, in a stepwise Patients were encouraged to recall, while in fashion and to use trance-induced coping strattrance, the feelings and thoughts associated egies and images as means of simplifying comwith pain onset and disability behaviors. For plex tasks and reinforcing successful perforone, it was a feeling of cramping and burning in mance of each step. Although the approach the back; for another, it was a dull throbbing in described here is structurally very similar to the head. Patients were given the suggestion techniques developed by self-control theorists that such signals could be reinterpreted as reand cognitive behavior modifiers (Meichenminders or cues for use of a coping strategy, baum, 1 97 1 ; Turk, 1 980), the emphasis on e.g. , pleasant imaging, deep breathing, muscle assisting the patient via the hypnotic environrelaxation, instead of producing the usual cycle ment to discover appropriate coping strategies of self-depreciatory thought patterns and disis different. For example, "Imagine walking ability behaviors. Thus an effort was made to down the healthy path as you begin to walk the establish novel signal values for pain stimuli. mile of prescribed exercise." "Focus on the Patients were given the following suggestion: pleasant and interesting sensation of air rushing past your limbs as you stand up, leave the You are starting to experience an episode of pain. house, and take your daily walk." Indeed, the Be very attentive to any beginning clues that pain is patient actively participates in finding his own coming. Some of you may feel a burning, others may solutions . feel cold, others a throbbing sensation . Imagine that your pain clues are changing to interesting, even pleasant, sensations. The burning becomes the warmth from a comforting fire; the cold becomes a refreshing breeze on a hot summer's day; the throb Pain Strategies by bing slows as your breathing becomes slow and Hypnotizability level regular and you imagine the ocean waves gently ebbing, and flowing on the shore. Now, as you become more comfortable and relaxed, no longer David S piegel, M . D . , and concerned with your pain, you have time to use any H erbert Spiegel , M . D . of the approaches you have learned in the group. Stanford, Ca!tforn1a, and New York, New York You may wish to enjoy your special scene or allow your image of healing to do its work. Others may just want to enjoy deep regular breathing and deeper Instructions for pain control differ dependand deeper levels of relaxation and comfort. Take ing upon the hypnotizability of the subject. your time and enjoy the experience. You will be able High hypnotizables are given instructions to use to clearly recall this exercise and use it regularly self-hypnosis to simply make the painful or whenever you notice any beginning clues of pain. affected area numb, or to imagine the;nseJves 68 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS floating above their body or even getting up know . . . that you have all the protection you and walking to another room while they are in need . . . that if your red light goes on . . . you pain. can cool it down. Mid-range subjects are instructed to experiment with changing temperature of the affected body part, making it warm or cold by imagining that they are in a warm bath or rolling in Splinting Techn ique for snow, for example. Or, they may imagine that Pain Control they are in the dentist's office receiving a shot of novocaine and that this numbness which Charles B . Mutte r, M . D . they first experienced in the mouth can now be Mtamt, Flonda spread with their hand to the affected part of the body. I N DICATION Low hypnotizable subjects are encouraged to use distraction techniques, focusing on com This technique is used to protect patients peting sensations elsewhere in their body, for with chronic pain from overexerting or hurting example, rubbing their fingertips together. All themselves. It follows techniques given for pain of these use the hypnotic state to focus on some control with patients who have chronic competing sensation or image which involves musculoskeletal disorders. These suggestions teaching them to filter the hurt out of the pain are used when the patient is in hypnosis. rather than fighting the pain, at the same time producing a sense of floating relaxation. SUGG ESTIONS Your unconscious mind has a sacred trust to protect your body. It knows the capacity of Reinterpreti ng Pain as every cell, every organ, every system . . . and it will protect you by causing you to turn and Protection twist or bend only within your physical capacity . . . and not beyond . . . so that when you Charles B. Mutter, M . D . attain comfort . . . you can move and keep that Mtamt, Flonda comfort for longer periods Q.f time. As your body becomes stronger, your mind will then [Various metaphors may be used with a allow you to turn, twist, and bend to a greater patient in hypnosis to reinterpret pain as a degree . . . but only within those limits . . . so protective mechanism rather than a debilitating that when you gain comfort, you need not fear one. The following metaphor is used while the reinjuring yourself. Should you have any dispatient is in hypnosis] . comfort, it is merely your body protecting When you drive a car and it overheats, a red you . . . by giving you a signal that you have light signal goes on the dashboard . . . that gone beyond those limits. signal tells you to pull the car over . . . to check the fan belt, the water pump, or radiator . . . because you know that if you continue to drive Erickson's l nterspersal the car when it is hot, you can damage the motor. It is good to know that your car has a Technique for Pain protective signal so that you know when to . . . cool it down . . . to avoid further damage. Particularly in cases of resistance and when Think of your body as your car . . . that gets he did not know a patient well, Milton Erickson you through a lifetime . . . and it is good to would "seed" ideas through interspersing words HYPNOSIS IN PAIN MANAGEMENT 69 or phrases within the context of a story or you can listen to me, Joe, so I will keep on talking discussion. These embedded suggestions were and you can keep on listening, wo ndering, just typically set off by the use of a slightly different wondering what you can really learn, and here is voice tone or a very brief pause. your pencil and your pad, but speaking of the Erickson (1966) masterfully used embedded tomato plant, it grows so slowly. You cannot see it suggestions in treating the cancer pain of a grow, you cannot hear it grow [suggestions for negative haJiucinations], but grow it does - the first patient named "Joe." Joe was a retired farmer little leaflike things on the stalk, the fine little hairs who had turned florist. Facial cancer had reon the stem, those hairs are on the leaves, too, like sulted in the loss of much of his face and neck the cilia on the roots, they must make the tomato due to surgery, ulceration, maceration and neplant feel very good, very comfortable if you can crosis. He experienced intolerable pain for think of a plant as feeling, and then you can't see it which medications were not very effective. A growing, you can't feel it growing, but another leaf relative was urgently requesting that hypnosis appears on that little tomato stalk and then another . be used, but Joe disliked even the mention of Maybe, and this is talking like a child, maybe the the word hypnosis. The patient was unable to tomato plant does feel comfortable and peaceful as it speak and could only communicate through grows. Each day it grows and grows and grows, it's so comfortable, Joe, writing. We will now pick up on Erickson's to watch a plant grow and not see its growth, not feel it, but just know that all is account. getting better for that little tomato plant that is Despite the author's unfavorable view of possibiladding yet another leaf and still another and a ities there was one thing of which he could be branch, and it is growing comfortably in all direcconfident. He could keep his doubts to himself and tions. [Much of the above by this time had been he could let Joe know by manner, tone of voice, by repeated many times, sometimes just phrases, someeverything said that the author was genuinely intertimes sentences. Care was taken to vary the wording ested in him, was genuinely desirous of helping and also to repeat the hypnotic suggestions. Quite him . . . . The author began: some time after the author had begun, Joe's wife Joe, I would like to talk to you. I know you are a came tiptoeing into the room carrying a sheet o f florist, that you grow flowers, and I grew up on a paper on which was written the question, "When are farm in Wisconsin and I liked growing flowers. I still you going to start the hypnosis?" The author failed do. So I would like to have you take a seat in that to cooperate with her by looking at the paper and it easy chair as I talk to you. I'm going to say a lot of was necessary for her to thrust the sheet of paper in things to you, but it won't be about flowers because front of the author and therefore in front of Joe. The you know more than I do about flowers. That isn't author was continuing his description of the tomato what you want. [The reader will note that italics will plant uninterruptedly, and Joe's wife, as she looked be used to denote interspersed hypnotic suggestions at Joe, saw that he was not seeing her, did not know which may be syllables, words, phrases, or sentences that she was there, that he was in a somnambulistic uttered with a slightly different intonation.] Now as trance. She withdrew at once] . And soon the tomato I talk, and I can do so comfortably, I wish that you plant will have a bud form somewhere, on one will listen to me comfortably as I talk about a tomato branch or another, but it makes no difference beplant. That is an odd thing to talk about. It makes cause all the branches, the whole tomato plant will one curious. Why talk about a tomato plant? One soon have those nice little buds - I wonder if the puts a tomato seed in the ground. One can feel hope tomato plant can, Joe, feel really feel a kind of that it will grow into a tomato plant that will bring comfort. You know, Joe, a plant is a wonderful satcsfaction by the fruit it has. The seed soaks up thing, and it is so nice, so pleasing just to be able to water, not very much difficulty in doing that because think about a plant as if it were a man. Would such of the rains that bring peace and comfort and the joy a plant have nice feelings, a sense of comfort as the of growing to flowers and tomatoes. That little seed, tiny little tomatoes begin to form, so tiny, yet so full Joe, slowly swells, sends out a little rootlet with cilia of promise to give you the desire to eat a luscious on it. Now you may not know what cilia are, but cilia tomato, sun-ripened, it's so nice to have food in one's are things that work to help the tomato seek grow, to stomach, that wonderful feeling a child, a thirsty push up above the ground as a sprouting plant, and child, has and can want a drink, Joe, is that the way 70 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS the tomato plant feels when the rain falls and washes You know, Joe, I could talk to you some more everything so that all feels well. [Pause.] You know, about the tomato plant and if I did you would Joe, a tomato plant just flourishes each day just a probably go to sleep, in fact, a good sound sleep. day at a time. I like to think the tomato plant [This opening statement has every earmark of being canknow the fullness of comfort each day. You no more than a casual commonplace utterance. If the know, Joe, just one day at a time for the tomato patient responds hypnotically, as Joe promptly did, plant. That's the way for all tomato plants. [Joe all is well. If the patient does not respond, all you suddenly came out of the trance, appeared disorihave said was just a commonplace remark, not at all ented, hopped upon the bed, and waved his arms; his noteworthy. Had Joe not gone into a trance immebehavior was highly suggestive of the sudden surges diately, there could have been a variation such as: of toxicity one sees in patients who have reacted "But instead, let's talk about the tomato flower. You unfavorably to barbiturates. Joe did not seem to have seen movies of flowers slowly, slowly opening, hear or see the author until he hopped off the bed giving one a sense of peace, a sense of comfort as you and walked toward the author. A firm grip was taken watch the unfolding . So beautiful, so restful to on Joe's arm and then immediately loosened. The watch. One can feel such infinite comfort watching nurse was summoned. She mopped perspiration such a movie. "] (p. 207) from his forehead, changed his surgical dressings, and gave him, by tube, some ice water. Joe then let the author lead him back to his chair. After a pretense by the author of being curious about Joe's Joe's response was excellent and during the forearm, Joe seized his pencil and paper and wrote, following month he gained weight and strength. "Talk, talk."] Oh, yes, Joe, I grew up on a farm, I Only rarely did he experience enough pain to think a tomato seed is a wonderful thing; think, Joe, need aspirin or demerol. A month later, think in that little seed there does sleep so restfully, Erickson visited again and after much casual so comfortably a beautiful plant yet to be grown that conversation, "Finally the measure was emwill bear such interesting leaves and branches . The ployed of reminiscing about 'our visit last Ocleaves, the branches look so beautiful, that beautiful tober.' Joe did not realize how easily this visit rich color, you can really feel happy looking at a could be pleasantly vivified for him by such a tomato seed, thinking about the wonderful plant it simple statement as, 'I talked about a tomato contains asleep, resting, comfortable, Joe. I'm soon plant then, and it almost seems as if I could be going to leave for lunch and I'll be back and I will talk some more. (pp. 205-206) talking about a tomato plant right now. It is so enjoyable to talk about a seed, a plant'" (p. 208) . As a result of these two extended sessions, Erickson ( 1966) indicated that despite his "ab Joe lived comfortably until his death over three surdly amateurish rhapsody" about a tomato months after the first contact. plant that Joe had an intense desire for comfort One would be incorrect to assume that and to be free from pain. This meant that Joe Erickson's primary therapeutic method was the "would have a compelling need to try to find use of interspersed suggestions within metasomething of value to him in the author's phors. Close long-term colleagues have estibabbling" (p. 207) which could be received mated that not more than 200Jo of Erickson's without his realizing it. "Nor was the work consisted of the use of metaphors reinduction of the trance difficult, achieved by (Hammond, 1 984, 1988b). Erickson flexibly two brief phrases, 'think, Joe, think' and 'sleep used both very direct and very indirect suggesso restfully, so comfortably' imbedded in a tions, depending on the clinical situation. Howrather meaningless sequence of ideas" (p. 207). ever, the clinician should be aware that the Joe was impatient and anxious to resume the patient's unconscious mind has the capacity to talk after lunch. "When it was suggested that he perceive meaningful suggestions offered in cease walking around and sit in the chair used seemingly casual conversation or metaphoric earlier, he did so readily and looked expectantly stories. Metaphoric communication offers us at the author. one more avenue for therapeutic intervention. HYPNOSIS IN PAIN MANAGEMENT 7 1 The Setting Sun Pain Metaphor M ETAPHOR Alexander A . Levitan, M . D . I remember the first time that I ever ate New Bnghton, Mmnesota Mexican food. I ate chili stew at Isleta Indian Pueblo in New Mexico. It contained so much [This metaphor is particularly indicated when red chili, that the broth of the stew was bright the patient has described the pain as a flaming red. My nose started running, my eyes watered, red sphere.] and my mouth kept hurting and kept burning, See yourself sitting on a tropical beach at no matter how much cold water I drank. I sunset. Notice the bright red sun as it descends couldn't imagine how anyone could eat such on the far horizon. See the colors begin to hot chili. I was almost unaware of the taste, change from orange to crimson, and then a because the pain was so great. deep, dark red-orange. Notice that as the sun But I spent the next year and a half living in approaches the water, there actually seems to New Mexico . And I'm not sure exactly when, or be two suns, one in the sky and one in the how, but my body changed and adapted. Or water. See the sun gradually sink into the perhaps in part it was my mind that changed. ocean. See the colors change from red to purple Because, before long, that sensation of the hot and then to blue. Notice the magical stillness chili in my mouth seemed different. Almost as that pervades everything just at sunset when the if somehow, my mouth had developed a callous. ocean is as smooth as glass and sounds seem to Somehow my mouth adapted, so there was no travel forever. Enjoy that delicious feeling of longer pain, and I could just enjoy the taste. I tranquility. Realize that that tranquility is availhad in a sense become callous to the pain, and able to you whenever you need it, on a moyet remained pleasantly sensitive to the delicious ment's notice, merely by giving yourself your flavor of the hot tamales or enchiladas or stew. own personal signal to relax! Perhaps you And you really should be willing to allow the might enjoy letting your finger and thumb nerves in the painful part of your body, to come together to make a magic "O .K." sign and adapt, and develop callouses, just as I did in that can be your signal to experience immediate order to eat chili and Mexican food. relaxation whenever you choose to employ it. Metaphor of Callous formation Mexican food : Metaphor of the D . Corydon H a m mond, Ph . D . Body Adapti ng to Pain Salt Lake City, Utah D. Corydon H a m mond, Ph . D . It's interesting every spring when I begin to Salt Lake City, Utah play golf again. After a long winter of not playing golf, in about early April I go up to the IN DICATIONS driving range and hit a bucket of balls . Before I'm done with a large bucket of balls, my hands This metaphor and the one that follows were are getting sore. And by the time I've hit a large designed for use with chronic pain patients. bucket of balls, I have a few blisters on my They were inspired by a metaphor by Milton hands. If the weather is rainy and cool the next Erickson (1983, p . 1 12) where he used a week, it may be two weeks before I go back to conceptualization that may be useful for pathe driving range to practice. And if I hit a large tients, despite not being medically sound, of bucket of balls again, I'll develop blisters on my developing a callousness to the pain. hands again. 72 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS But if I go to the driving range for a short WARMTH AN D M ETAPHOR OF time on Monday afternoon, and share a small M E LTING BUTT E R OR C REME bucket of balls with my son, and then go back on Wednesday and share another small bucket, You can change the sensation of discomfort and again for a short time on Friday and to warmth [or cold if appropriate] , and feel a Saturday, blisters don't develop. When I gradwarm comfortable tingling in your . . . [area of ually increase what I do, callouses gradually pain] . Let the sun shine on your [area of pain] form. My body gradually adjusts. And before and feel how the warmth penetrates the skin, long I can play nine holes of golf, and my hands the subcutaneous tissues, the muscles and all are only a little sore, and I don't have any the way down to your bones. You can visualize blisters. And then before long, I can play a pad of butter or some soothing creme on your eighteen holes of golf, comfortably, because skin, and as it melts, so will your discomfort my body has adjusted, and callouses have melt away. So good, so relaxing, so comfortformed. ing. You can be very proud of your success and And in this same way, you can gradually your ability to change your sensations at any allow callouses to form in your pain nerves, time you wish, and to any degree you desire. allowing your body to adapt gradually. And if And when you use self-hypnosis several times a I had a painful , I'd be willing to day, you will notice that with practice you will spend just as much time allowing callouses to be able to go deeper, and it will take less and develop around those nerves, as I do allowing less time to change and control your sensations. my hands and fingers to develop callouses. During the rest of the day you need not pay any attention to . . . [area of pain] . Your body knows how to make you breathe, and your heart to pump your blood around [etc.] com Suggestions for Patients with pletely, without your help. Pay all your attention to your work, your play, and your sur Chronic Pain roundings. You have learned a new skill and you can use it to see and hear and taste and Li l l ian E . Frede ricks, M . D . touch in a new way. In a way which will be very Palm Beach, Florida pleasing to you. When you walk through the woods, you will [After appropriate induction of trance and come to a fork in the road, and you can choose deep relaxation, I use behavior modification whether you want to go to the right or the left. with positive suggestions]: Up to now you went unconsciously to the left. You are so deeply relaxed and comfortable You did not know how to choose. Now you right now that you will be able to follow my have the skill and the power to choose the right suggestions with ease. You know with the use of road, the road of comfort and to a productive hypnosis that you can alter perception, experiand happy life. ence and memory, and you can regain control over your sensations. With this newly learned tool, you will be able to alter the course of Pai n Red uction events. Just like the person steering a sailboat B eata Jencks, Ph . D . can turn the rudder in such a way that the wind Murray, Utah catches the sails, and the boat turns around and goes the opposite direction; so are you steering I NTRODUCTION your boat of life and you can turn around and go the opposite direction. You can be relaxed The best approach for coping with pain is comfortable, and in control of your sensations: first to try to analyze its peculiar characteris- HYPNOSIS IN PAIN MANAGEMENT 73 tics, differentiating it from other possible out by concentrating exclusively on relaxing the pains; then to decide what might change or body during exhalations in places which are not alleviate it; and finally to experiment with affected by the cramp. This has proven very appropriate imagery, relaxation, diversion, dishelpful for getting rid of cramps without sociation, or physical treatments like heat, changing the position during yoga practice and cold, or massage. for continuing swimming with a cramp. Lymph drainage massage is good for prevention. AllEVIATION OF DIVE RSE PAI N S LOCAL WARMTH . Warm a hand, for instance on It must be remembered that all the following the abdomen or chest, and then put it on the suggestions work with some, but not with othpainful area. Imagine during inhalations iners. Different exercises should be tried, and haling the warmth into the painful area and those which bring relief should be conscienpain streaming out through it and away from it tiously practiced. during exhalations. DULL ACHES. These have been relieved by imagcooLN ESS. Coolness or warmth can be atining during exhalations a hot water bottle tributes of one kind of pain and may be remewhich warms and relaxes , or by treating the dies for another kind. Usually the opposite is aching area with warm water or alcohol, or required for relief. Experiment while rememeven by imagining receiving a painkiller shot bering that coolness, rigidity, and tensions are into it. Thinking of softening the area or feeling enhanced by inhalations, the opposites by exthe pain "evaporate" during exhalations also halations. proved helpful. ANESTHETIC. Imagining strongly having a body SHARP PAIN AND STABBING PAI N . These have been part immersed in ice water or snow, or having partially relieved by imagining that the painful been injected with a numbness-producing anesarea was icy and very rigid, or by imagining thetic, can evoke an effective anesthesia in that it was very soft, like foam rubber, so that dentistry and otherwise. the stabbing met with no resistance. This has not worked for stabbing pains so strong that ARTHRITIC PAI NS AND STIFFNESS. Arthritic pains they halted the breath. can be eased by imagining a warm shower over the shoulders and neck during exhalations, or a BURNING PAIN AND PAINS FROM BURNS. These can warm blanket over the knees. Cupping a be relieved by thinking coolness and soothing painful area with a warm hand increases the lotions being applied during inhalations, and effect. Imagine further that the afflicted area relaxation during exhalations . However, thinkloosens up and becomes soft and warm during ing coolness for burnt soles of feet may make it exhalations. possible for the burn victim to walk, but the Before any movement, imagine moving the tissues will suffer additional damage. Common body parts involved in the movement, be it an sense must always be a guiding factor for arm for reaching or the legs for walking. deciding whether pain reduction is beneficial or Limber up the body in the imagination before not. getting up in the morning. Invigorate the limbs during inhalations while making imagined CRAMPS. These can be handled in at least three movements and relax during exhalations. Only ways: relax as much as possible, tense as much then attempt to move in reality. Move then only as possible, or relax and tense alternately. Time during exhalations, since this avoids unnecesthe tensing with inhalations and the relaxing sary body tensions and increases limberness. with exhalations. A cramp can also be waited Inhale between movements. Hold the breath 74 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS during movements only if the pain is excruciatcially with conditions such as chest and abdoming. Lymph drainage massage is also helpful inal pain, prior to providing hypnotherapy. before getting out of bed. Also, get up from (Ed. ) sitting and climb stairs during the exhalation Start the relaxation at the throat. Exhale a phase. Halt during inhalations. few times slowly and deeply and imagine For bending, as for instance for tying shoemaking the throat wide and open. Relax and laces, bend as far as possible during one long think during exhalations "soft, gentle, wide, exhalation. Wait and relax during several open," and so on, with respect to places inside breathing cycles while the body adjusts to the the throat, chest, and abdomen. Do any or all position it reached. Then stretch a little further of the following exercises according to need. during another long exhalation. By thus bending stepwise, one may extend the reach a great deal. OPENING FLOWER. Feel whether and where there Anticipation of relief is also helpful. If a hot is narrowness or tension in the throat. Imagine bath or a hot whirlpool can ameliorate the pain, a flower bud opening in it, as in a time lapse film. imagine going to the hot water. Imagine the Repeat this during two or three exhalations. Feel anticipation very vividly during exhalations. what happens to that throat region during the Then imagine being in the hot water. next two or three exhalations. Is there a widening? Softening? Moisture flowing? H EADACH ES. Distinguish the features of the headache. It can be in different places and have I NVERTED FUNNEL Imagine an inverted funnel, different qualities. It may be general, frontal, narrow above, wide and open below. Imagine or one-sided, pressing, stabbing, nagging, dull, this funnel starting at the mouth-throat juncor pounding. Next, find body areas which are tion. Feel during exhalations a widening, softtense. Tension headaches can be due to tensions ening, and opening up toward the lower, wide in the head itself or in the neck and shoulders, open end of the funnel. Ascertain the place the spine, the small of the back, or even the down to which the throat or chest opened up. legs. Do appropriate relaxation exercises and Then start the narrow top of the funnel about experiment to see if relaxation of certain body an inch or two above that place, and repeat the areas will reduce the headache. widening, softening, and opening up during For pressure headaches try the following. If exhalations. Imagine that some liquid of pleasthe pain feels like a "board before the foreant temperature and consistency streams down head, " think of the area softening and bethe funnel. Relax in this manner the throat, coming relaxed or warm during exhalations. chest, and abdominal cavity. During inhalations think that the bony walls of the skull expand or that coolness streams into GUIDE ROPE. Imagine the exhalation to be a the head. The thought of opening the head at guide rope along which you can glide, slide, or the crown to "let fresh air in" also allayed or feel your way down into the chest cavity. ameliorated pressure headaches. Experiment Repeat this for about three consecutive exhalawhether this works better for you during exhations. Relax while going down. Continue down lation or inhalation. It differs. Also experiment into the abdominal cavity along the guide rope whether coolness or warmth is better to amelioof the exhalation. rate headaches. ELEVATOR. Imagine riding down an elevator within yourself from the throat into the chest RELI EVING DI SCOMFORT IN T H E during exhalation. Make a stop at the place the CH EST A N D ABDOMI NAL AREA elevator has reached at the end of the exhalation. Allow the inhalation to stream in pas The nonmedical clinician is reminded to alsively. Then descend further during the next ways obtain careful medical evaluation, espe-exhalation. Repeat, starting and stopping as HYPNOSIS IN PAIN MANAGEMENT 75 necessary, and go down through the chest into a. "See yourself standing in front of a the abdomen. full-length mirror. See tiny [colored] lights in different parts of your body. KNOT DISSOLVES. Remember the feeling Of a The colors represent the feelings of those "knot in the stomach," or actually create it by parts. When you can see the total picholding the breath and tensing inside. Then ture, your yes finger will lift to let me gently release the tenseness, or, for that matter, know." tenseness which was there without creating it, b. Scan the body, getting the color of each during successive exhalations by thinking "the light and what that color represents to knot dissolves." If no relief is felt, check if the the patient. The process starts with unjaw or base of the tongue are tense. Such important parts of the body, ending with tension is often related to stomach discomfort. exploration of the organ or extremity Release these tensions . suspected of having problems. For example, with rheumatoid arthritis, in SETTING suN. Internal tensions can be reduced which multiple joints are involved but in the chest as well as in the upper and lower some are more painful than others, one abdominal area by thinking of a setting sun might proceed as follows, selecting the during exhalations. Feel the gentle warmth, the least painful for the first therapeutic red glow, the slow sinking, and allow the "inner approach. Confidence builds with each space" to expand like a horizon, while the body success from least to most painful. walls seem to soften and expand elastically. "Look at the entire image of yourself and let your unconscious mind select the RELAXING THE LOWER ABDOMEN. Repeat first the joint you know to be the least inflamed, widening of the chest and abdominal cavity. the least painful. When you know what Then observe passively where discomfort it is, your yes finger will lift to tell me makes itself known. Give such places a gentle, which joint and what color." but deep finger pressure massage during deep 2. Therapeutic Rejraming exhalations. Wait passively, but attentively, a. "Let your inner mind shift back to a time until the body reacts. The abdomen usually when there was a light that represents "makes known" its reaction by air movements comfort and flexibility. When you are and pressure changes. Wait passively and then there, your yes finger will lift. [Wait for massage again where necessary. the signal.] Now come forward to the first moment that color (light) was put RELI EF OF H EARTBURN. Think "cool" during inhathere in place of the comfortable light. lations and "calm and relaxed" during exhala When your yes finger lifts, please tell me tions, or imagine drinking soothing cool milk how old you are and what is happening." with the thought of coolness during inhalations. b. "Now, is there any good reason why you should continue with pain in that joint?" 3 . Ratifying Therapeutic Gain "Body Lights" Approach to a. "Now that you know what has been Ameliorating Pain and happening, is your inner mind willing to I nflammation (Arth ritis) let you turn off that unconscious pain and continue the process of healing?" [If Ernest L. Rossi, Ph . D . , and the answer is no, it will be necessary to David B . Cheek, M . D . orient to whatever factor is standing in Ma!tbu, Ca!tfornta, and Santa Barbara, Caltfornta the way, as in Step 2.] b . "Go forward now to the time when you 1 . Accessing and Transducing Symptoms into will not only be free of the pain in that "Lights" joint, but will have turned off the pain in 76 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS all the joints that have been troubling SUGG ESTIONS FOR PAI N CONTROL you - a time when you are no longer afraid of pain returning, when you are You are peaceful, calm, relaxing deeper and really well in every respect. When you deeper, deeper and deeper, deeper and deeper. are there, your yes finger will lift and As I talk to you, you continue to go into an you will see a month, day, and year, as even deeper state of relaxation. In the past you though they were written on a blackhave had feelings of anxiety, doubts, fear, board." [This is done as a measure of the panic, and the sense of loss of control arises patient's confidence level.] from flashbacks of reliving aspects of the shingles or from other past experiences which have evoked those kinds of feelings_ All of these feelings and behaviors have interfered with Suggestions with Postherpetic your growth, sense of oneness, and natural Neu ralgia ("Shingles") healing processes and you acknowledging your uniqueness and goodness. If you experience any Diane Roberts Stoler, Ed . D. of those negative feelings as we're talking, either you can allow yourself to choose to look Boxford, Massachusetts at what is causing those feelings at that time when you experience them, or you can imagine I NTRODUCTION putting them into my locked file cabinet in my office. They will remain in the file cabinet in my This script was developed for an 86-year-old office where they will be stored. These feelings man who had a severe case of shingles on his will not surface and cannot be touched unless scalp which continued down to his left eye. He you choose to retrieve them to work on them had been on pain medication for over six yourself or in therapy, to help you learn to live months with no relief and the physician was and enjoy life. You will always know where concerned about addiction and side effects of they are because you have the control and you the drugs. He loved the ocean and was an have chosen to place them there. By knowing ex-auto mechanic. The suggestions were given this, if a flashback occurs, you have a way of following induction and extensive deepening having power to control those feelings and you techniques. no longer need to stuff them inside, but rather have a way of dealing with them to resolve them and help you to have greater control over your SUGG ESTIONS FOR SE LF-HYPNOSIS own life. As you allow yourself to go deeper and [The following suggestions for self-hypnosis deeper, you are realizing, perhaps for the first were given during the induction-deepening protime, that you can allow yourself to take concess.] Each morning upon rising you can permit trol over your body through your mind. You yourself to allow your body to become relaxed can become more relaxed and with this relaxand in balance, then you will permit yourself to ation your body's healing mechanism can functake one long deep breath in through your nose tion appropriately and normally. And as your and out through your mouth while using the body responds in this deeply relaxed way, you thumb and index technique. This will be a are becoming aware that you can permit yoursignal to go into the deepest level of hypnosis self, when needed, to take greater control over whereby you will feel your strength and confiyour body than you ever thought possible. You dence and knowledge that you can control the are acquiring confidence in yourself. You feel a pain from the shingles and have the ability to realization growing within you of the fact that heal the shingles all together. you have the ability to make changes, and these HYPNOSIS IN PAIN MANAGEMENT 77 changes make your body healthier, and you can With your relaxation and concentration, assist your body's normal healing functions which activates your natural healing process, with your relaxation and concentration. you will allow yourself a sense of strength and You can allow yourself to activate the anticonfidence which will fill your body. You have viral mechanism via the Mystery Oil, to attack the ability to cleanse your body and help heal it, and kill all herpes virus, along with activating and with this knowledge comes a sense of calm, your white blood cells to attack and kill all peacefulness and serenity. You permit yourself bacteria on the turtle's back. The warmth of the to enjoy the sounds of the birds and you sun will allow the scabs to heal, and with this become even more relaxed. As you listen to the awareness you can permit yourself to change sounds of the gulls and the sound of the ocean, the various dials on the alt meters to help you you allow yourself a sense of joy and happiness heal and to adjust the level of discomfort which fills your body, and you can allow yourrelated to the pain in the various parts of your self to become even more relaxed. face and head. You can allow yourself to adjust Relaxation will give you that peace of mind these various meters so that you may achieve a and inner tranquility which will enable you to comfortable level and by putting your thumb cope with the tensions and stresses of everyday and index fingers together. This will be a signal living. You will be able to tolerate the persons, to go into a deeply relaxed state, a deeply places or things that used to disturb you and relaxed state. annoy you. You will be there for you in all As long as there are any signs or sensations of circumstances. the pain near your eye, face or head you can No one can bother you here. You have no allow yourself to adjust the various dials to cares or worries. You feel safe, secure, calm, produce a comfortable level for yourself, peaceful and relaxed. There is a sense of peace whereby you will feel pressure and no discomwith the environment around you. This spot is fort. And you will be aware o f the causes and peaceful and serene. You feel calm, peaceful, reason for the discomfort, but you need not feel confident. This spot is a safe, secure spot. No a greater sensation than discomfort unless you one can bother you here. You are peaceful, do injury to that area, whereby you will feel calm, relaxed; you go deeper and deeper, pain. deeper and deeper and as I talk to you. You As you turn the dial on the alt meter you will continue to go into an even deeper state of produce the feeling of pressure and by adrelaxation. Everything but my voice is becomjusting the volume control you can adjust the ing remote now, quite remote; nothing else but level of intensity from sharp, to dull, to total my voice seems important, nothing else is imnumbness. You will be able at all times to portant, nothing else but my voice. adjust and control the level of sensation to obtain the appropriate level for you to maintain comfort, whereby you feel sensation but no pain, pressure but no pain. Suggestions to Reduce Pain As the night settles in and the sun is setting in Following Hemorrhoidectomies the west, your ability to take greater control of your life and the discomfort will increase, day by Ernest W . Werbe l , M . D . day, as you learn to concentrate your mind and San Lws Ob1spo, Cal1forn1a relax more and more. I f there is a psychological and/or physical reason for the pain you have been experiencing, this knowledge will come up I NTRODUCTION through images, thoughts and dreams. With this information, you will be able to share it either The following suggestions were used before with me or the necessary medical doctor. surgery and were reinforced the day following 78 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS surgery. Eight of eleven patients receiving hyp Suggestions for Pain Control nosis reported no pain postsurgically, while three experienced moderate pain. In contrast, Don E. G i bbons, Ph. D. only two of eleven nonhypnotically treated patients reported no pain, four reported mod DI RECT SUGG ESTIONS FOR erate pain, and five reported severe pain. Note ALLEVIATION WITH SIG NAL PAI N Dr. Werbel's use of trance ratification procedures along with the suggestions . It is antici After the trance has been concluded, you will pated that when something like catalepsy, levifind that your pain is almost completely gone. tation, or glove anesthesia is used for There will still be a little discomfort remaining, ratification, that the success rate will be greater. just to serve as a reminder for you to take it (Ed.) easy; and you will still continue to let up as much as you need to for the healing to proceed properly. But the extra pain, which serves no SUGG ESTIONS useful purpose, is going to be completely taken away. And you are going to be greatly relieved You are now in a relaxed state. An individual at how much better you will feel. who is as relaxed as you are does not feel pain as acutely as a person who is tense. In fact, sometimes, he feels no pain at all. [Then one of SUGGESTIONS FOR H EADAC H E S the patient's hands is elevated. It usually remains in that position.] Please open your eyes INTRODUCTION. I have had excellent results and look at your elevated hand and note how with the following suggestions, which use vesperfectly motionless it remains, just as if you tigial remnants of the diving reflex to alleviate were a statue. Now close your eyes again. Your the discomfort of migraine and other stressextremity remains motionless because you relax induced headaches . By slowing the heartbeat so well that your muscles are in equal tone and and decreasing blood pressure by means of this are not pulling against each other. [I then technique, circulatory congestion in the head request the patient to look again at his motionmay be alleviated and the headache symptoms less uplifted hand to convince him thoroughly gradually cease. (Of course, suggestion also that he is in a trance.] You relax wonderfully plays an important - and perhaps the most imwell. You are an excellent subject. Therefore, portant - part in enhancing the effectiveness of there is no need for you to feel pain following this underlying physiological rationale.) [These surgery. I want you to remember that there is suggestions will undoubtedly be most effective no need for you to feel pain. You may feel for patients who are familiar with and enjoy pressure. skin diving. (Ed. )] [Dr. W erbel then demonstrated glove anes The effect of the following suggestions may thesia, after which he continued:] This shows be enhanced by requesting the subject to asthat you need have no pain following surgery. sume a sitting position prior to the induction, Remember you need have no pain following and, as the "diving" suggestions are given, surgery. If you have any pain at all it should be handing him a cloth moistened in cool water to minimal. . . . When you have your first bowel hold against his face as he bends forward movement be relaxed just as you are now and slightly and puts his head down. you need feel no pain. Remember, when you move your bowels following surgery, be relaxed suGGESTIONs. Picture yourself now as a dolas you are now and your bowels may move just phin, swimming lazily along just below the as easily and comfortably as they did prior to surface of the sea. Feel the water above you surgery. gently warming your back; and feel the cooler HYPNOSIS IN PAIN MANAGEMENT 79 water beneath you, as you swim lazily along. that the subject is slowly rising back to the Just let yourself continue to swim slowly along, surface, followed by suggestions that the scene concentrating on the images and the sensations is fading and that the subject is becoming fully which you feel as you continue to listen to my aware of himself as a person once more, still in voice, and soon you will be able to experience trance and still retaining the feelings of relaxeverything I describe to you just as if it were ation, peacefulness, and wellbeing which were actually happening. part of his undersea experience. The trance may You think how refreshing it would be to dive then be terminated in the usual manner, todown, all the way to the bottom. Let yourself gether with suggestions that the subject will begin to dive now, diving easily and gently, all continue to feel peaceful and relaxed, with no the way down to the bottom. Feel the cooler further trace of discomfort. currents against your face as you angle your At the conclusion of the trance session, the body toward the bottom, and feel yourself subject may be instructed to repeat the forebeginning to adjust to the increasing depth and going imagery at the appropriate intervals by the pressure of the water around you as you means of autosuggestion, either to ward off continue to descend. an oncoming headache or to alleviate one Any previous discomfort you may have felt is which has already begun. More responsive fading away now, as you feel the cool, soothing subjects should eventually be able to experience currents rushing by as you sink deeper and similar sensations merely by closing their eyes deeper, and your system continues to slow and silently repeating to themselves the word down in response to the increasing pressure and dive. cold. The water continues to grow even colder now, as you continue to sink, but your body adapts to it easily and comfortably. You con SUGGESTIONS FOR A PAI N F U L tinue to drift down and down, sinking past CONVALESCE NCE seaweed forests and deep coral canyons, sinking all the way down to the bottom, almost I NTRODUCTION A N D I N DICATIONS. The following there. suggestions may be helpful in assisting a subject Now you find yourself drifting slowly along, to get through a particularly stressful period, exploring the bottom of the sea. Just savor the such as a painful convalescence, which is not experience for a few moments and enjoy the unduly exacerbated by underlying personality cool freshness as you swim along. conflicts or by various "secondary gain" fac In just a short while, I'm going to return you tors . . . . These suggestions may also be emto your normal sense of time and place; but ployed, together with directly suggested after you return, this feeling of peace and sleep . . . to assist a seriously or terminally ill wellbeing will remain with you, and all traces patient in coping with intervals of unusually of your previous headache will have vanished. severe discomfort. In the case of terminal ill Even after you have returned to your normal ness, however, such suggestions should usually sense of time and place, you will continue to not be relied on to the extent that they may feel just as good as you do right now. So just deny the patient sufficient time to accept and to continue to let yourself explore this undersea come to terms with the fact of his own imworld for a moment or two, experiencing all the pending death; and other patients who may enjoyment and pleasure that goes with it; and learn to use such techniques by means of autosoon it will be time to return you to the suggestion should be cautioned not to employ environment from which you left. them to avoid having to cope with problems which ought to be dealt with instead of merely coMMENTARY. After a moment or two has being endured, such as the periodic drinking elapsed, suggestions may be given to the effect bouts of an alcoholic spouse. 80 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS TIME DISTORTION SUGGESTIONS. As a result of making your temples colder and colder and what I am telling you now, your awareness o f colder. It feels as though you were holding an the passage of time i s going t o be changed, so ice cube against your temples. It feels just like that the days (or hours) will just seem to be your hand feels when you hold a glass with your flying past, and you are going to be pleasantly favorite drink in it. Do it right now, and feel surprised at how swiftly they have gone. You how it gets colder, and colder, and colder, it will be able to carry out all of your routine gets tingly and numb, and sometimes even activities in the usual manner, for this will have anesthetic so you cannot feel it anymore." no effect on the speed with which you do If the patient loves to take a bath: "You are things; but just as a few minutes can seem like now taking a bath, immersing yourself into this an hour at times, and an hour seem like only a wonderfully warm and soothing water. You few minutes, your perception of the passage of feel cozy and warm and comfortable all over. time is being changed now, so that every minute The only part of your body outside of the that passes is going to seem much, much shorter water is your head. As you turn the hot water than it actually is. faucet on to renew the water and make it even warmer, you notice that your temples are coMMENTARY. As with other techniques, it may getting colder and colder and colder. As you be necessary to repeat the foregoing suggestions feel your body getting hotter, notice your at appropriate intervals (or to teach the subject temples getting colder. A very good and to do so by means of autosuggestion) for them comfortable feeling in your head. It becomes to remain effective for the desired length of clearer, more lucid, and all the congestion time. But is should also be made clear to the disappears. The discomfort gradually drains subject that these suggestions are only intended out with the rest of the water in your tub, and to be effective for a limited period of time. This you can just stay there and enjoy this comfortcan most easily be accomplished by adding the able feeling all over you. following sentence each time the suggestions [Never tell a patient, "You will just have to are administered, whether by the subject himlive with your pain." Subconsciously the patient self or by another: will retain his/her pain because if there is no "These suggestions will be effective only pain, he/she is not alive. ] until , at which time your normal sense of the passage of time will be fully restored. " Suggestions for time condensation may also Suggestions with Migraine be used in conjunction with suggestions for emotional enrichment as a means of counteracting J .A. D. Anderso n , M . A. Basker, and unpleasant or negative affect by directly sugges R. Dalton tion the opposite sensations (Sacerdote, 1 977). London, England I NTRODUCTION Hypnosis for Migraine Using hypnotherapy, Anderson, Basker and Dalton (1 975) obtained complete remission Li l l ia n E. Fredericks, M . D . with 10 of 23 patients (in comparison with only Palm Beach, Flonda three of 24 patients on prochlorperazine). Patients were taught self-hypnosis. They were I dissociate my patients to a cold place (in the provided with a simple explanation of migraine winter to go skiing or walking in the mountains both in and out of hypnosis, including an in the snow, etc.). I suggest that "the icy wind emphasis that migraines result from abnorand snow is touching your forehead, and is mally swollen blood vessels in the scalp. They HYPNOSIS IN PAIN MANAGEMENT 8 1 were also asked to visualize the arteries in the Suggestion for Symptom head and neck. The following suggestions were Su bstitution given. Gary R. E l ki n s, Ph . D . SUGG ESTIONS Temple, Texas Migraine is caused by . . . and always made When you are ready to begin to resolve your worse by tension . . . thus making the arteries problems, it may be possible to let go of the in the head congested and large. I want you to tension and pain. When you are ready, you can visualize the arteries in the head . . . picture have some other symptom to replace the pain. them large and throbbing . . . now, as you The pain can fade and become less and less as relax and become less tense . . . each day . . . you become more aware of another sensation your arteries become smaller . . . smaller and that replaces it. smaller . . . more normal. The arteries stay normal . . . and your head feels comfortable. (p. 51) The Progressive Anesthesia I nd uction-Deepen ing Tech nique Diminution Rather Than Elimination of H eadache D . Co rydon H a m mond, Ph . D . Salt Lake Ctty, Utah I rving I . Secter, D . D . S . , M.A. Southfteld, Mtchtgan I N DICATIONS AN D I NTRODUCTION [In accord with my findings on other compa This method, a modification of Watkins rable patients, I considered that permitting ( 1986) procedure, may be valuable with mediretention of a small amount of the illness, with cal, cancer or burn patients who are experiencinstruction to have it at times when it is least ing considerable pain, as well as in hypnotic disturbing, could be an effective measure of preparation for surgery. It may be more therapy. Accordingly, after this patient apconfidently used when the practitioner has peared to be in a satisfactory trance, I told him facilitated glove anesthesia in the patient previto take a few minutes time and if he so desired ously. In a talented subject, it may be used as he could go into a deeper state of relaxation by the initial induction; in other cases, induction breathing more slowly. I always give the patient and deepening may precede the use of this sufficient time to become as deeply relaxed as method. There are several other options in desired. When I believe this has been accomusing this technique. When a prior induction plished, I give the following suggestions] : has been done and the anesthesia has spread through the entire body except the head, the Every time you are in bed ready to go to sleep, you patient may be given the following suggestions will get the feeling you are getting a headache; as as part of his training: "Would you like to have soon as you experience this feeling, you will breathe a pleasant, surprising experience? In a moslowly, regularly, and deeply, as you are doing now; ment, I'm going to have you awaken from with each slow, regular, deep breath, the feeling that trance, but you will only awaken from the neck you are getting a headache will begin to subside, and then leave you completely. You will then go into a up. Would that be all right? So that in a normal, natural, deep sleep; you will sleep the night moment, as I instruct you to, you will only through, and awaken refreshed at the correct, proper awaken from the neck up, and the rest of your time, feeling very good, sound in body, sound in body will remain asleep in a deep trance. You mind. will only awaken from the neck up." After 82 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS experiencing this for a minute or two, the like feeling has spread all the way up to your patient is instructed to close his/her eyes and elbow, your head can begin to nod again. go into an even deeper state. The technique of [Pause] [Repetition of suggestion may be used having the patient's body remain in trance occasionally as needed.] while the patient awakens may also be used Would it be all right for that comfortable with only one limb that is painful and which numbness to continue to spread? [After affirmay also be made cataleptic. Watkins prefers mative reply] All right. [Lightly stroking from to have each part of the body become rigid as it the elbow to the shoulder] Gradually that is anesthetized, removing only the rigidity after numbness and immobility continues spreading the entire body is numb. upward, at its own pace and speed, through your elbow and into your upper arm. Flowing into your biceps, and your triceps, and then it SUGGESTIONS will flow into your deltoid muscle. So that soon, it begins to feel as if that arm is asleep, Please concentrate on your right hand, and [pause] almost as if the arm is detached someas you do so, a feeling of heaviness will begin to how, [pause] as though it's no longer a part of develop. As you notice that feeling of heaviyou, but just resting motionless, there. When ness, please nod your head. [Pause] Good, and that feeling has spread through the entire arm now as you keep focusing on that hand, and as up to your shoulder, your head can nod again. I stroke it, you will begin to notice a numbness [Again, following pauses, use repetition as developing. [Lightly stroking the one hand, and needed. The anesthesia may then be transferred pausing until a response is given.] Nod your across the shoulders and subsequently down the head when you become aware of the numbness other arm, reinforced with light strokes. Then, starting to develop. [Pause] Urn hmm. And I'd without any further stroking (which could be like you to notice, with a kind of sense of construed as having sexual connotations), the curiosity, how that numbness and anesthesia anesthesia and sense of detachment are moved begin to spread all through your hand, through down through the rest of the body. Throughout the fingers, the palm, the back of the hand, all this procedure, if it is being used as the initial through the entire hand. [Pause] Notice how induction, observe the patient's eyelids and that numbness deepens more and more, and as utilize any heaviness or blinking that is noted. it does so, it's such a pleasant feeling that it Thus eye closure may be facilitated at any time, feels as if it's really too much bother to move or one may wait until the last part of the even a finger. That hand just feeling a kind of procedure when the anesthesia spreads to the heavy, relaxed, immobility, almost as if, it's head and face.] going to sleep. Almost as if, it's beginning to Now feel that comfort, that still, quiet, rest sleep now, almost as though it's no longer a and comfort spreading from your shoulders part of you. And as you're aware of that, your down, [pause] through your chest, [pause] head will nod again. [Pause] through your back. [pause] A still, passive, Now as I stroke your forearm, the numbness comfort, spreading into your stomach, [pause] begins spreading into it too, as though someyour lower back, [pause] your abdomen. thing is flowing into it, bringing this feeling of Bringing a sense of rest, a sense of comfort and numbness, and immobility to your forearm. immobility, and stillness. Resting so quietly, [As this is being said, lightly stroke from the that it's as if parts of your body are beginning back of the hand through the upper forearm to sleep now. two or three times.] And you feel that numb[Progress at the approximate pace the patient ness beginning to spread, do you not? And you required through the earlier parts of their body, can be rather fascinated by that. And when that or ideomotor signals may be requested at difanesthesia and kind of heavy, almost wooden-ferent points in the progression. Use repetition HYPNOSIS I N PAIN MANAGEMENT 83 as required. Facilitate the spread of anesthesia "feeling increasingly detached, almost separate through the trunk, the right leg and foot, and from your body." Further suggestions may then the left leg and foot. Continue using terms finally be given for the anesthesia to flow up the like: "quiet," "still," "motwnless," "immobilineck, across their head, and down through the ty," "woodenlike," "as if it's going to sleep," patient's face.] � 4 HYPNOANESTH ESIA AND PREPARATION FOR SURGERY I NTRODUCTION Role of Presu rgical and I ntraoperative Suggestions LERE ARE A VARIETY of encouraging studies indicating that presurgical hypnotic suggestions and suggestions delivered while the patient is under anesthesia or in the recovery room may reduce postoperative pain and complications and speed recovery (Bonello et al. , 1 960; Bonilla, Quigley & Bowen, 1 96 1 ; Doberneck, McFee, Bonello, Papermaster, & Wangensteen, 196 1 ; Evans & Richardson, 1 988; Goldmann, Shay, & Hebden, 1 987; Kolough, 1 962; Werbel, 1 960). AWARENESS U NDER CH EMICAL ANESTHESIA. Milton H. Erickson ( 1963) made the pioneering observation in 1 932 that anesthetized patients could perceive conversation at some level of awareness, and it was David Cheek ( 1959) who published the first paper on this topic. Since that time there have been numerous case reports of memories of both events and conversation that took place while the patient was under chemical anesthesia (e.g. , Brunn, 1963; Goldmann, Shay, & Hebden, 1 987; Hilgard, Hilgard, & Newman, 196 1 ; Hilgenberg, 1 98 1 ; Kumar, Pandit, & Jackson, 1 978; Levinson, 1 969; Rossi & Cheek, 1 988; Saucier, Walts, & Moreland, 1 983), some of which were confirmed as accurate by individuals who were present during the surgeries. Particularly impressive have been some of the reports about what we may call "fatty" comments where a surgeon made an insulting remark in reference to someone's weight during surgery (Bennett, 1 988; Halfen, 1 986). It is particularly impressive that such comments, unconsciously registered, seem capable of causing continuing psychosomatic problems (Rossi & 85 86 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS Cheek, 1 988) and can be traumatic enough to cause postsurgical complications, depression and vegetative responses (Bennett, 1 988; Goldmann, 1986). A lawsuit has now been settled out of court concerning a "beached whale" comment made by a surgeon around an anesthetized patient, which was recalled several days later by the patient and confirmed by a nurse who was present (Bennett, 1988). Early case reports of awareness under anesthesia quickly led to recommendations to exercise caution about making derogatory remarks or inadvertently verbalizing negative suggestions in the presence of anesthetized patients. Furthermore, some anesthesiologists and surgeons began giving positive suggestions for speedy recovery, free of complications and pain, with positive results (Bonello et al. , 1960; Bonilla et al. , 1 96 1 ; Doberneck et al. , 196 1 ; Evans & Richardson, 1 988; Kolough, 1 964; Werbel, 1960). Wolfe and Millet ( 1 960) reported on 1 ,500 patients where positive suggestions were delivered, and half of the patients required no postoperative pain medication! Hutchings (1961) described positive results from using positive intraoperative suggestions with 200 patients. He believed that children seemed even more responsive than adults, and indicated that 1 40 of the 200 patients required no pain medication after surgery and that 12 of 88 abdominal surgery patients needed no postoperative pain medication. Unfortunately, both studies lack control groups . FAILURE ro REPLICATE STUDIES. Such reports led to some investigations o f memory retrieval that, i n an effort t o obtain experimental rigor, used recall of such things as unrelated nonsense syllables , poetry, music, or common words as their outcome measures. The memory for such information was often assessed a short time following surgery (Brice, Hetherington, & Utting, 1 970; Browne & Catton, 1973; Dubovsky & Trustman, 1976; Eich, Reeves, & Katz, 1 985; Lewis, Jenkinson, & Wilson, 1 973; Loftus, Schooler, Loftus, & Glauber, 1 985; Millar & Watkinson, 1 983; Stolzy, Couture, & Edmonds, 1 986). In general, these studies failed to find that surgical patients could recall what they heard during surgery. These results led reviewers (Dubovsky & Trustman, 1 976) to conclude that surgical personnel need not curtail their operating room talk and that attempts to promote healing through suggestions delivered during surgery were not successful. However, there were some serious methodological flaws in these studies (Bennett, 1 988). For instance, these studies generally used information for recall that was not the least bit meaningful or relevant to the surgical patient. When more meaningful information has been used as a criterion measure, patients tend to recall far more (Bennett, 1 988). Furthermore, as indicated above, some studies tested postsurgical patients relatively soon afterwards, but it has been found that, when there are longer periods (e.g . , several days t o several weeks) between surgery and postsurgical testing, there is greater recall of what occurred or was said during surgery (Adam, 1 979; Bennett, 1 988). Some failure to replicate studies have also used tape HYPNOANESTHESIA AND PREPARATION FOR SURGERY 87 recordings, often of a voice unfamiliar to the patient (e.g. , Abramson, Greenfield, & Heron, 1966; Bennett, Davis, & Giannini, 1 984, 1985; Bonke & Verhage, 1 984; Pearson, 1 961). Prerecorded tapes have generally not produced positive results in enhancing recovery from surgery. Finally, some studies have asked for verbal recall of intraoperative suggestions, but this has been found to be more difficult to obtain. In contrast to verbal recall measures, when behavioral measures are utilized, significant results are generally found, as will be cited shortly. CONSCIOUS RECALL OF SU RGICAL EVENTS. Hypnosis has proven effective in SOme cases in facilitating conscious patient recall of events or comments in surgery that were meaningful to the patient (Bennett et al., 1985; Cheek, 1959, 1 966, 1 98 1 ; Goldmann, Shay, & Hebden, 1 987; Rossi & Cheek, 1 988). For example, in an impressive study, Levinson ( 1 965) staged a "surgical crisis" with ten dental patients under deep (stage 3) ether anesthesia. Four of the ten patients were able to recall the event under hypnosis. Thus, at least part of the time, hypnosis may promote recall of comments made during surgery. In particular, Cheek's (Rossi & Cheek, 1 988) belief that a deeper level of consciousness is tapped through using the method of ideomotor signaling (Hammond & Cheek, 1988) to obtain recognition of disturbing events has received independent experimental validation (Bennett, 1 988; Rath, 1 982). EFFECTS OF SUGGESTIONS UNDER ANESTHESIA. Despite difficulty in recalling information consciously, even with the use of hypnosis, there is compelling evidence that suggestions delivered personally under surgical anesthesia do produce behavioral responses, even though there is conscious amnesia (e.g. , Bennett et al. , 1 984, 1 985; Goldmann, 1 986). This validates that auditory messages are in fact perceived at some level of consciousness under anesthesia, despite the lack of conscious ability to remember. Furthermore, when an anesthetist addresses the patient by name and asks him or her to remember something, it may facilitate responsiveness even further (Bennett, 1 988; Millar & Watkinson, 1983; Stolzy et al. , 1 986). Interestingly, in studies using tapes that also gave posthypnotic type suggestions for a behavioral response to a cue that would be presented later, significant levels of behavioral responses were still obtained (Bennett et al. , 1984, 1 985; Goldmann, Shay, & Hebden, 1 987). The effectiveness of these personalized suggestions validates that messages are perceived, even though taped suggestions usually did not facilitate improved recovery. Barber, Donaldson, Ramras, and Allen ( 1979) have also documented that subjects breathing 200Jo-400Jo concentrations of nitrous oxide had better response to posthypnotic suggestions than control subjects breathing oxygen. Mainord, Rath, and Barnett ( 1 983) and Rath (1 982) found fewer postsurgical complications in subjects receiving positive suggestions under deep surgical anesthesia. In fact, Rath ( 1 982) found that patients receiving suggestions required less pain medication, had lower pain ratings, and were 8 8 HANDBOOK O F HYPNOTIC SUGGESTIONS AND METAPHORS discharged from the hospital sooner, confirming other less rigorous studies (e.g. , Kolough, 1 964). Bensen (1971) reported on results of utilizing positive suggestions in the recovery room immediately following surgery. In 1 00 cases (primarily involving hemorrhoidectomies, dilettage and curettement, tonsillectomies, and some surgeries for removal of growths or tumors), 72% reported little or no postoperative pain, 980Jo experienced normal appetite and thirst, and bleeding was 900Jo controlled. On a related note, it is also fascinating that studies have shown that suggestions delivered to sleeping subjects (Stage 1 REM sleep) may also produce behavioral responses to a cue (Evans, 1 979; Evans, Gustafson, O'Connell, Orne, & Shor 1 966, 1 969; Perry, Evans, O'Connell, Orne, & Orne, 1 978). As is usually the case in studies of suggestions given under surgical anesthesia, subjects were amnestic for the suggestions given during sleep, but the suggestions were nonetheless effective in producing the suggested behavioral responses. HYPNOSIS WITH CHILDREN. Collaborating the positive findings Of Hutchings (1961), cited earlier, it should also be noted that hypnosis has often been successfully used as an adjunct to chemical anesthesia with children (Antich, 1 967; Bensen, 1 97 1 ; Betcher, 1 960; Crasilneck, McCranie, & Jenkins, 1 956; Cullen, 1 958; Daniels, 1 962; Jones, 1 977; Kelsey & Barron, 1 958; Marmer, 1 959; Scott, 1 969; Tucker & Virnelli, 1 985; Wiggins & Brown, 1 968). In fact, in a controlled study of the effects of hypnosis on anxiety and pain in children (ages 5-10) , those receiving hypnotic preparation were found to be significantly less anxious and more cooperative, and they only required one-fifth as much postoperative pain medication as controls (Gaal, Goldsmith, & Needs, 1 980). In summary, the evidence seems unequivocal that presurgical hypnotic suggestions or verbal suggestions made while the patient is under chemical anesthesia (that are meaningful to the patient) will influence physiological, behavioral, and unconscious processes of the patient. H YPNOAN ESTH ESIA It is well documented that hypnosis may actually be used as the sole anesthetic for both minor and maj or surgeries (August, 1 960, 1 96 1 ; Bowen, 1 973; Elliotson, 1 843; Esdaile, 1 846/ 1976; Finer & Nylen, 1 96 1 ; Lait, 1 96 1 ; Marmer, 1 959; Minalyka & Whanger, 1 959; Monteiro & d e Oliveira, 1 958; Rausch, 1 980; Steinberg, 1 965; Tinterow, 1 960). Some of these operations have included mitral commissurotomy, coarctation of the aorta, hysterectomy, thyroidectomy, hemorrhoidectomy, transurethral resection, dilation and curettage, mammaplasty, amputations, cesarean sections, tonsillectomies, and cholecystectomy. It should be noted, however, that the use of hypnoanesthesia as sole anesthetic is seldom necessary except under extenuating circumstances. Also, perhaps only 1 00Jo-200Jo of patients are sufficiently talented hypnotically to accomplish this. HYPNOANESTHESIA AND PREPARATION FOR SURGERY 89 Crasilneck and Hall ( 1 985) cited the following indications for hypnosis in anesthesiology: 1 . In situations where chemical anesthetic agents are contraindicated because of allergic reaction or hypersensitivity. 2. For certain surgical procedures during which it is desirable for the patient to be able to respond to questions or commands and when it is important to observe the patient's state of consciousness during surgery (e.g., stereotactic neurosurgical procedures, therapeutic embolizations of carotid and vertegral arteries, and for monitoring intraoperative spinal cord function). 3. With patients where fear and apprehension of general anesthesia are so significant that they may contribute to anesthetic risks. 4. When organic problems increase the risk of using chemical anesthetics and interfere with diagnostic or surgical treatment. More commonly, hypnosis may be used in combination with chemical anesthesia. There is evidence that when hypnosis is used to augment chemoanesthesia, less general anesthesia is required (Bartlett, 1 966; Crasilneck et al. , 1 956; Fredericks, 1 980; Van Dyke, 1 970). Hypnosis may also be very helpful in combination with local anesthesia (Crasilneck & Hall, 1 985 ; Golan, 1 975; Lewenstein, Iwamoto, & Schwartz, 1 98 1). SUMMARY Hypnosis and positive suggestions may thus be used in the following capacities with surgical patients: 1 . To reduce presurgical fear and apprehension, while simultaneously creating feelings of calm, optimism, motivation and increased cooperation. 2. To create hypnoanesthesia as the sole anesthetic for surgery in the rare instances when this is indicated. 3 . Giving positive suggestions during surgery and in the recovery room to maintain calm, reduce complications, minimize pain (and the need for postoperative medication), facilitate appetite, reduce bleeding, enhance healing and speed recovery. 4. For analgesia or anesthesia to be used in combination with lower levels of chemical anesthetic agents. In this section of the chapter you will have an opportunity to review the finest available suggestions and approaches that are used in the hypnotic presurgical preparation of patients, as well as suggestions to be used during and immediately following surgery. You will also find illustrations of suggestions to promote healing and for hypnoanesthesia. The reader interested in applications of hypnosis with burns and emergencies should also consult Chapter 8 . 90 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS Preparation for Surgery awaken from a peaceful, natural sleep. You will be relaxed and pleased to feel so good, so Li l l ian E. Fred ericks, M . D . happy, and so comfortable. All your physiolog Palm Beach, Florida ical functions will return promptly and you will feel thirsty and hungry, and will look forward to your next meal. I NTRODUCTION After your surgery, you will do all the pre Obviously you have to adapt the basic sugscribed breathing exercises, and you will be a gestions that follow according to each patient good and cooperative patient. You may feel and the type of surgery the patient underwent. some sensations in the operative area which will You obviously will not suggest that the patient tell you that you are healing well. You will have is thirsty and hungry if he/she had a gasa dry and comfortable wound and you will heal trectomy or bowel surgery, etc. Also, please very promptly. Let these sensations be a signal never say to a postoperative patient, "You are to you to let that area go limp and loose, soft finished, " since the patient may take this literand relaxed. You will have time to rest and ally, resulting in considerable anxiety or negarestore; so much time to enjoy all the care you tive effects. are getting. You will enjoy your visitors and the planning for the return to your home. You will be able to eradicate from your mind any pain or T H E PREOPERATIVE VISIT problem you might have had prior to surgery. Just like sailboats going forward only, and [After reading the chart and introducing myenjoy all the things you can do again to make self to the patient] : What do your friends call life more productive, more interesting, and you, Mr./Mrs . . . ? May I call you . . . ? [First more to your liking. You also will be surprised name only] Where would you rather be right and pleased to see how short the hospital stay now? . . . [Patient's favorite place] . . . Would will seem to you. you like me to show you a way to go through tomorrow's surgery and anesthesia with com POSTOPE RATIVE SUGG ESTIONS I N fort and safety? [Pause] T H E RECOVE RY ROOM Just close your eyes and let all your muscles go limp and loose and relaxed, from the top of Your operation has been completed and you your head to the tip of your toes. That is very are doing very well. You are healing and your good. Now let's go to that lovely place of your immune system is working at full speed to choice, and thoroughly enjoy every minute. prevent any infection. You are nicely relaxed While you are there, feeling good and comfortand comfortable, thinking happy and pleasant able and happy, I will explain to you what will thoughts. Your body and mind work together; happen tomorrow, and how I will prepare you your body reacts to the way you think and feel. for a relaxed sleep so the surgeon can perform You can breathe easily and deeply and with the operation to the best of his ability. Pay great comfort. You can cough and clear your attention to my voice only. All other noises are throat any time you want to. You will be thirsty unimportant to you; they are just like backand hungry, and as you swallow, let that be a ground music. [Tell the patient on his/her level signal to your digestive tract to relax and funcof understanding, briefly, what you will do.] tion normally. Your wound will be dry and I will be with you all the time, watch over you comfortable. Your body knows how to do all and make sure that you are comfortable and that, and you will be surprised how easy it will safe. When you are as nicely relaxed as you are be to empty your bladder and move your now, you will need less anesthesia and you will bowels at the appropriate time. Feel good and awaken at the end of the operation as you happy knowing all is well. HYPNOANESTHESIA AND PREPARATION FOR SURGERY 9 1 Suggestions for Anesthesia and your throat as needed and go on breathing Su rgery gently, easily, deeply and comfortably. 8 . You have time now to rest . . . to think of pleasant things like how nice it will be to Bertha P. Rodger, M . D . feel like yourself again . . . Time to enjoy Palm Harbor, Flonda all the T.L.C. of the doctors, nurses and others working with you to help you get better fast. PREOPERATIVE SUGG ESTIONS 9. You will be quite calm, comfortable and cooperative throughout, following all the easy instructions given to help you. 1. From the moment your medication is 10. You can be pleasantly surprised to find it given, until you are back in your room much easier than you anticipated . . . and again, you pay attention only to the voice be very thankful! that speaks directly to you. All other sounds seem pleasantly far away, a lulling, soothing sound . . . like background SUGGESTIONS DURING OPERATION music . . . or the sound of waves gently lapping on the shore. That drowsy, 1. As the patient is placed on the table, blood dreamy, sleepy feeling increases with each pressure is taken, etc. , repeat preoperative sound . . . making you more comfortable. suggestions . 2. Your medication can be the signal to start 2 . Intubation: "I'm going to slip in a soft a pleasant daydream going of some pleasairway while you take a deep breath. " ant activity in a special place where you 3 . Added relaxation: "Make the operative area feel safe, secure and contented. soft, limp and comfortable." 3. The whole operative area remains soft, 4. At closing of incision: loose, limp and comfortable throughout a. The operation is completed . . . your the operation and afterward until comcondition taken care of (relieved). pletely healed. b. You can look forward to getting better 4. You awaken in the recovery room as if fast. from a restful, peaceful sleep, refreshed c. The body is made to heal . . . and can do and pleasantly surprised to find your so quickly, comfortably, completely. operation completed, your condition red. All body functions return rapidly as the lieved, and healing already well under anesthesia wears off. way. e. You awaken smoothly, enjoy a rest pe5 . The sensations you feel are those of healriod, respond to the voice speaking diing, a little pulling that tells you the area is rectly to you. well put together again . . . slight crampf. You breathe easily, deeply, clear your ing . . . a little heaviness or tingling rethroat and go on breathing easily, rhythminds you that healing is already begun mically, naturally. and acts as a signal to let the area become g. You can be glad that little soft tube is soft, loose and comfortable again . . . and there doing work for you so function is to keep it that way. rapidly restored. 6. You can recover quickly, completely, com5 . Intraoperative suggestions for cancer pafortably. tient 7. You can be pleased to find how easily you a. The tumor has been removed. Now the can pass water, move bowels, enjoy meals, immune system goes to work to combreathe deeply. You can cough to clear plete healing. It can take care of any 92 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS remaining cells just as it knows how to SPECIAL N E E DS take care of infection. b. You can look forward to feeling much 1 . You may feel some little discomforts . . . better, to getting better, to enjoying life occasional cramping or pulling, a heaviness fully. in the operative area from time to time. You c. Nothing need disturb you . . . nothing can welcome these as part of the healing need bother you. process and relax in response. d. You can live all the rest of your life, 2. There may be a soft tube in your bladder making the most of it. (nose/mouth etc.) to keep it drained so it can function easily as soon as the tube is removed. You can be glad to know it is POSlOPE RA liVE VE RBALIZA liONS there working for you. It conforms to the contours of the area so you are aware only 1 . You are now in the recovery room. Your of a slight fullness . operation is completed and healing is al3 . You can keep your arm (with the I . V.) still ready well underway, your condition taken so that the fluid you are getting can speed care of, you can get better now. healing. 2. Pay attention only to the voice speaking 4. Whenever dressings need to be changed, directly to you. All other sounds seem very you can keep the area soft, and limp like a far away, soothing and lulling, like distant Raggedy Andy doll so it will remain com TV. fortable. You have time then for a pleasant 3 . You can now recover quickly, completely, daydream that makes it seem like a very comfortably. short time and the time passes rapidly. 4. All body functions return rapidly as the anesthesia wears off. You can look forward to enjoying that good food and finding it so Hypnosis and the Anesthetist satisfying to drink fluids . 5 . The sensations you feel will b e those o f the john B . Co rley, M . D . healing process . . . setting everything right . . . so you need not mind them. They The anesthetist visits the patient preopremind you to keep the area soft, limp and eratively. In a casual but personally conversacomfortable. tional fashion he/she addresses the patient. He 6 . You can breathe deeply and easily and communicates those understandings and attiswallow to clear your throat. This is the tudes that he/ she knows as an experienced signal to your digestive system, "One-wayanesthetist will be of most value in effecting go straight on down. " So it becomes more within the patient that state of wellbeing most and more comfortable. conducive to successful surgery and a favorable 7 . Your body knows how to bring enough postoperative course. This communication is blood to the area to bring the raw materials made slowly, thoughtfully, with pauses of for healing . . . not enough to spill over nor varying length to meet the patient's needs in to interfere with carrying away waste produnderstanding. These pauses are indicated in ucts. the following material by the indicated spacing 8 . Notice with pleasure how soon your body in the words employed. functions all return to normal . . . how I am Dr. Smith . . . . I am going to give you an easily and fully you regain control of your anesthetic tomorrow . . . . I wanted to meet you. I bladder and bowels . . . how much more wanted to check . . . a few simple things . . . mycomfortably you function than you anticiself . . . to make sure . . . everything goes smoothpated. ly . . . tomorrow morning. HYPNOANESTHESIA AND PREPARATION FOR SURGERY 93 The anesthetist then examines the patient exespecially when you feel my hand . . . upon your actly as he/she would under other circumshoulder . . . just like this . . . [demonstrating] . . . stances, continuing the remarks: you will be surprised . . . how very easy it will be . . . to recall how comfortable . . . you are Everything is fine . . . . I suppose everybody . . . is now . . . . And you will be inclined . . . if you will a little apprehensive . . . before an operation . . . . allow yourself . . . to take a deep, deep breath . . . and become most comfortable . . . and very con But you need not be. . . . You are in very good tent . . . to leave everythmg to me . . . . It is pleascondition . . . for an operation . . . and you have an excellent surgeon. . . . You could not be in better ant, isn't It . . . to just lie there and relax . . . with hands . . . and, of course I'll be there too . . . . I your eyes closed . . . feeling warm and comfortpromise I'll look after you . . . very carefully . . . . able . . . and very safe . . . JUSt letting yourself relax? . . . Just be indolent and lazy . . . . I will leave Everything, you will find . . . will go very smoothly . . . . Tonight the nurse will give you a seda-you . . . for a few minutes now . . . . I have to see tive . . . to make sure you will relax . . . and have a another patient. . . . But I will be back . . . very good sleep . . . it always helps, doesn't it . . . to JUSt soon . . . . While I'm gone . . . be comfortable . . . very comfortable . . . and just relax all over. relax . . . and not to worry unnecessarily? . . . Actually . . . it is much easier to relax . . . than most people ever realize . . . . Here . . . let me show you The anesthetist then leaves the room in accord something . . . useful . . . and very pleasant. . . . with his statement to the patient. When he Just close your eyes . . . for a moment . . . take a returns: deep breath . . . and make yourself more comfortable . . . That's very good. . . . Now open your eyes . . . and let me place your hand . . . like I'm back. . . . I'm glad to see . . . you were this . . . [demonstrating] in front of your face . . . . able . . . to relax so well . . . . It is very plea�ant, Is that comfortable? . . . Good . . . now all you isn't it? . . . . I just wanted to remind you . . . that have to do . . . is to choose some spot . . . upon everything is well in hand . . . for tomorrow mornyour hand . . . like that furrow there . . . and delib-ing . . . . You have an excellent doctor. . . . He is erately concentrate . . . on that spot . . . and JUSt let very good . . . as you already know . . . and you're your hand . . . do what it wants to do . . . . That's very fit for the surgery . . . . And don't forget. . . . I very good . . . . Notice how the fingers separate . . . will be there myself . . . to give your anesthetic . . . how light appears between the fmgers . . . how the and to make sure . . . that everything . . . goes fmgers spread . . . spread far apart . . . just hke a smoothly . . . . After the operation . . . you'll be fan . . . . That's very good. . . . See how the hand pleasantly surprised . . . to find how well you'll itself . . . has now begun to move . . . towards your really be . . . . You'll be able to breathe easily . . . . face . . . . Just let it. . . . As the hand comes clos-You will be able to pass your water. . . . You will be er . . . to your face . . . how comfortable . . . you able to be remarkably relaxed . . . and very pleased begin to feel. . . . And actually, when the hand does to find it is all over . . . . Operations today . . . are touch your face . . . several pleasant things will very different . . . from what they used to be . . . happen . . . . Your hand will feel very comfortI'm going to awaken you now . . . . Remember . . . able . . . against your face . . . it will feel . . . as if it when we meet in the operating room . . . and you is stuck . . . with glue . . . very comfortable . . . . recognize my voice . . . and especially . . . when I And your eyes will be so tired . . . you will find it touch you on your shoulder . . . just like this . . . very pleasant . . . as they close . . . and you take a [demonstrating] . . . you will find It very easy . . . deep, deep breath . . . and begin to relax all if you wish . . . to take a deep, deep breath . . . and over. . . . That's very good . . . so pleasant . . . so be very comfortable . . . . I will count to 3 . . . . When comfortable . . . Just for a moment now . . . notice I do . . . you will awake . . . . completely awake and how pleasant it really is . . . when I touch you rested . . . very relaxed . . . . And when the nurse . . . gently . . . on your shoulder . . . like this . . . [dem-tonight . . . brings you your sedative . . . you will onstrating] . Now the gentle pressure . . . of my take it . . . and find it very easy . . . to drift off to hand . . . makes it so very easy . . . to take another sleep . . . and sleep a very restful sleep . . . . I . . . deep, deep breath . . . and begin to let eoperating 2 . . . 3 . . . That's excellent. . . . Good night. . . . room . . . and you recognize my voice . . . and I'll see you in the morning. 94 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS Summary Steps for Preoperative comfort in the surgical area after you Hypnosis to Facil itate H eali ng have regained consciousness?" (If the answer is no, it is time to check on Ernest L. Rossi, Ph . D., and possible resistance; but it may be only David B. Chee k, M . D. that more time and rehearsals are neces Mal1bu, Caflforn 1a, and Santa Barbara, California sary.) b. "Elimination of postoperative pain with 1 . Initial training in anesthesia and wellbeing hypnosis allows the most rapid healing a. Ideodynamic signaling for exercises in to occur because inflammation is minianesthesia and/ or analgesia: mized. Is your inner mind willing to "Your yes finger can lift when you can work on this for the sake of yourself and feel the numbness (coldness, stiffness, the people who love you?" (A no answer etc.)." indicates an unconscious need to suffer b . Ideodynamic exploration and correction or to punish someone else. The source of misconceptions and fears about surmust be found and removed.) gery. c. "Does your inner mind know you can go 2. Accessing and utilizing inner resources home as soon or even sooner than sura. "After surgery of this kind, most pagical patients who have had no preparatients are well and ready to go home in X tion such as you have had?" (This days. Does your inner mind know it can projects your confidence in the patient's facilitate healing so you may do even ability to do well. It strongly suggests better than that?" that the patient will live through the b. "Let your inner mind now select a time surgery and will be going home.) when you've gone on a vacation. Your yes finger will lift when you are leaving; your no finger will lift when you are back in your home again. The injection you receive before surgery will be your E ricksonian Approaches i n ticket to leave on that trip. Your yes Anesthesiology finger can lift when your unconscious knows this. All the sounds of the oper Bertha P. Rodge r, M . D. ating room will translate into back Palm Harbor, Flonda ground noises associated with your trip." c. "Your yes finger can lift when your unconscious knows it can ignore all con E M E RGE NCY ROOM V E RBALIZATIONS versation in the operating room unless I speak to you using your first name. I will You won't mind being comfortable while we keep informed about the operation but I work, will you? You know anything hurts less want you to pay all your attention to the when you can relax even a little bit, or when things you see, the people you are with, you begin to distribute some of your attention and the enjoyable food you eat during elsewhere. [No one can argue with this. The that trip. As you do this, you will be truism initiates positive response, the important using all the normal biological processes "yes-set" of mind.] You know the pleasant for healing your body." sensation of warmth on your skin when you 3 . Ratifying postoperative healing stretch out in the sun in a favorite spot. You a. "Does the inner part of your mind know have time now to think about such things, to let that you can ignore sensations of dis— your mind wander . . . and wonder . . . as you HYPNOANESTHESIA AND PREPARATION FOR SURGERY 95 wander. You don't even have to pay attention tuning out everything else. You may even get so to what I am saying. The deep part of your absorbed in what is going on that it seems as if mind can listen to the voice speaking directly to you are really there, participating in the action. you. All other sounds can deepen that sense of This is called 'dissociation.' It is just a matter of comfort that comes as you relax and rest so degree. So you have the choice of concentrating pleasantly. on the hurting - or turning to something more interesting. The more you do the latter, the less anything bothers you. '' PRE PARATION FOR This falls within the realm of setting the stage HYPNOAN EST H ESIA for increasing collaboration. To go on with demonstrating a point is vastly more effective The following verbalization is a mosaic than remonstrating. It gives a firm basis upon which also illustrates a number of Erickson's which to build: "Tightening muscles seems to teachings. Most ideas are drawn directly from set nerves on edge so that discomfort increases. Seminars on Hypnosis [led by Erickson and Tension always aggravates pain and can even others in the 1 950's, leading to the founding of cause it. Yet as much as 4007o of pain is relieved the American Society of Clinical Hypnosis] or by simple relaxation. You can test this out for other workshop notes. Many have filtered yourself. Double up your fist and hold it very through the lectures of others trained by him. It tightly. Pinch the back of your hand to discover is no longer possible to sort out the sources of how sharp it feels. Now make your hand go as such contributions. Words, phrases, and aplimp and floppy as a Raggedy Ann doll and proaches come spontaneously into use after note how little a pinch bothers it now. '' long steeping in them. It's a little difficult to record on paper the A patient referred for learning hypnogrimace that accompanies the first pinch and anesthesia was somewhat diffident and apprethe smile that goes with the second. Both are hensive about hypnosis. Hence it seemed best to important. With the fact verified that helpful separate trance development from its use, as information is indeed being supplied, it is easier Erickson so characteristically did: "I really to proceed. This time a certain vagueness is cannot hypnotize you. But at some time in the introduced, producing slight confusion. Comfuture when you are ready to learn to go into a munication techniques use multiple levels of trance, I can help you do so. Then you can verbal content, voice variance, and nonverbal learn to use it . . . and go on doing so all the demonstration. All of these reinforce the rest of your life." changes in awareness and provide guidance. It made clear that the patient, not the facili To continue: "Turn your attention to the tator, "does the hypnotizing," retaining conwealth of sensations you can sense in your trol. Appearing to put it off to the nebulous hand . . . and to their changes. Just which part future decreases its threatening aspect. Yet it is the heaviest? Is it in the fingers? In the palm? leaves the matter open for change as readiness Near the wrist? Where does it feel lighter? As if for it comes. it might like to lift? To float upward? Does that The anesthesiologist continues: "Meanwhile, tingly feeling start first in your fingers? Or the there are some very interesting things you can back of your hand? Is there a bubbly feeling learn that will help you. You can forget about along with this? Or does it feel stiff . . . as if it hypnosis until you understand more about it is made of wood . . . feeling only a slight and want to work with it. . . . There are certain vibration . . . if anything? Notice where it feels things you already know about dealing with most comfortable of all . . . where nothing discomfort or pain that you can put to use right bothers it . . . nothing disturbs it. And that now - like the distraction that occurs when you feeling of comfort is so pleasing . . . you wongive your full attention to a TV program, der . . . how long it really needs to take . . . to 96 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS spread even further . . . and deeper . . . and breathe in little spasms . . . deeper . . . through that whole area . . . and even befaster . . . get that blood pressure up highyond . . . for an extra margin . . . and how er. . . . It's so very uncomfortable, isn't it? So well it can remain . . . to keep you entirely why don't you stop halfway? Wouldn't you comfortable. The comfort can stay as long as really rather just let your eyes close? And normal healing is going on. Your body knows snuggle down . . . just listen . . . to the voice how to heal. As you keep yourself comfortthat speaks directly to you . . . to tell you just able . . . all the energy goes to the healing what to expect . . . and how to respond . . . so process. Jt's so good to be able to work so nicely as to keep yourself quite comfortable . . . . " with your body." "You can let the time of the contraction seem Numerous techniques are e ffected including: to go by like a flash . . . so fast you hardly conviction of her ability to develop and retain notice it except for timing it. The time between control; raising her expectation of something contractions can seem like a nice long time. So desirable happening; showing her the creative you have plenty of time to rest, relax and enjoy choices; and focusing on the goodness of her whatever you wish." body. All lead her to an experience of better functioning by her own skills. ALTE RI N G PE RC E PTIONS OF PAI N STRUCTU Rl NG EXPECTATIONS "Erickson pointed out that when a child is hurt, it is in his entirety. Narrowing down the It is essential to pay attention to the patient's area to where the pain is actually felt and expectations. One who expects to feel nothing recognizing that all the rest of the body is free during treatment may be quite upset to feel from pain enables easier management. Now a something, interpreting any sensation as pain. desensitization process can whittle away at it Anticipating this is part of paying adequate further. It is more readily accomplished a bit at attention to detail. It might be explained in this a time, dimming sharpness, turning 'dull misway. "Analgesia is like turning down the rheoery' into a 'wonderful weariness,' even a 'lovely stat, the dimmer, to where sensation is toleralassitude' as that feeling is slowly attenuated. ble, even comfortable. Anesthesia is like turn The 'red hot poker' effect can be cooled ing off the switch. It's possible you might feel a through 'real hot' to 'still too warm,' which is little something. If you were able to feel the like moving away from the hot fireplace until it incision, it would feel like a fingernail drawn becomes 'comfortably warm' or 'pleasantly lightly across the skin-a tickle or a trickle." cool' or even 'numbingly cold'." Demonstrating this so lightly as to tickle makes it clear. SOLI LOQUY O N PAI N SUGG ESTIONS FOR TH E PATI E NT I N "Give your full attention to your pain. Try LABOR not to let your mind wander from it - even for a moment. Find out exactly where it is located, A frightened patient just admitted to labor exactly how it feels. Keep your mind fixed on it room was on the verge of panic, becoming so you won't miss anything significant about unmanageable. Grasping both her hands in the it." [Starting with what the patient is already manner of a handshake, I spoke firmly to her, doing, giving full attention to his pain, the task "If you really have to panic, you ought to do a is made more difficult by the effort it takes to good job of it! Come on . . . I'll help you . . . . keep such intense concentration. A point of no Get your heart beating faster . . . pumping return is soon reached, after which the harder harder . . . much harder . . . and faster . . . one tries, the less he succeeds. Erickson long HYPNOANESTHESIA AND PREPARATION FOR SURGERY 97 ago observed that when he spotted an acquainthan burning your fingers . . . . It cools in the tance walking ahead of him, he could catch up , process enough to be handled comfortably." get in step, then as he slowed his steps, speeded "You tell me you have pain . . . and I know them, turned right or left, the other would go you really do have pain . . . and you know it along with his assumption of leadership quite hurts less when you relax. You know how to out of awareness. Such minute observation hurt. No one has taught you how not to hurt. I fostered his unique communication by indirect can do that. Simple relaxation can deal with as ways which avoid resistance.] much as 400Jo of pain. That's almost half. As [Now mental imagery is introduced.] "There you learn to let the area go as soft, limp and is a building in Boston containing a circular floppy as a Raggedy Ann doll and keep it that room with a bridge across its center. Standing way, you can have the pain or you can halve on the bridge is like being on the inside of a it! " globe, with colored maps of the world on the [Thus the patient is led away from being surrounding walls. Imagine walking into such a steeped in negative thinking and responses with globe with a map of your pain on its walls, alternatives couched in broad enough terms to lighted from outside so you get a really good allow for individual adaptation. He can learn to look at it. The color in the area of pain shows part with pain a little at a time or to trade it for the intensity and concentration as well as the a sensation less disturbing, less restrictive of exact area covered. " [A vivid picture, painted in function. While this re-education is going on, "living color" is easily held, easily changed with he has the option of having or halving the the speed of thought to stir helpful associapain.] tions. It allows a search for meaning or causation without bringing material to consciousness unless the patient is ready to do so. Mental PLAY ON WORDS energy is thus accumulated and directed usefully.] [To a cancer patient whose family was ada "Watch what happens now, as a diluting mant that she not be informed of the diagno-color is put into the one representing pain. It sis .] "You know you have pain . . . and many begins to fade a little, turn paler. Some neutralpainful feelings too. And this pain . . . and the ization seems to be occurring, as if it's being painful thoughts that go with it . . . can so fill suctioned out, washed out further, rendered your mind . . . as to drive out all other more harmless. It looks better. You can see thoughts. You know you have pain . . . and more clearly what was beside it, beneath it, you know that you know it . . . and no one can behind it, around it, within it. You can also see tell you any different. What you do not relationships of timing . . . when it began . . . know . . . is that you also have areas of no when it recurs . . . in relation to what . . . and pain . . . and you can know this no-pain . . . to whom." [Putting the picture into a different and the time of no-pain . . . can get longer and frame allows broader vision, possibly the longer . . . . The area of no-pain can get larger taking of a new road instead of continuing in and larger . . . so you have more and more the same old rut. Yet this is done without no-pain . . . until you are entirely free! " meddling. The patient can find his own mean "You would like so much to say no to all ing when he is ready, encouraged by this underpain. . . . You want your no to be a good standing support.] "You wonder how long its no . . . the rrght no. There are many things you duration really needs to be . . . to fulfill its know . . . and you know others know purpose as an alerting signal . . . that somethem . . . and sometimes they do not want you thing is going on that might need attention . . . to know they know them. So you do not let some care. It's like when a hot potato is tossed them know that you know them . . . to protect to you, you find that tossing it back is better their feelings. There may be one person with 98 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS whom you can share what needs to be Preparation for Su rgery shared . . . without distress to anyone. There are so many things you do know that will help San d ra M. Sylvester, P h . D . you to say the right no . . . and let you become Tucson, Arizona more and more aware of no-pain . . . until you consistently feel no pain ! " I NTRODUCTION The following suggestions may be used in hypnosis with the patient, and may be tape Examples of Preoperative recorded for the patient to use in tape-assisted self-hypnosis for reinforcement of the sugges Suggestions tions. (Ed. ) j oseph Barber, Ph . D . SUGG ESTIONS Los Angeles, California I NTRODUCTION AND I N DUCTION. Hello, this is Dr. 1 . You can enjoy an undisturbed, restful Sandra Sylvester and I am here to help you night's sleep. prepare for your surgery. What I am going to 2. You can awaken in the morning with feeldo at this time is to speak to you a little about ings of calm and the anticipation of being surgery and the healing process and also give well taken care of, and just let everyone else you some instructions that will help you betake complete care of you. come more comfortable and more relaxed as 3 . You can daydream as fully as you would you prepare for your surgery. like, with no need to pay attention to all Now, would you please lie in a position the goings on in the hospital; you can which is very comfortable for you. Take time to ignore the noise and lights, and just be arrange your body, position your pillows, so delighted (if not surprised) that there is that you feel poised and balanced and very really nothing to bother you, and nothing comfortable and at ease. Take a few moments to disturb you. to do this. Adjust your head so that you are 4. During the comfort of anesthetic sleep, you comfortable . . . your back . . . your arms . . . can continue to let the doctors take care of your feet . . . and legs. As we continue, if you you, but know that you can also do anywould like to change your position to become thing you need to do to increase your comeven more comfortable, please feel free to do fort. so. 5 . Upon wakening, you can still let yourself The process of coming into the hospital for daydream, without having to be clearly surgery is a very common and routine proceaware of anything except questions and dure for all of us here at the hospital. But for requests directly made to you. you it may be a once in a lifetime experience. 6. [If appropriate] You can enjoy comfort And so, if I may, I would like to talk with you able, satisfying, deep breaths; free, effortabout what we have learned about the healing less, urination; appropriate control of process so that you can prepare yourself in the bleeding; uneventful healing. best possible way for your surgery. 7. You can be pleased to surprise the nurses And so to begin: As you are lying in this when they don't get to give you medication comfortable position, look up at the ceiling and for pain, and to enjoy noticing that there find a spot which is easy for you to see. Just any are no feelings to bother you or disturb spot on the ceiling will do. Please continue to you. look at that spot while I continue to speak with HYPNOANESTHESIA AND PREPARATION FOR SURGERY 99 you. Already as you are looking at that spot inhale and exhale, your chest goes up and down you may begin to perceive some very subtle in a comfortable, easy rhythm. An interesting changes in your vision. For example, you may thing about your breathing is that you breathe notice that that spot becomes very easy to see. day and night every moment of your life And you may also notice that the periphery of without having to think about it. Your autoyour vision surrounding that spot may begin to nomic nervous system directs and controls your get hazy, so that as you keep that spot in focus, breathing in a comfortable way; in a way that is the rest of your vision moves out of focus. You so much better than you could ever do conmay also notice that your eyes begin to tire and sciously; in a way that occurs without any fatigue . . . and sometimes your eyes will indieffort on your part. Your body, in a sense, cate that by tearing. So you may notice your breathes by itself. As you continue to breathe, eyes watering a bit. You may notice that as your you may notice that each time you exhale, you eyes blink, you sense a feeling of comfort come can relax more and more. Each time you exhale over your body in that brief moment when your you can feel as if you are sinking deeply into the eyes are closed. And as your eyes continue to support of the mattress. Each time you exhale tire, and they continue to blink, you will find you can feel as if you are letting go of more and more and more comfort and pleasure as your more muscle tension. So that each time you eyes are closing. And soon you will notice that breathe out, it is as if you are letting go of it is more comfortable for you to just allow tightness and you feel your muscles becoming your eyes to close. When you notice that it is soft and loose. You may experience this as a more comfortable for you to allow your eyes to comfortable feeling of heaviness, so that each close, let them close, so that you can notice the time you exhale, you feel your body becoming changes which occur when you have turned off soft and loose and heavy. If you notice that your sense of vision. there is any part of your body which is still tense, which is holding on to tension, imagine FOCUSING ATTENTION AND UTILIZING HOSPITAl SOUNDS. as you exhale, that you breathe out through One thing you may notice almost immediately that body part which was holding tension and is how easy it is to hear the words that I speak let your breath melt the tension so that, as you directly to you. It is also easy to hear and breathe out, those muscles too become soft and continue to hear all of the sounds around you. loose and comfortable. Take a few moments to And yet, those sounds which are not important make a tour of your body, taking time to notice to you at this moment can fade into the backif there is any tension anywhere within your ground, and even though they are still there, body. If you notice any tension in your body, they need not disturb you in any way. You can take a few moments of extra care, letting hear pages in the hallway and know that you do yourself breathe out through that part of your not need to listen to them. You may hear body and melt the tension away. talking or sounds from your neighbor, the You may also notice that your heartbeat television set, snatches of conversations. While assumes a regular, even, rhythmical pattern, these go on, notice how pleasant it is to know which is most beneficial for you at this time. that you need not bother to respond to anything You know again that your unconscious mind unless it is directed specifically at you. directs the beating of your heart day and night, every moment of your life whether you con AUTOMATICITY, TRUSTING THE UNCONSCIOUS, AND DEEPsciously think about it or not. It is the circula ENING. You may also notice how easy it is to tion of oxygenated enriched blood throughout begin to tune in to the rhythm of your breathyour body which aids very much in the healing ing, noticing that when you are still, your body process. And so for these few moments, just takes a rhythm of breathing which is most feel the rhythm of your heartbeat. You may beneficial for you at this moment. As you notice somewhere within your body a pulsing, 1 00 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS regular, even rhythm. Sometimes your heartright now is to feel and experience the rhythms beat may be so subtle that perhaps the only way going on within your body - feeling a sense of to feel it is on a cellular level, for every single comfortable stillness, feeling a sense of quiet living cell in your body feels the regular influx deep within you, allowing your unconscious of nutrients with every beat of your heart. This mind to work freely and easily in this process of process also cleanses away all waste products in healing. each and every cell in your body. And, as mentioned earlier, this process goes on auto SUGGESTIONS FOR H EALING AND REFRAMING PAIN matically whether you think about it or not. One of the ways that your body heals itself is by Your blood pressure lowers to a level which is circulating rich oxygenated blood to every best for you right now. Because you are lying single living cell in your body, filling that cell down in a position of relaxation and comfort with nourishment and carrying away waste and you feel a certain sense of stillness, your products and poisons, and filtering them outblood pressure can lower. If you were to get up side of your body. This process is a process that and move around, your blood pressure would you can participate in and facilitate. One of the rise so that you could carry on that activity. So ways that you can facilitate this process is to the important thing about your blood pressure keep in mind that your body is constantly is that it be flexible, rising when you need it to healing itself, sloughing off dead cells , nourrise and lowering when you are not doing ishing that area, and growing new cells all of anything which places a demand on your body. the time. As part of your healing process you will experience many d1fferent kinds of physical UTILIZING INTERNAL DIALOGUE. You may also nosensations. You may feel the sensation of tice that as I continue to speak with you, stretching and shrinking as tissues join together thoughts continue to drift through your mind, and mend themselves. You may experience as if your thoughts are like drops of water in a sensations of warmth as the healing process river. And you know, sometimes those drops of continues, or sensations of pressure as swelling water move very quickly in the form of white begins to subside. It is important to know that, water rapids, bubbling over rocks, moving very as your body heals itself, changes do occur and quickly downstream. Yet, in the very same those changes may be perceived by you. You river, if you walk downstream far enough, you can cooperate with the work of your body by will come to a spot in the river where the water remaining calm, as you are now, continuing to is so deep that it is almost impossible to detect breathe in a rhythmical easy rhythm, letting any movement at all. In fact, perhaps you your breath enrich your blood supply, which in cannot see the water move until you wait and turn will carry nutrients to your cells, allowing watch a leaf detach itself from a branch of a your blood pressure to go to a level which is tree, begin to drift downward toward the surmost beneficial to you now. If you are feeling face of the water, touch the surface of the any sense of discomfort, breathe in and out water, pause for just a moment and then begin through that area so that your warm breath can its journey downstream. Feel the rhythm of soothe those muscles and allow them to feel your thoughts without bothering to pick out soft and warm and relaxed. So let yourself rest any one thought to think about. Just feel the and let your body take its time to heal. gentle drifting rhythm of your thoughts as they Now, leaving you with these thoughts, allow drift through your mind like drops of water. yourself to continue to breathe, relaxing more and more with each breath, fully enjoying that DEPOTENTIATING CONSCIOUSLY TRYING. Know that feeling of deep comfort and peace. Allow the at this moment there is nothing special for you drifting of your thoughts to match the easy to do, there are no demands being placed upon rhythm of your breathing as you inhale and you, no expectations. There is no one to please, exhale. Then, give to your unconscious the task no one to satisfy. The only thing for you to do of directing your healing process with the same HYPNOANESTHESIA AND PREPARATION FOR SURGERY 1 0 1 efficiency that it directs your respiration, diges I'm going to wash the skin [or mucous memtion, and circulation - knowing that your unbrane] off with some cold, wet fluid that will conscious can direct your healing process, wash away most of the feeling . . . right here whether or not you consciously think about it. [rubbing the area briskly and thoroughly with alcohol or any antiseptic] , so that what I do is REALERTING. In a few moments, you will begin not a bit important to you . . . [giving the skin to rouse yourself and reorient yourself to this a few flicks of the fingernail to complete the room. You can begin to do so when, and only anesthesia, washing again with the antiseptic when, you are ready to do so, taking all the and rapidly inserting the needle] . time you need; allowing yourself to retain that feeling of comfort and a sense of wellbeing. As you do begin to move around a bit, you may feel sensations returning to your hands and Switching Off the Senses feet. Be curious as you open your eyes, and notice how bright the colors can appear. You B e rtha P. Rodger, M. D. can feel refreshed as if you have just awakened from a long and restful sleep. Palm Harbor, Flonda I invite you to play this tape as often as you wish so that you can use it to help put yourself 1 . Assume a COMFOR TABLE and BALin the best possible mind-set for your surgery ANCED position. Allow your body STA Y and for the healing process, which for the next STILL and NOTICE how much quieter and few days and weeks will be your full-time j ob . more COMFOR TABLE you become as the Thank you. sense of MOVEMENT, is SHUT OFF. 2 . REST your EYES, on a spot or GAZE into space, NARRO WING the FIELD of VI Temperature Suggestion SION, decreasing DISTRACTION, with Following Chest/ Abdominal less stimulation from OUTSIDE your body, you CENTER it more and more on Surgery INNER REALITIES. You become MORE D. Corydon H a m mond, Ph . D. QUIET. Your body KNO WS HO W when you SET THE STAGE for it and ALLOW Salt Lake C1ty, Utah the quietness to come to you and ALL You will begin to get pleasantly warm now. THROUGH you, very, very pleasantly. We have placed a heat lamp over you, which NOTICE these feelings. They are UNIQUE will rapidly warm your body back to normal to you. temperature, almost as if you were snuggled up 3 . Let you eyes CLOSE and STA Y closed. warmly in bed, or resting comfortably in a You begin to feel a familiar DRO WSY, warm bath. DREAMY, SLEEPY feeling. Yet you are neither asleep nor in the process of going to sleep. You are ALERT to whatever is IM Suggestions for I nsertion of POR T ANT, UNDISTURBED by the unim Needles or Short Procedu res portant. It is a PURPOSEFUL FOCUSING of attention. DISCO VER how infinitely Esther E. Bartlett, M . D. more COMFOR TABLE it is. Qwncy, Massach usetts 4. Pay attention to the WEIGHT of one ARM . . . perhaps your DOMINANT one. [These suggestions may be used as waking SENSE the heaviness of its bones, muscles, suggestions with effectiveness, or with hypnosis soft tissue, blood vessels. NOTE the pleasfor even greater effectiveness.] ant feeling that it is really TOO MUCH 1 02 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS BOTHER to move even to lift a little finger! as you BREA THE IN . . . " UP' . . . and You feel a L O VEL Y LASSITUDE, perhaps return FULL o f VIGOR. even a WONDERFUL WEARINESS! 5. Note that BOTH ARMS are ACTUALL Y HEA VY. Are they EQUALL Y so? Which is heavier? Which is LIGHTER? Perhaps you Rapid I nduction Analgesia LIKE the LIGHTNESS better? Pay attention to ALL the feelings of lightness. RE Joseph Barber, P h . D . MEMBER a time you felt a DELIGHTFUL Los Angeles, Caltfornta lightness . . . of FLOA TING . . . like a PEA THER on a gentle breeze . . . a LEAF on the water . . . a BIRD on the wind, I NTRODUCTION AND I N DICATIONS soaring EFFOR TLESSL Y. 6 . While you rest and relax so comfortably, [Elicitation o f cooperation] I'd like to talk NO FEELING need DISTURB you. You with you for a moment to see if you'd like to can RECOGNIZE any feeling but need not feel more comfortable and relaxed than you pay A TTENTION to it . . . nor REA CT to might expect. Would you like to feel more it UNLESS it is REALL Y important to do comfortable than you do right now? so. You can do whatever is NEEDFUL in I'm quite sure that it will seem to you that I response without being bothered by any have really done nothing, that nothing has feeling, physical or emotional. happened at all. You may feel a bit more 7. NO SOUND need DISTURB you. There is relaxed, in a moment, but I doubt that you'll no interference with hearing. You need not notice any other changes . I'd like you to notice, REACT to it UNLESS it is important. though, if you're surprised by anything else you Many can sleep through a thunderstorm but might notice. OK, then . . . the really best way awaken to the cry of a tiny baby. ANY to begin feeling more comfortable is to just SOUND can be the SIGNAL to go more begin by sitting as comfortably as you can right deeply into the STA TE OF COMFOR T. now . . . go ahead and adjust yourself to the 8 . NOTICE that your BREA THING becomes most comfortable position you like [Initiation more CALM, DEEP AND EAS Y. Your of deep relaxation] . . . that's fine. Now I'd like HEAR T beat becomes CALM, STRONG, you to notice how much more comfortable you , and REGULAR . Measurements would can feel by j ust taking one very big, satisfying show your BLOOD PRESSURE coming deep breath. Go ahead . . . big, deep, satis TO WARD NORMAL where it STABIfying breath . . . that's fine. You may already LIZES, responding appropriately to changnotice how good that feels . . . how warm your ing needs. A pleasant feeling of WARMTH neck and shoulders can feel. . . . Now, pervades your entire being . . . as if your then . . . I'd like you to take four more very personal THERMOSTA T is turned to exdeep, very comfortable breaths . . . and, as you actly the right temperature . COMFOR T exhale, notice . . . just notice how comfortable FLO WS through your whole being. You your shoulders can become . . . and notice how feel CALM . . . CONTENTED . . . SAFE comfortable your eyes can feel when they . . . SECURE. These feelings STA Y with close . . . and when they close, just let them you even when you return to another state stay closed [Eye closure] . . . that's right, just of ALER TNESS. notice that . . . and notice, too, how when you 9. As a way of REORIENTING yourself exhale, you can just feel that relaxation beginquickly and pleasantly . . . WHEN you are ning to sink in . . . . Good, that's fine . . . now, READY . . . you can say to yourself as you as you continue breathing, comfortably and BREA THE OUT . . . " WAKE' . . . and deeply and rhythmically, all I'd like you to do is HYPNOANESTHESIA AND PREPARATION FOR SURGERY 1 03 to picture in your mind . . . just imagine a ning, perhaps, to really, really enjoy your restaircase, any kind you like . . . with 20 steps, laxation and comfort . . . SIX . . . six steps and you at the top . . . . Now, you don't need to down the staircase . . . perhaps beginning to see all 20 steps at once, you can see any or all of notice that the sounds which were distracting the staircase, any way you like . . . that's become less so . . . that all the sounds you can fine . . . . Just notice yourself, at the top of the hear become a part of your experience o f staircase, and the step you're on, and any others comfort and relaxation . . . anything you can you like . . . however you see it is fine . . . . notice becomes a part of your experience of Now, in a moment, but not yet, I'm going to comfort and relaxation . . . SEVEN . . . seven begin to count, out loud, from one to 20, steps down the staircase . . . that's fine . . . and . . . as you may already have guessed . . . perhaps noticing the heavy, restful, comfortas I count each number I'd like you to take a ably relaxing feeling spreading down into your step down that staircase . . . see yourself stepshoulders, into your arms . . . [confusingly, ping down, feel yourself stepping down, one permissively eliciting arm heaviness] . I wonder step for each number I count . . . and all you if you notice one arm feeling heavier than the need to do is notice, just notice, how much other . . . perhaps your left arm feels a bit more comfortable and relaxed you can feel at heavier than your right . . . perhaps your right each step, as you go down the staircase . . . one arm feels heavier than your left . . . I don't step for each number that I count . . . the know, perhaps they both feel equally, comfortlarger the number, the farther down the stairably heavy . . . . It really doesn't matter . . . case . . . the farther down the staircase, the just letting yourself become more and more more comfortable you can feel . . . one step for aware of that comfortable heaviness . . . or is it each number . . . all right, you can begin to get a feeling of lightness? . . . I really don't know, ready . . . now, I'm going to begin . . . . [saying and it really doesn't matter . . . EIGHT . . . each number with the initiation of subject's eight steps down the staircase . . . perhaps noexhalation, watching for any signs of relaxation ticing that, even as you relax, your heart seems and commenting on them] ONE . . . one step to beat much faster and harder than you might down the staircase . . . TWO . . . two steps expect, perhaps noticing the tingling in your down the staircase . . . that's fine . . . fingers . . . perhaps wondering about the flut THREE tering of your heavy eyelids . . . [Each number, . . . three steps down the staircase . . . and maybe you already notice how much more each suggestion of heaviness enunciated as relaxed you can feel. . . . I wonder if there are though the hypnotist, too, is becoming inplaces in your body that feel more relaxed than tensely relaxed] NINE . . . nine steps down the others . . . perhaps your shoulders feel more staircase, breathing comfortably, slowly, and relaxed than your neck . . . perhaps your legs deeply . . . restful, noticing that heaviness refeel more relaxed than your arms. . . . I don't ally beginning to sink in, as you continue to know, and it really doesn't matter . . . all that notice the pleasant, restful, comfortable relaxmatters is that you feel comfortable . . . that's ation just spread through your body . . . all. . . . FOUR . . . four steps down the stair TEN . . . ten steps down the staircase . . . case, perhaps feeling already places in your halfway to the bottom of the staircase, wonbody beginning to relax . . . . I wonder if the dering perhaps what might be happening, perdeep relaxing, restful heaviness in your forehaps wondering if anything at all is happening head is already beginning to spread and [Integration of sighing with enunciation is helpflow . . . down, across your eyes, down across ful . . . watch for responsiveness] . . . and yet, your face, into your mouth and jaw . . . down knowing that it really doesn't matter, feeling so through your neck, deep, restful, heavy . . . pleasantly restful, just continuing to notice the FIVE . . . five steps down the staircase . . . a growing, spreading, comfortable relaxquarter of the way down, and already begin-ation . . . ELEVEN . . . eleven steps down the 1 04 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS staircase . . . noticing maybe that as you feel deeper relaxed . . . heavy . . . comfortable . . . increasingly heavy, more and more comfortrestful . . . relaxed . . . nothing really to do, no able, there's nothing to bother you, nothing to one to please, no one to satisfy . . . just to disturb you, as you become deeper and deeper notice how very comfortable and heavy you can relaxed . . . TWEL VE . . . twelve steps down feel, and continue to feel as you continue to the staircase . . . . I wonder if you notice how breathe, slowly and comfortably . . . restfuleasily you can hear the sound of my voice . . . ly . . . NINETEEN . . . nineteen steps down how easily you can understand the words I say the staircase . . . almost to the bottom of the [Suggestion to pay attention] . . . with nothing staircase . . . nothing to bother, nothing to to bother, nothing to disturb . . . THIRdisturb you as you continue to feel more and TEEN . . . thirteen steps down the staircase, more comfortable, more and more relaxed, feeling more and more the real enjoyment of more and more rested . . . more and more this relaxation and comfort . . . FOURcomfortable . . . just noticing . . . and TEEN . . . fourteen steps down the stairnow . . . TWENTY . . . bottom of the staircase . . . noticing perhaps the sinking, restful case . . . deeply, deeply relaxed . . . deeper pleasantness as your body seems to just sink with every breath you take . . . as I talk to you down, deeper and deeper into the chair, with for a moment about something you already nothing to bother, nothing to disturb . . . as know a lot about . . . remembering and forgetthough the chair holds you, comfortably and ting [Amnesia suggestions] . . . you know a lot warmly . . . FIFTEEN . . . fifteen steps down about it, because we all do a lot of it . . . every the staircase . . . three-quarters of the way moment, of every day you remember . . . and down the staircase . . . deeper and deeper rethen you forget, so you can remember somelaxed, absolutely nothing at all to do . . . but thing else . . . you can't remember everything, just enjoy yourself [More and more directly all at once, so you just let some memories move suggesting enjoyment of the experience . . . quietly back in your mind . . . I wonder, for more taking for granted the fact of the relaxinstance, if you remember what you had for ation] . . . SIXTEEN . . . sixteen steps down lunch yesterday . . . I would guess that, with the staircase . . . wondering perhaps what to not too much effort, you can remember what experience at the bottom of the staircase . . . you had for lunch yesterday . . . and yet . . . I and yet knowing how much more ready you wonder if you remember what you had for already feel to become deeper and deeper relunch a month ago today . . . I would guess the laxed . . . more and more comfortable, with effort is really too great to dig up that memory, nothing to bother, nothing to disturb . . . SEVthough of course it is there . . . somewhere, ENTEEN . . . seventeen steps down the stairdeep in the back of your mind . . . no need to case . . . closer and closer to the bottom, perremember, so you don't . . . and I wonder if haps feeling your heart beating harder and you 'll be pleased to notice that the things we harder, perhaps feeling the heaviness in your talk about today, with your eyes closed, are arms and legs become even more clearly comthings which you'll remember tomorrow, or the fortable . . . knowing that nothing really matnext day . . . or next week . . . I wonder if ters except your enjoyment of your experience you'll decide to let the memory of these things of comfortable relaxation, with nothing to rest quietly in the back of your mind . . . or if bother, nothing to disturb [ 18-20 said more you'll remember gradually, a bit at a time . . . slowly, as though in increasing anticipation of or perhaps all at once, to be again resting in the being at the bottom] . . . EIGHTEEN . . . back of your mind . . . perhaps you'll be sureighteen steps down the staircase . . . almost to prised to notice that the reception room is the the bottom, with nothing to bother, nothing to place for memory to surface . . . perhaps disturb, as you continue to go deeper and not . . . perhaps you'll notice that it is more HYPNOANESTHESIA AND PREPARATION FOR SURGERY 1 05 comfortable to remember on another day altoate . . . whenever [doctor's name] touches your gether . . . it really doesn't matter . . . doesn't right shoulder, like this . . . or whenever I matter at all . . . whatever you do, however touch your right shoulder, like this . . . you'll you choose to remember . . . is just fine . . . experience a feeling . . . a feeling of being absolutely natural . . . doesn't matter at all . . . ready to do something [Posthypnotic suggeswhether you remember tomorrow or the next tion for a variety of behaviors, but with purday, whether you remember all at once, or pose of developing a trance . . . and with imgradually . . . completely or only partially . . . plication for analgesia] . . . whenever I touch whether you let the memory rest quietly and your right shoulder, like this . . . or whenever comfortably in the back of your mind . . . [doctor's name] touches your right shoulder, really doesn't matter at all . . . and, too, I like this . . . you'll experience a feeling . . . a wonder if you'll notice that you'll feel surprised feeling of being ready to do something . . . that your visit here today is so much more perhaps a feeling of being ready to close your pleasant and comfortable than you might have eyes . . . perhaps a feeling of being ready to be expected [Analgesia suggestions] . . . I wonder even more comfortable . . . perhaps ready to if you'll notice that surprise . . . that there are know even more clearly that there's nothing to no other feelings . . . perhaps you'll feel cubother, nothing to disturb . . . perhaps ready rious about that surprise . . . surprise, curiosito become heavy and tired. . . . I don't ty . . . I wonder if you'll be pleased to notice know . . . but whenever I touch your right that today . . . and any day . . . whenever you shoulder, like this . . . you'll experience a feelfeel your head resting back against the headrest ing . . . a feeling of being ready to do some- [Direct posthypnotic suggestion for analgething . . . it really doesn't matter . . . perhaps sia] . . . when you feel your head resting back just a feeling of being ready to be even more like this . . . you'll feel reminded of how very surprised . . . it doesn't really matter . . . comfortable you are feeling right now . . . even nothing really matters but your experience of more comfortable than you feel even now . . . comfort and relaxation . . . absolutely deep comfortable, relaxed . . . nothing to bother, comfort and relaxation . . . with nothing to nothing to disturb . . . I wonder if you'll be bother and nothing to disturb . . . that's reminded of this comfort, too, and relaxation, fine . . . . And now, as you continue to enjoy by just noticing the brightness of the light up your comfortable relaxation, I'd like you to above . . . perhaps this comfort and relaxation notice how very nice it feels to be this way . . . will come flooding back, quickly and automatto really enjoy your own experience, to really ically, whenever you find yourself beginning to enjoy the feelings your body can give you . . . sit down in the dental chair . . . I don't know [Preparation for end to this comfortable expeexactly how it will seem . . . I only know, as rience] and in a moment, but not yet . . . not perhaps you also know . . . that your experiuntil you're ready . . . but in a moment, I'm ence will seem surprisingly more pleasant, surgoing to count from one to 20 . . . and as you prisingly more comfortable, surprisingly more know, I'd like you to feel yourself going back restful than you might expect . . . with nothing up the steps . . . one step for each number . . . to bother, nothing to disturb . . . whatever you you'll have all the time you need . . . after all, are able to notice . . . everything can be a part time is relative . . . feel yourself slowly and of being absolutely comfortable [Every sensacomfortably going back up the steps, one step tion creates the analgesic experience (nothing for each number I count . . . more alert as you detracts from it)] . . . and I want to remind you go back up the steps, one step for each number that whenever [doctor's name] touches your I count . . . when I reach three, your eyes will right shoulder, like this . . . whenever it is be almost ready to open . . . when I reach two, appropriate, and only when it is appropri-they will have opened . . . and, when I reach 1 06 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS one, you'll be alert, awake, refreshed . . . per-feel the cold, your yes finger will life haps as though you'd had a nice nap . . . alert, unconsciously. Tell me when you are refreshed, comfortable . . . and even though feeling cold from your knees down." you'll still be very comfortable and relaxed, b. "When you are in cold water, you soon you'll be alert and feeling very well . . . perhaps get used to it. It is no longer cold. surprised, but feeling very well . . . perhaps You are about half as sensitive as you ready to be surprised . . . no hurry, you'll have usually are. If you stubbed a toe or all the time you need, as you begin to go back bumped your shin, you would feel a up these restful steps. [Numbers on inhalabump but there would be no pain. Your tion . . . lilting, arousing intonations . . . more no finger will lift to let you know when quickly at first . . . watch for responsiveness] you are half as sensitive as you were at TWENTY . . . NINETEEN . . . EIGHfirst. " TEEN . . . that's right, feel yourself going c. "Now walk i n until you feel the cold back up the steps . . . ready to be surprised, water up to your ribs. When you feel knowing what you had for lunch yesterday, and cold from your ribs to your knees, your yet . . . SEVENTEEN . . . SIXTEEN . . . yes finger will lift. When you are numb FIFTEEN . . . a quarter of the way back up, from your ribs down to your toes, your more and more alert . . . no rush, plenty of no finger will lift." time . . . feel yourself becoming more and d. "Now press your left thumb and index more alert [If no apparent arousal, slow down, finger together. This associates instant inject more suggestion for arousal] . . . FOURcoolness and numbness, and you will be TEEN . . . THIR TEEN . . . TWEL VE . . . able to do this with increasing speed ELEVEN . . . TEN . . . halfway back up the every time you repeat this exercise." stairs . . . more and more alert . . . comforte. "Now loosen your pressure on the left able but more and more alert . . . NINE . . . hand, and press the index finger and that's right, feel yourself becoming more and thumb on your right hand to bring back, more alert . . . EIGHT . . . SEVEN . . . instantly, all the feelings that have been SIX . . . FIVE [After 5 , increasingly slowcool and numb." ly . . . repeat suggestions for arousal and posf. "Practice this at home until you know itive experience] . . . FOUR . . . THREE . . . you can reproduce these sensation that's right . . . TWO . . . and ONE . . . changes any time you wish. " That's right, wide awake, alert, relaxed, re2. Therapeutic facilitation freshed . . . that's fine. How do you feel? Rea. Have patient repeat exercise until conlaxed? Comfortable? fidence is assured. b. Explain that making labor more like the work of sawing wood than like a long arduous experience will allow the baby Surgical and Obstetrical to be born feeling welcome and free of Analgesia guilt. c. "By turning off unconscious, painful stimuli, you will heal without inflamma Ernest L. Ross i , Ph . D. , a n d tion and will be able to go home David B . Chee k, M . D . sooner." Malibu, Californ ia, and Santa Barbara, California 3 . Ratifying and extending new ability "Learning this skill will not only make your 1 . Accessing unconscious control of analgesia immediate task easier, but also will aid you a. "Walk into an imaginary, cold lake until in meeting unrelated tasks with confidence the water reaches your knees. When you in the future." HYPNOANESTHESIA AND PREPARATION FOR SURGERY 1 07 Techniques for Surgery are relaxed, and, with every breath you take, you will find yourself going deeper and deeper Wi l l iam S. Kroger, M . D . relaxed. You are doing just fine. Just relax all Palm Spnngs, Ca/tforn ta the muscles of your abdomen and chest. You are breathing slower, deeper, and more regular. RE H EARSAL TEC H N I C FOR S U RG E RY That's right. In and out . . . in and out. Going [During a typical rehearsal session for abdeeper and deeper relaxed. You feel nothing dominal surgery the patient is told:] Now your except a little pressure. The more relaxed you skin is being sterilized." [At this time the abare, the less tension you have, the less discomdomen is swabbed with an alcohol sponge.] I fort you will have. [Frequently there is a slight am now stretching the skin and making the trembling of the eyelids . This often is indicative incision in the skin. [The line of incision is of deep hypnosis. One can use this objective lightly stroked with a pencil. ] Now the tissues sign to deepen the hypnosis, as follows: ] I are being cut. Just relax. You feel nothing, notice that your lids are now trembling. That's absolutely nothing. Your breathing is getting a good sign. And, as they continue to tremble, slower, deeper and more regular. Each side of you will go deeper and deeper relaxed. You will the incision is being separated by an instrufeel yourself falling, falling, deeper and deeper ment. [The skin and the muscles are being relaxed with every breath you take. Remember, pulled laterally from the midline.] Now a blood if you want to open your eyes at any time, you vessel is being clamped. [A hemostat is clicked may. Voices won't bother you. shut.] You will feel absolutely no discomfort. [Production of catalepsy by light stroking of You are calm, quiet and relaxed. Your breaththe skin frequently minimizes capillary bleeding is getting slower, deeper, and more regular. ing, probably as the result of vasospasm. Here Just relax! Now I am going deeper and entering the law of dominant effect is put to use: a the abdominal cavity." [For the peritoneum, psychological suggestion is enhanced by a physsuggestions of relaxation and assurances of iological effect. As the region that is going to be complete pain relief are repeated several times.] operated on is stroked light, I remark:] This Just relax. You are getting deeper and deeper area is getting very stiff, cold and numb. Think, relaxed: your heartbeat is getting slower and feel and imagine that there is an ice cube on more regular. Just relax. You feel nothing, your skin. Now it is getting more numb and absolutely nothing. [The viscera are relatively colder. Numb and cold. Very, very cold. [This insensitive to cutting. One does not have to verbalization and the stroking are most advanworry about pain. However, the patient has to tageous where bleeding from the skin is exbe prepared for the discomfort produced by pected. If the hypnosis fails during surgery, one pulling and torsion of the abdominal organs.] can easily switch to intravenous or inhalation [The steps for closure of the peritoneum, anesthesia. It is always advisable to have these muscles, fascia and skin are also described in a available for prompt use.] similar manner. There are really only three times when pain can be expected: when the skin is incised, when the peritoneum is incised, and POSTOP E RATIVE VE RBALIZATION FOR when one is tugging on the viscera.] DE HYPNOTIZATION MAI NTENANCE OF [Patients are dehypnotized as follows:] You HYPNOAN ESTH ESIA DURING will feel just as if you have awakened from a deep sleep, but, of course, you were not asleep. SU RG E RY You will be very, very relaxed. Any time in the [The following is a verbalization for mainfuture when I touch you on the right shoulder, taining hypnosis:] All the muscles in your body if I have your permission, you will close your 1 08 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS eyes and let your eyeballs roll up into the back not hesitate to eat the food given to you, and as of your head. Then you will count backward a matter of fact, you will relish every bite. You from 1 00 to zero slowly, and you will go deeper will be very, very hungry. The more nutritious and deeper relaxed with every breath you take food you are able to consume, the faster your and every number you count. You will find that tissues will heal. I am going to count to five and the period after your operation will be a very you will open your eyes. [Dehypnotization pleasant one. Should you have any discomfort should be done slowly:] You will feel comin and around the wound, you may use the pletely alert, refreshed, and wonderful after glove anesthesia which you learned to develop you open your eyes. One, you are feeling fine. to "knock it out." You will be able to relax and Two, more alert. Three, still more alert. Four, sleep soundly. Should you require medication sound in mind, sound in body, no headache. for sleep, it will make you very sleepy. You will Five, open your eyes. You feel wonderful. � 5 EGOSTRENGTH ENING: ENHANCING ESTEEM , SELFEFFICACY, AND CONFIDENCE INTRODUCTION T.m CONCEPT OF "egostrengthening" was popularized by John Hartland (1971). His egostrengthening approach, reprinted later in this chapter, simply consisted of generalized supportive suggestions. Their purpose was to increase the patient's confidence and belief in him or herself, enhance general coping abilities, and minimize anxiety and worrying. It was his common practice to give egostrengthening suggestions as part of almost every induction, seeking to reinforce selfreliance and a positive selfimage. Although not a practitioner of hypnosis, Bandura ( 1 977) and others (e.g., Marlatt & Gordon, 1 985) have emphasized the concept of selfefficacy: the expectation and confidence of being able to cope successfully with various situations. This has come to be a key concept in the emerging field of relapse prevention. Individuals with high selfefficacy perceive themselves as being in control. In the helping professions we have a relatively limited number of interventions available to us for increasing self-esteem and selfefficacy. We may give patients positive feedback and compliment them, but they often discount such comments. Cognitive therapists of various persuasions have provided us with some methods for helping patients examine assumptions and irrational thinking patterns that undermine esteem. Traditional insightoriented approaches to therapy examine the historic roots of one's selfimage, and can be effective but sometimes rather time-consuming. Behaviorists (Bandura, 1 98 1 ) emphasize that selfefficacy is increased by engineering success experiences for patients, but this is often quite difficult to accomplish. Roleplaying and mental rehearsal techniques which may also 1 09 1 10 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS enhance coping abilities, have more recently been emphasized by behaviorists (Marlatt & Gordon, 1 985) as methods for increasing selfefficacy expectations for specific situations. Hypnotic techniques offer the clinician an abundance of other options for enhancing self-esteem and selfefficacy: rapid unconscious exploration and working through of the roots of selfimage problems; obtaining unconscious commitments from the patient (as modeled by Barnett's approach); direct suggestions and indirect suggestions and metaphors; positively-focused age regression to successful and happy life experiences; age progression and mental rehearsal; hypnotic conditioning techniques (e.g. , the clenched fist technique); symbolic imagery techniques; methods for altering imprinted ideas (as modeled in one of T.X. Barber's contributions); the use of trance ratification procedures to convince the patient of the power of his own mind and inner potentials; the use of personalized self-hypnosis tapes to provide regular reinforcement of suggestions; learning selfhypnotic self-management skills for coping with anxiety, anger or other emotions; hypnotic reinforcement of cognitive (e.g. , rationalemotive) therapy concepts; and hypnotic reinforcement and facilitation through posthypnotic suggestions of positive internal dialogue and selftalk. The enhancement of feelings of esteem and selfefficacy has been found to be a powerful tool in working with a great diversity of patients and problems: depression, low self-esteem, overemotionality, substance abuse, posttraumatic stress disorder and victimization; patients with developmental deficits, anxiety and phobic disorders, grief reactions, coping with chronic illness; athletes, business executives, students, children, and patients with eating and habit disorders. In this chapter you will find a tremendous diversity of options for increasing esteem and efficacy. EgoStrengthening gery is performed. At times his condition strengthens to the point that an infection is Mos he S . Torem, M . D. cured due to the strengthening of the patient's Akron, Oh10 immune system. At times just the mere teaching of self-hypnosis for relaxation and calmness and the use of egostrengthening techniques I NTRODUCTION may be enough so that a patient's symptoms spontaneously disappear. John Hartland pointed out that only a few In my opinion, egostrengthening is a techpatients will let go of their symptoms before nique that is indicated for all patients who come they feel confident and strong enough to do to us looking for an alleviation of their sufwithout them. Hartland's egostrengthening fering regardless of what their symptoms are. techniques are comprised of positive sugges It is like saying that healthy and good nutritions of self-worth and personal effectiveness. I tion is helpful to all patients regardless of what view egostrengthening as analogous to the their diagnosis or illness is. After I teach the medical setting in which a patient is first patient self-hypnosis, I then intror\uce egostrengthened by proper nutrition, general rest, strengthening suggestions. Later, I ask the paand weight gain before a radical form of surtient to repeat after me specific statements of EGOSTRENGTHENING· ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 1 1 egostrengthening. The following is a verbatim memories of the past, you know that you don't example of suggestions given, following induchave to be the memories themselves . That's tion, to a patient recovering from depression. right. You can be free of the past and live better in the present, more adaptively, coping more effectively with the tasks of daily liv SUGG ESTIONS ing . . . knowing that every day, in every way, you are continumg to get better and better, to With each breath as you exhale, this calmness see things more clearly, knowing that you are becomes stronger and stronger, spreading all the moving forward. Becommg stronger, wiser, way from your head down to your toes, from top improving your understanding of life and the to bottom, inside out and outside in, Immersing purpose of living in your special role in your you in an ocean of calmness. An ocean of calmfamily and society. ness . . . that's right. And as that continues, You continue to strive for accomplishments, peace and serenity are takmg you over, inside but at the same time, strike a very special and outside, thus putting your mind and body in balance between your career, life, and your sync with each other. Creating a special state of family life. You strike a very special balance internal harmony, and peace, and serenity. between time and energy you spend in accom That's right. That's right. As you continue to sit plishing your goals, and the time and energy here and listen to me, there is this center core you spend in protecting and improving your within your unconscious mind that's logical and relationships with other people. In doing that, rational, cool and collected, calm and relaxed, you learn to accept yourself as you are, respect clever and wise . . . the one that wants you to your thinking, your feelings, your emotions, heal and recover and get well as a whole person. and develop a sense of pride and self-worth. That's right, very intelligent and very knowl You become more authentic and develop edgeable. In fact, it knows so much that your greater courage to assertively express your conscious mind doesn't even know how much it needs in an adaptive way, as you relate to other doesn't know. people in the workplace and in the family. You This center core within your unconscious develop a new sense of balance and moderation mind has always been there with you, since the between leading a life of structure and committime you were a little child. It has helped you ment, and a life of playfulness and spontaneity. survive difficult predicaments in the past, and As you continue to move forward, you learn to will continue to help you in the future. People accept yourself with grace and ease, viewing refer to this center core in your unconscious as yourself in a positive light, developing greater the inner guide or the internal adviser. Some confidence, your talents, your gifts, your skills, refer to it as the higher self, and others as the and your attitudes and abilities. guardian angel. But regardless of the name of You have the capacity to visualize yourself in what it is or how you call it, it has this very the future, living up to your dreams with a special function of guiding you from within, to sense of joy and accomplishment. Now, all of continue to find your own way for selfthe things I have smd, you do not have to fully actualization, your own way to learn the remember if you don't want to, or you don't difference between the past and the present. need to remember them, but your unconscious This will allow you to remember what you need mind and the center core will continue to guide to remember about the past and what hapyou like an internal coach, even when you are pened to you. And once you do remember, in asleep at night. This will continue every mofact, you have been an ingenious survivor, ment of the hour, every hour of the day and rather than a victim of unfortunate circumnight . . . every day and night of the week . . . stances. That's right, and now you can let go of every week of the month . . . every month of these memories. And know that you have the year, every year for the rest of your life. 1 1 2 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS And as you continue to move forward, you The key to your success is confidence . . . begin to realize that life is a journey, and that confidence in yourself . . . confidence in your the goal of living is not traveling to a specific ability to do . . . whatever you truly want to destination, but the journey itself becomes your do . . . confidence that you can and will acdestination, and the quality, grace, and form in complish your goals through the power of your which your travel on this j ourney we call life, is own mind . . . the power of your own in itself the goal of living, and in doing so you thoughts. What you tell yourself has the are writing the book of your own journey. greatest of power over your life . . . . What you Now take a deep, deep breath again. Let the tell yourself determines whether you feel cheerair out slowly, that's right, and I want you to ful, or gloomy and worried . . . and the way know that you have the capacity to use this you feel, whether you feel joyous, or sad and specific technique for self-hypnosis on your worried, determines, to a great extent, the own, anytime you want to. In doing so, you will health and wellbeing of your physical body. reinforce again and again this specific tech When you are bothered and unhappy, your nique, boosting your ego and your whole self, body simply cannot function properly. What as a whole person. And now I will slowly count you tell yourself has an enormous impact on together with you from three to one, and when your life . . . . What you tell yourself ultimately we get to one, your eyes open and they come determines what you are and are not able to do. back to focus. You will be fully alert, awake, Now, tell yourself that your life is just startand oriented, knowing exactly where you are ing, and that from this day on you will begin to and what you need. You will know what you live fully, moment by moment, and really apwant to do after the session to function preciate and enjoy being alive each moment. adaptively in the tasks of your daily living, Tell yourself that you will no longer worry knowing that you have the capacity to do this unnecessarily, either about things that hapagain on your own as you come out of this pened in the past or about what might happen exercise of hypnosis. in the future, unless there is something con[The patient is then realerted. This technique structive you can do to change them . . . beis followed by a brief discussion of the patient's cause the past and the future exist only in our experience and what it was like. This will allow thoughts . . . life exists only in each moment. If him to ask questions or clarify certain issues.] you spend your moments worrying about the past or the future, these moments, which are your life, pass you by. So, let yourself become deeply involved in each moment . . . deeply involved in everything that is happening around An Example of Positive you . . . less conscious of yourself-and more Suggestions for WellBeing at peace with yourself and with the world. Tell yourself that with each passing day, you will Sheryl C . W i l son, Ph . D. , a n d feel happier, more content, more joyous, more Theodore X. Barber, Ph . D. cheerful, because you choose to feel this way by controlling your thinking. And because you feel Frammgham, Massach usetts, and this way, life will be more fun . . . . you will Ashland, Massach usetts enjoy each day . . . . and you will become more and more healthy, as your body functions easily [The illustrative suggestions, as presented in a tension free environment. below, are an example of the kinds of positive Day by day, let yourself feel more alive, more suggestions that we have used in conjunction energetic, and at the same time, less tense, less with many other suggestions in the treatment of nervous, less worried or anxious. Tell yourself smoking and obesity.] that your mind and body are relaxed, calm, and EGOSTRENGTHENING· ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 1 3 you are at peace with the universe. And because always somewhere in the sessions, we give some you are calm and at ease, you will have greater of these kinds of suggestions. We make a tape energy and your mind will be clearer, and for each client which includes these suggestions, sharper, and more focused. Consequently, you tailoring the tape to fit that person's needs. It will be able to see problems in perspective and should be clear that these are by no means the handle them easily, efficiently, effectively, and only kind of suggestions that we use in our confidently, without becoming bothered or therapeutic endeavors. We use a wide variety of tired out. suggestions and a wide variety of procedures Above all, stop telling yourself that you can't and techniques. do something which you want very much to do [such as stopping smoking or losing weight] . As long as you tell yourself you can't do it, you POSITIVE SUGGESTIONS FOR can't. Instead, tell yourself that even if it is E FF ECTIVE LIVING d1fficult, you will be able to do it. When you tell yourself that you can and will, you have [We begin by asking the client to sit quietly, taken the first step towards accomplishing what close the eyes, and begin to relax. Then we go you want to accomplish. And you will find that on somewhat as follows.] you can and will accomplish your goal. These Let yourself begin to relax and feel calm, things that you will now be telling yourself will with peace of mind. Just feel yourself at ease, begin to affect your life more and more. They tranquil, at peace, relaxed. Take a deep breath, will affect the way you feel about yourself, and just take a deep breath, and as you let out the the way you feel about your life, and consebreath, feel all the tensions leaving, you feel at quently will affect every aspect of your life. peace, calm, and at ease. All bothers, worries, anxieties, just fading away, just gone far away. There's lots of time, feel your mind at peace, calm, at peace, relaxed and at ease - that your Positive Suggestions for mind becomes calm, your mind and body are at Effective Living ease, peaceful and relaxed. Become more and more ready to retain those ideas that I will give T. X. Ba rber, Ph . D. you, as you will let them go deep in the back of your mind, and you will use them as you wish Ashland, Massach usetts throughout your life. Every day, beginning now, you'll feel this way, calm, and at peace, INTRODUCTION while you're interacting, while you're working, while you're doing, you'll still feel peaceful, I'm going to present positive suggestions for calm and at ease. Be able to enjoy life now, effective living that we use with a wide variety with peace of mind, at peace with the universe, of clients. These suggestions are especially a feeling of peace and tranquility. And a feeling made to emphasize that life can be a little of it's so good to be alive, with peace of mind. different, that people can live more effectively; At peace with everyone around you, relaxed they can enjoy more, they can see things in a and calm and at ease, and enjoying every better way, they can feel better about themmoment of living. Starting now, a feeling of selves. We have found these kind of general underlying happiness, and peace of mind can be suggestions to be useful with a wide variety of with you, can be with everyone in the universe, individuals. We use them when we're trying to because we make it ourself, as we let our mind help someone stop smoking, when we're trying be calm, and relaxed. As we become more to help someone lose weight, when we're trying calm, and relaxed, you feel a kind of underlying to help somebody who's depressed. Almost energy also . The relaxation and calmness fits in 1 14 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS with energy, vitality, being fully alive, at all over the years will no longer be stale for you, as times and in all situations. More and more, you become aware again that we can be the way starting today, you'll feel more and more calm, we were once, looking at each thing as miracuat ease, and at peace, feeling so good to be lous, as beautiful, as wonderful as the first time alive. So good to be vibrant, energetic, vital, we ever saw them, when we were children. healthy, and strong, alive and vibrant, able to As if we're here now, again, for the first time. flow with everything around you, every day, As if we're here from another planet. We've just and to enjoy every day, more and more, to landed and we see the wonders of the earth, and enjoy every aspect of every day, as you feel we see the people on the earth, and we see their peaceful, and calm, and at ease, with energy, hair, and their face, and their nose, and their with vitality, feeling the strength and energy in skin, and the wonders of their being and their your being, feeling the flowing and vibrations mind. And we see each person as if we've never and energetic flow of your life. seen this person before. We see them fresh and new, and we see all the wonderful aspects of their being. And we look again at every cloud S E E I NG AND APPRECIATING T H E and we feel every breeze. And we begin to feel WORLD AN EW the air around us, and we become more aware of the oxygen we breathe, and we become more With peace of mind, calm, and at ease, being aware of the colors and the details of the able to look out at every part of the universe, at flowers and the trees, and the people, and the every person around you, at every flower and buildings, and the grass, and the books, and tree and plant, grass and children, and in a new everything that surrounds us, every day, every way, as you begin, starting now, to see the person, every child, every adult, every person, world in a new way, with a freshness, and every animal, every plant - we see it anew. wonder, and awe of a little child. You begin Experiencing each moment in a new way, now to see the world again as you once did starting now, as if a fog has been lifted, as if when you were an unspoiled child, and you can everything is becoming sparkling clean, as if regain that capacity again, to see and appreciate we've come from another planet and we look everything freshly, and naively, in a simple way around, and we see, and we feel, and we as you can begin once again to see things anew, experience in a new way, starting now, and fresh, wonderful, clean. Now you can begin to every day. And this feeling will grow more and look at every sunrise as if it's the first sunrise more as time goes on - you will be able to feel you've ever seen, and every sunset, and you will more and more at ease and calm and peaceful see the colors, and the wonder, and the beauty with vibrant energy, enjoying every aspect of surrounding you again, as if it's the first time your being, feeling strong, healthy, with peace you've ever seen it. of mind, calm mind, body at ease, and yet very Starting now, every bird that you see will be vibrant and energetic, looking at everything in a as if you've never seen a bird before, as if you're new way, as if you've been here now, just a a new child, and you're beginning again to look short time. You're beginning to experience the with wonder and amazement at the world world again, fresh, clean, sparkling new, new around you. You see every bird in a new way, perceptions, aware of everything around you and every tree, and the leaves on the tree, and freshly, once again. And this will grow every the seeds on the tree, and the bark on the tree, day. and the green leaves and the sun shining, and With this new way of looking at life, you'll the grass around you, you'll be able to see it in find every day that your energy will increase a new way, fresh, with wonder and awe. As you and you'll feel so healthy, and you feel healthy, gain the capacity to appreciate everything as and free, you'll feel all the tensions will leave. you once did. Everything that's become stale You'll feel at ease and calm, and free as you EGOSTRENGTHENING· ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 1 5 become more aware of the blood circulating in remember how to play and to have fun, by your your body, and the strength in your muscles, own creativity and imagination, using your own and the wonders of your strong, healthy being. ingenuity, able to regain your lost spontaneity, You begin to feel that you're living, you're your naturalness, your freshness - it will come beginning to live more and more, growing every out and you will feel at ease with it. day, becoming more aware, more filled with energy, more vibrant. Starting today, you'll begin to feel that life is just beginning, that C REATING HAPPI N ESS T H ROUGH your potential for living a very good life is CHANGING YOU R T H I N KI N G there, and it will increase and you'll become more aware of the potential, and you'll become Starting now, more and more, you will reaware of how you can enjoy life more and more alize that happiness, and unhappiness, are due every day. And you'll look forward to every to your own thoughts, the way you think about coming day as another exciting day that you situations. You will be able to shift your can live fully, growing, changing, maturing, thoughts, the way you think about situations. healthy, strong, vibrant, and energetic. You You will be able to shift your thoughts to the will realize that you have the potential to be positive aspects, and look at the positive aspects happy, strong and much greater than you of living, enjoy every day. You will become thought. That you have vibrant energy, that more and more aware that if life's situations are you're able to flow with everything around you, not the way you always want them, you will to be able to flow and move with every person, work to change them, without frustration, every individual you meet. You'll be able to feel without anger, without being bothered. You with them, be able to feel with every animal, will work to change things that are not the way and every plant, and every part of the earth. you want them, but you will do it with a calm, From this day on, you'll begin to live fully, peaceful mind, being at ease and at peace with moment by moment, every day. You'll get so the universe. much out of every day, more and more, starting You will become more and more aware that now, every day, every hour, every second, will everyone has problems in living, but you will become more and more exciting, full, enthralalso be aware that as you become more mature, ling, amazing. You'll become more and more that you can face problems with a calm mind, aware of the wonders of your being, yourself, with strength and determination, to work to the earth, and everything around you. You'll improve them. When you cannot change become more and more deeply involved in things, you will accept them calmly, you will be everything that is happening around you, the aware that anger and frustration do not help. people you meet, the tasks you meet, and the You'll realize that life is too precious and too children that you see, and everything that wonderful to waste it in being bothered over comes into your life. You'll be aware, and little things, little annoyances. Starting today, become more and more involved, like a child, you will work to change anything that is living fully, enjoying every moment, being changeable that you can change with peace of unself-conscious, feeling free. You'll be able to mind, without being bothered, without frustramake more and more activities, and something tion, without anger. You will be less and less like an enjoyable game, that you can play, and worried about the future, problems of the dance, and move, and enjoy. And your activifuture, dangers of the future which will never ties will be the way they were when you were a occur anyway. Most of the things you worry child, free and unspoiled, at ease, enjoying, about won't happen anyway. You'll let the able to get into things, more and more, as you worries go, you'll enjoy the day, you'll let were once able to be creative, ingenious, able to yourself go, you'll enjoy yourself, as worries make everything mto a fun game. You'll again drop out of your life. 1 1 6 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS LIVING WITH EMPATHY, RESPECT, desires to be kind, to be good, to do things for AN D HARMONY others also. You'll feel with other individuals. You'll become more and more empathic as time goes on. And day by day, you'll find yourself more You'll be able to help others, to help others to and more successful in living at peace with the feel good, to help others enjoy life. And as you universe, with yourself, with everything around help others enjoy life, you'll be able to enjoy it you, with no unnecessary worries . As each day yourself, more and more as time goes on. passes, you will feel more and more at peace, more and more lively, feeling alive, enjoying each moment, living now, today, enjoying G E N E RAL SUGG ESTIONS FOR every day more and more as you let these WELL-B E I N G thoughts go to the back of your mind. They will be more and more this way, as you let them And each day, as you wake u p i n the mornguide your life. You'll become increasingly able ing, you'll have an inner feeling of excitement, to meet the responsibilities of your life, and will a feeling of energy and underlying joy, eager to be able to determine for yourself what the truly get up from bed and to get going. You feel so necessary activities are in life. good, refreshed, awake, relaxed, with energy, With ever increasing frequency, you'll bean inner feeling of joy, and wellbeing, when come more and more deeply interested and you wake up in the morning. And throughout aware of other people, seeing that other people the day, a feeling of joy of living, of vibrant have problems, and you will be aware of their energy, and as you wake up in the morning it problems, able to help them, as you become less will be so good to begin to plan for the new day and less concerned about yourself, and more ahead. You'll feel refreshed, strong and concerned about others, more and more aware healthy, as you'll have slept calmly and at of the beauty of other individuals around you. peace, knowing that each day as life goes on, As each day passes, you'll find yourself more you will enjoy it more and more as you mature aware of and concerned with the feelings of and become more and more aware of every others. You'll be deeply interested in the people beauty, and every mystery and amazing thing around you, more and more forgetting yourthat surrounds you, as you become more and self, not concerned especially about yourself, more aware of the amazing nature of the uninot self-conscious, giving others your undiverse and life. vided attention, really interested in them, their life, what they think and say, feeling good, and relaxed, and happy, and natural. SUGGESTIONS FOR SLE E P You'll realize that everyone around you is more or less insecure, and doesn't feel perfectly And each night when you go to bed, you'll be secure with others. And you'll realize more and at ease and relaxed, you'll feel relaxed and calm more that others want you to like them, they knowing that every day is another adventure. want to feel that they matter, that they're Even though some days will have problems and important. And once you realize this, it bethings we don't like, every day will be an comes more and more a part of your being, to adventure. Starting now, as you go to bed every be able to help others to feel good about night, you'll be calm, and at ease, your mind themselves. You'll realize more and more that and your body will be calm, tranquil and they're struggling to be happy, to love, to feel relaxed. You'll be able to sleep calmly, at peace, good about themselves, and you'll be able to able to sleep the way you did when you were a empathize and feel with other individuals, to baby - so calm, so relaxed, so completely at feel with their feelings and insecurity, with their peace. You'll sleep so well. You'll be able to EGOSTRENGTHENING· ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 17 sleep soundly, knowing in the back of your potentials for living beautifully that are there mind, that day by day you're beginning to live all the time, you'll be able to have more and more fully, more deeply. As time goes on, you more calm, peace of mind, awareness, and a will live with more and more wisdom, and feeling of strength and health and energy, that you'll let yourself sleep the way a baby does, will grow as the days pass. Your mind will be at when a baby feels good and very secure. You'll peace and calm. You'll feel strong and healthy, sleep very well, and very calm, and when you and very vibrant and alive, and that feeling will wake up in the morning, you'll be fully rested, pervade your being. You'll become more aware very refreshed and at peace. of it, but it will be there, at the back of your mind, starting now, every day. SUGGESTIONS ABOUT WORK Every day will be as if it's the first day in your You'll be at ease with your life and everything life. You'll be able, more and more, to feel as if around you. You will be so glad and so happy it's so wonderful, as you see things again in a to have another day to live and enjoy, every fresh new way, experiencing everything in a day. And when you're at work, you'll be able to fresh new way - the way you may have experifocus on a task, and become absorbed and enced it when you were a child, as you begin to involved in the task at hand. You'll be able to look at the grass and the flowers, and the trees also become absorbed and involved with the and the birds. You become aware of their people around you. When you work, you'll be delicate textures. You become aware of the able to work well, and efficiently, able to details of their being. You become aware of the concentrate, able to enjoy your work and able breeze every time it touches you. You become to enjoy the task. aware of everything you do with your hands, and the strength of your hands, and the won E N HANCI NG PRESENT AWARE N ESS derful manipulative ability of your hands, and the wonderful abilities of your body. You be And able to enjoy everything you do -the come more and more aware of so many things people around you, the food as you eat modthat you've taken for granted, and you begin to erately and with peace of mind. Able to enjoy see them in a new way, no longer stale, no the water you drink, with peace of mind, calm longer something that you're used to, no longer and at ease, enjoying every aspect of the beausomething that you just don't even notice tiful, wonderful earth. You'll be able to enjoy fresh as if you've just come to this earth. everything you see and touch, and you'll be Starting anew. come more aware of touch and the beauties of And you begin to meet the challenges of life touching. You'll become more and more aware every day with a calm mind, a calm, peaceful of the fragrances and the aromas, and everymind. So good to be alive, and with this thing around you. And you become more aware calmness, and feeling the strength of your of all the beauties of your senses, as you see, being, the vitality and health flowing through and hear, and touch, and smell, and feel. And your being, you'll be able to change those things you become more and more aware of people that can be changed every day. But those things around you. You become more and more aware that can't be changed, you will accept with of their amazing nature, of the depths of their calmness and peace of mind, knowing that life being, of their strivings and hardships and can be so beautiful, no matter what problems problems. you may face. You'll become more and more absorbed in RE I N FORCEMENT OF EARL I E R your work, in the people around you, con SUGGESTIONS sumed very much about the wonders of being And as you become more and more aware able to think, and feel, and talk, and plan, and that your life is only beginning, and of the imagine, and in the wonders of your mind and 1 1 8 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS your being, and being able to use them in your difficulties [misfortunes, illnesses, rejecwork and with people around you. Loving tions, deaths of loved ones] . every individual and every creature that you • You have helped many people in your see, and being more and more aware of nature. life. Living more and more fully, more and more • You did well in a very difficult situation. deeply, every day, starting now. And as you let • You really care about people. these thoughts enter the back of your mind, • You have much empathy and love for you'll feel, starting now, more and more at others that you have not been able to peace, calm, and at ease, with peace of mind. express. Vibrant, strong, and energetic body, and peace • You are a kind person. of mind. You begin to feel more and more at • You have so much that you haven't ease and calm and alive, and you see everything begun to use - so much more love, so in a fresh, new way, new, beautiful. Your life much more competence, so much more will become more and more wonderful and ability to be at ease, to enjoy life, to live exciting. You'll be able to fulfill the many, fully. many potentials that you have starting now, so In addition to interspersing these kinds of let these thoughts now go to the back of your statements in our discussions, I also include mind. Let them guide your life as you wish. Let them as suggestions in the hypnosuggesthem guide your life, starting now, as you wish. tive procedures; for example, after the Let them go to the back of your mind, and client has been given repeated suggestions now, as you wish, you can become more and of deep relaxation, he or she may be given a more alert to everything around you, more and series of suggestions on various topics, more ready to begin to live with vibrant energy, interspersed with suggestions that "Starting and with peace of mind, as you become now now, you can begin to focus more on your more alert and ready to open your eyes, beginstrengths and positive aspects . . . you can ning now to open your eyes. become more aware of your ability to overcome obstacles . . . your caring and love for people . . . your growing ability to be at ease and to enjoy life," and so on. 2. A second hypnosuggestive approach that Suggestions for Raising aims to enhance self-esteem derives from Self-Esteem the fact that clients with low self-regard have typically been criticized by parents or T. X. Barber, P h . D . other significant individuals in their early lives, and they have incorporated the criti Ashland, Massachusetts cisms into their selfimages. In the therapy sessions, we trace back the destructive crit1 . First, I look for and emphasize all of the icisms the clients have received from parmanifest and latent positive characteristics ents, siblings, or other important people that I can observe about the client. I am "You're dumb, stupid, ugly, clumsy, rotten, always able to find many such attributes, no good," etc.). After we have uncovered and I sincerely tell the client about them at some or many of the origins of the low intervals in our discussion, using statements self-esteem, I proceed as follows in a such as the following: hypnosuggestive session. I first give to the • You have done so much [or worked so client (and indirectly to myself) suggestions hard or struggled so much] in your life. for deep relaxation and then, when the • You have been able to overcome so many client and I are both relaxed with eyes EGOSTRENGTHENING: ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 19 closed, I speak to the client from my "inner themselves relax deeply, and to let the ideas self" - for instance, somewhat as follows: "go deep into your mind." Although these tapes are individualized for each client, they We understand now why you have felt you typically emphasize positive aspects of the were unattractive, unintelligent, and not likclient that have been neglected or supable. It is clear now that your mother had a pressed and that can be released and tremendous amount of resentment and anger expanded. Examples of the kinds of suggesand was unable to love you or anyone else tions that are included in the hypnobecause of her own father, who degraded her suggestive tapes are as follows: and made her feel totally unlikable and worthless. It's clear that you were too young to understand why your mother constantly put You have much caring and concern and love you down and screamed at you and made you for others that you hold down and keep withm feel there was something wrong with you. You you . . . You can begin now to let out these good can now see how your negative feelings about feelings . . . allowing the kind, caring, good yourself were due to negative suggestions you feelings to flow out to others . . . You can begin received constantly from your mother, who was more and more to be your true self as you release negative about everything and everyone because your warmth and empathy toward others. of her own misery. Now you can begin breaking Starting now, you can be more and more through the negative suggestions you have reaware of your true self that is being released, ceived, you can begin coming out of the negaand you can stop criticizing yourself . . . You tive hypnosis you have been in for so many can stop blaming yourself for what you did that years, and you can begin to be your true self you should not have done or what you did not that has been held down for so long. You can do that you should have done, and you can see more and more clearly that as long as you forgive yourself as you forgive others . . . You were negatively hypnotized and believed you can be as kind to yourself as you are to others were stupid, ugly, and no good, you reacted to . . . as loving to yourself as you are to others events and people around you in a . . . You can stop criticizing and blaming yournonconf1dent, afraid way, which tended to conself, and you can be free - free, more and more, firm your own beliefs. You can now begin to let to be your true self. go of these negative suggestions and begin to be Starting now, you can more and more allow your own true self, realizing more and more yourself to be the person you can be . . . apeach day that you are a good, kind, loving, and preciating again and grateful again to be able to lovable person. Each day you can become less see, to hear, to smell, to touch, to be alive . . . and less afraid, more and more at ease, more Appreciating again as if it's your first day on and more able to enjoy life and to be your true earth, as if you've never felt the sun before, self. [emphasis added] never heard a bird sing, never smelled a flower before . . . Grateful to be able to touch the rain 3. As part of the hypnosuggestive approach to and a stone, to hear the laughter of children and raising self-esteem, I make additional casthe sound of the sea, to smell the grass and sette tapes for the clients. These tapes, appreciate tasty food, to see the colors of the which are made when the client and I are in earth and the stars . . . Appreciating again the my office, begin with suggestions for deep strength and power in your body . . . Feeling relaxation, followed by specific suggestions the energy and health vibrating and flowing through your being . . . Feeling again the exthat aim directly or indirectly to enhance citement and enthusiasm and the feeling of self-esteem by guiding the clients to focus aliveness that has been suppressed for so on their underlying strengths, virtues, and long . . . more and more ready to enjoy, to positive qualities. The clients are asked to have fun, to play and laugh and sing . . . More listen to the cassette tape at home once a and more feeling good to be you and to be alive. day during the forthcoming week, to let [emphasis added] 1 20 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS Barnett's Yes-Set Method of When the patient answers ')'es, " ask: "Is EgoStrengthening there any part of your inner mind that does not entirely agree with me?" [This is a double check for a hidden ego state or part of the personality Edgar A. Barnett, M . B . , B . S . that is still negative. If such a part exists, Kingston, On tario, Canada undiscovered, it may sabotage the egostrengthening suggestions.] I N DICATIONS STEP THREE. Help the patient to accept his/her feelings, and establish a yes-set. Then, let go of old, negative feelings. This method of egostrengthening is recom "I know that all human beings have uncommended following the use of other methods to fortable feelings as well as comfortable feelenhance the patient's esteem; otherwise, paings, and I know that you have had feelings that tients with minimal self-esteem will usually fail are uncomfortable. I know that you have had to respond positively to step two and further feelings of sadness, like any other human being. work will be required. This method may be If you agree with that, your 'yes' finger will valuable in facilitating greater acceptance of float up to signal me. And you have had one's own feelings and in promoting feelings of happiness, like any other human assertiveness and self-regard. Ideomotor finger being. If you agree with that, again your 'yes' signals should be established prior to using this finger can lift. And you have had feelings of method. (Ed. ) anger, just like any other person, have you not? And feelings of love, just like any other human STEP ONE. State a belief in humanity's worth being. [Wait for signal, and if necessary, ask, and importance, seeking the patient's affirm "Have you not?" or "Haven't you?"] Feelings of ation of this belief. fear, just like any other human being. And "Now, I want your unconscious mind to feelings of safety and security, just like anylisten very carefully. And when the deepest part body else." of your mind is listening carefully, your 'yes' "Now, all of those feelings are normal, human finger can lift to signal me. [Pause] Good. And feelings and you don't need to feel ashamed or keep listening very carefully. guilty or embarrassed about any of them. I be "I believe that every human being is unique lieve that you have the right to all of your feeland important. Do you agree?" [If the patient ings, whether or not they are unpleasant. Do you answers "no," exploration about this may be agree?" [If the answer is "no," seek to determine done with ideomotor signaling. Another apthe reason. For example, perhaps anger is reproach is to say, "Even though you do not agree garded as an unacceptable feeling. Reason with with me, do you believe me when I say that I the patient, justifying the value of any type of believe that every human being is important feeling he or she regards as problematic.] and unique?"] "I believe that you have as much right to your feelings of sadness as any other human being. If STEP rwo. Persuade the patient to accept himyou agree, your 'yes' finger will float up again. self (herself) as an important and worthwhile [Pause] And you have as much right to your human being. feelings of happiness as any other human being, "I believe that you, (patient's name), are do you not? [Pause] And you have as much unique and special - just as unique and imporright to your feelings of anger as anyone else; as tant as any other human being. Do you agree?" much right to your feelings of love; as much [This question will typically be met with conright to your feelings of fear and to your safe siderable thought and delay.] feelings. Do you agree?" EGOSTRENGTHENING: ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 2 1 "It i s your privilege t o have those feelings, No one has the right to put him/her down, so and you don't need to feel guilty, ashamed or protect him/her from anybody who wishes to embarrassed about any of your normal human do that. Take care of him/her at all times. In emotions . You have a right to keep them for as fact, I want you to take care of him/her, but long as you need them. But you also have a also to care for him/her. Care for (patient's right to let them go when you don't need them name), love him/her. If your unconscious mind any more. And if you agree with all of this, is willing to do all these things, your 'yes' finger your 'yes' finger will float up again." [Pause] will lift." "And any of these old, out-of-date, uncom "And as you do all of these things, some fortable feelings that you've been carrying wonderful things will happen: you feel very around and which you no longer need can be let safe, very secure. It feels like you have the go. And if you feel that you are letting go of answer to so many things which used to puzzle them right now, your 'yes' finger will float up. you. You will feel so safe, so secure, that you [Pause] And you can stay free of those old , will no longer let things get you down because out-of-date, uncomfortable feelings. You can you know how to handle them. You always did finish letting go of them now. [Pause] You have know, but you did not know you knew. And a right to those feelings of hurt if you need use the knowledge. You can use it to the best of them back; you have a right to have your your ability. And with that good knowledge, feelings of anger back if you need them back at you can do the things that you really want to some time; you have a right to have your do. You will be able to do them because you feelings of fear back any time you need them. feel friends with yourself. It's a nice thing to But, when you don't need them any longer, you feel good friends with yourself. And if you are can feel happy, you can feel loving, and you feeling friends with yourself right now, your can feel safe and secure." 'yes' finger will lift." [pause] "Now, I would like your unconscious mind to "Continue to be friends with yourself. Conmake a commitment that you will respect (patinue to listen to yourself, hear yourself, and tient's name) always. By that, I mean that you give yourself good advice. And take the good will respect his/her feelings. And if your unconadvice that you give yourself. And as you feel scious mind is willing to do that, your 'yes' finger very good about yourself, I am going to ask will float up. [Wait for 'yes' signal.] You'll like you, please, to know that you don't need to put him/her because he/she has human feelings and anybody else down. You don't have to put a right to those feelings. And because you like anybody else down, because you feel that you him/her, you will listen to his/her feelings and can respect other people, and respect them as not put him/her down for having them. He/she having their problems and being human, just has a right to have them. And you will find ways like you." of helping him/her to feel comfortable - good "And because you are feeling so good, today ways that are helpful. Never put him/her down can be a very good day. I would like you to see for having uncomfortable feelings, for he/she yourself having a very good day. When you can has a right to them. Listen to them, respect see that, let your 'yes' finger lift. [Pause] Good. them, like them. I want you to always protect You feel so good. There's a nice, calm, relaxed, him/her, as you have been doing in the best way smiling feeling all through you. And keep that that you could; but now, you have better ways feeling. Keep it each day. Feel good about of protecting him/her. Listen to his/her feel (patient's name), being the person you are, ings. You've got better ways. You've found betliking (patient's name), and taking care of ter ways. Always look for better ways to take him/her." care of (patient's name)." "I want you to know that you can remember "And don't allow people to put him/her what you need to remember at all times, and down. He/she is just as good as anybody else. forget what you need to forget, because your 122 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS unconscious mind will always remember every T H E G E N E RALIZED EGOthing that we have talked about. If that is E N HANCE M E NT TEC H N IQ U E understood, your 'yes' finger will lift. [Pause] It will keep all of the suggestions that we have The technique embraces the following steps: agreed upon, so that your conscious mind does not have to bother with trying to remember all 1 . Physical relaxation induced by concentrathe many things that we have discussed. Your tion upon the breath, following it as it flows conscious mind can leave all of the rememin and out, letting go tension, tightness, and bering to your deep, inner, unconscious mind, discomfort with each breath out. Patients so that when your open your eyes, your conare encouraged to develop a detached attiscious mind can be free, to think about other tude, as if they are watching someone else things." [Awaken and distract the patient.] breathing. The simple following-of-the-breath physical relaxation technique permits patients to "let go" specific problems, unwanted Ego-E nhancement: A Five-Step thoughts, and physical discomforts which have been discussed before induction is Approach commenced. Thus, it serves as both the first step in trance induction and the commence H arry E. Stanton, Ph . D . ment of therapy. Hobart, Tasman 1a, Australia 2. Mental calmness encouraged through imagining the mind as a pond, the surface of which is completely still, like a mirror . I NTRODUCTION Thoughts are watched in a detached way, being allowed to drift through above the Opportunities to tailor the approach to water, attention then being brought back to handle specific problems occur within each of further contemplation of the water's these five steps. Due to its flexibility, this stillness. approach to ego-enhancement may be used to In the "pond" mental relaxation step, help patients with a wide variety of presenting patients may be encouraged to imagine the problems. Approximately 8507o of my patients area above the water as their conscious find that the ego-enhancement approach afminds and that below as their unconscious fords considerable relief. This is true whether minds. Accordingly, they have the power to they want to learn how to relax, overcome "drop into" the pond of their mind anything anxiety, sell more insurance, kick a football they desire. This may be formulated in farther, or let go of habits such as smoking, terms of a trance-deepening suggestion, overeating, and alcohol abuse. As it is basically with the patient imagining a beautiful stone gentle and nonintrusive in nature, egorepresenting, say, mental calmness sinking enhancement is a technique unlikely to cause down and down, deeper and deeper, until it harm and would seem capable of effective use comes to rest at the bottom of the pond. It with most patients finding difficulty coping is then suggested that the patient's mind with their life situations. However, as I have locks around this calmness, a calmness not employed the approach with patients sufwhich is to become a permanent part of his fering with severe character disorders, I am or her life. The same procedure may be unable to comment on whether it would be followed with other stones, each one represimilarly helpful and noninjurious in such a senting a specific suggestion relevant to the context. particular patient, and each one assisting EGOSTRENGTHENING· ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 23 the deepening of the trance as the stone patients find their special place, it is sugsinks "down and down, deeper and deeper." gested that they think of themselves as they As a normal practice, mental calmness, want to be, imagining themselves behaving physical relaxation, confidence, and happithe way they want to behave, and "seeing" ness comprise the "stones," but these may be themselves achieving the success they wish replaced with others such as concentration, to achieve. Sometimes particular images to mental control, and healing where it seems meet the expressed needs of patients will be appropriate. The "pond," then, provides a suggested; on other occasions patients may basic framework within which considerable generate their own material. flexibility is possible. The "special place" visualization is a 3. Disposing of "rubbish" as subjects imagine common aspect of many hypnotherapeutic themselves "dumping" mental obstacles, treatments. One particularly useful pattern such as fears, doubts, worries, and guilts, is to have patients imagining themselves down a chute from which nothing can regoing through a door which they can shut turn. Physical obstacles, such as cigarettes behind them to exclude the rest of the and excess weight, may also be disposed of world. Suggestions may then be made that, in this way. in this place, they will be able to get into 4. Removal of a barrier representing everycontact with the unconscious part of their thing that is negative in the lives of subjects. minds which will then solve any problems Embodied in this barrier are self-destructive they might have. One aspect of such thoughts, forces of failure and defeat, solutions will be that things which have mental obstacles, and self-imposed limitaworried or upset them in the past will tions, everything which is preventing subsimply drop out of their lives as if they jects from employing their lives as they never existed. Because these things have would like. This barrier is destroyed now become so unimportant, patients will through use of the imagination. probably forget they were ever disturbed in The corridor, rubbish chute, and barrier this way. At this point, use may be made of metaphors may also be used to meet indian Ericksonian approach to the encouragevidual needs. Smokers may wish to discard ment of amnesia by reminding patients of their cigarettes, alcoholics their alcohol, and the frequency with which, in the past, they the obese may care to strip away their have forgotten people and possessions that, unwanted weight. Patients may also genat one time, were very important to them. erate their own variations, this being one of Once this importance has faded, so too the main benefits of the approach . . . . Simdoes memory, a process that can take place ilarly, they often put into the barrier negawith those things which used to worry and tive aspects of their personalities which they upset them. have not mentioned in pre-trance discus As it is usually preferable for patients to sion. However, because they feel these are be left free to choose their own special holding them back, they decide for themplace, they can be told that when they pass selves that they should go into the barrier. through the door, a place will be waiting. Other specific negative influences which ap This could be somewhere from their childpear to be interfering with individuals' enhood where they enjoyed themselves while joyment of life are placed in the barrier by growing up, or perhaps a fantasy place, the therapist. maybe even a comfortable emptiness . 5. Enjoyment of a special place where subjects Wherever it is, beach, garden, lovely room, feel content, tranquil, and still. In this place or a comfortable bed, in it the patient will they "turn off" the outside world. Once feel happy, content, tranquil, and still. 1 24 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS Suggestions for Modifying perfection, we will just automatically feel inad Perfection ism equate, because we can't reach such a goal. I think, however, that you can be pleasantly D. Corydon H am m ond, Ph . D . relieved, when you change your goal from perfection, to being competent and making a Salt Lake C1ty, Utah contribution. Life can be so much more enjoyable, so much more rewarding, when our goal is I N DICATIONS simply to do things well, and just keep gradually improving. I want you to appreciate the Perfectionism may be a part of many clinical value, the benefit, of accepting yourself as syndromes, including depression (and low esimperfect, but in the process of growing, in the teem), anxiety disorders, obsessive-compulsive process of gradually learning and getting better disorder and personality, and type-A behavior. and better. These are direct and cognitively oriented suggestions aimed at modifying perfectionistic ten PATI E NCE WITH GRADUAL dencies. Cognitive, Adlerian and rationalemotive therapists may find these suggestions IMPROVEM E NT AND CREDITING particularly compatible with their approaches. ONESELF Many of these suggestions are for patients who The natural process o f change i s generally a are caught up in overcompetitiveness and process of taking a series of steps. We roll over striving for perfection. Those with a birth order and learn to crawl before we learn to walk, or as the oldest child and who feel that they must run, or ride a bicycle. We learn addition before be first, best or superior, and second children we progress to multiplication or algebra. The who are caught up in the Avis Complex ("We're natural order of things, is gradual growth and second, so we try harder.") may benefit from improvement. We don't have to be perfect, and such suggestions. Some of the other suggestions certainly not overnight. We change by gradumay foster self-acceptance of one's humanness, ally walking up a series of steps; no one can despite making mistakes. leap up a whole staircase, far less leap a tall building in a single bound. We are human, and PE RFECTIONISM, SU PE RIORITY, A N D it is unrealistic to expect ourselves to be superhuman. And different people make progress in OVE RCOMPETITIVE N ESS different ways. So I'd like to suggest that you be patient with yourself, because you're unique, I wonder if you may be one of those people and you have your own unique process of who feel that they can't settle for less than growth. And I'd like you to really enjoy, each perfection, and perhaps even that you may as small improvement, each small change. Experiwell not even try if you can't do something ence changes fully, and take credit for the perfectly. Many people make themselves miserimprovements and gains you make. I'd like you able by striving to be superior, the best, the to just appreciate how you make changes, and first, or perfect. They become enslaved, striving not become impatient with how fast those for the mistaken goal of perfection and superichanges take place. ority. They mistakenly believe that the only thing worth being in life is a star - above other people, the best, the first, or perfect. That is a CHANG I NG YOU R GOAL TO belief that will bring misery. Expecting perfec COO P E RATION AND CONTRI BUTING tion from yourself and others leads to disappointment and depression because we are all And as you accept the goal of being compehuman and imperfect. When we have a goal of tent, and making a contribution, instead of EGOSTRENGTHENING: ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 125 being perfect (superior), your relationships with scious mind has altered this inward, basic goal, people will become more gratifying, more haryou will find that all this will occur so easily, monious. People who strive to be the best or without your even thinking. And you can celesuperior to others come to view the world as an brate your humanness, and enjoy having the unpleasant, competitive, dog-eat-dog jungle. courage to be imperfect. People dislike them. When your goal is to be better than others, you're forever competing, and continually inse REFRAMI NG MISTAKE MAKING cure, because it's impossible to measure who's the best. But you can free yourself, from the We've all made mistakes . And I'm sure that tyranny of trying to be better than others. It can you can recall a time when you made a misbe so gratifying, so refreshing, to simply have take - a mistake that taught you something. the goal of making a contribution to other Even though it may have been unpleasant, you people. When you simply strive to improve, can recall making a mistake that you learned and make a contribution in life, people become something valuable from, can you not? [Negafriends, allies and confederates, instead of tive to discharge resistance] [Assuming you get threatening competitors; we feel a fraternity an affirmative head nod, you can proceed. and bond with people. The goal is now coop Otherwise, you may enlist an unconscious eration, not competition. And if your unconsearch for such a time, with an ideomotor scious mind is willing to change your inner goal signal when such a memory is identified.] to growing, improving and making a contribu And as you recall that memory, I want you to tion, instead of perfectionism and competitivebegin to appreciate the fact, that without ness, your "yes" finger will float up to signal having made mistakes like that, you would have me. [Await a response, and after 20 seconds if never learned and progressed. As a kid, did you an affirmative response has not occurred, add, ever touch a light plug and get a shock that "Or your 'no' finger can float up if your unconreally kind of jolted you? Many of us had that scious mind is not willing to change your inner experience, and we learned something very imgoal." If the latter is the case, ideomotor exploportant from that, even though it was a very ration may be employed concerning roadblocks unpleasant jolt! And similarly, it's because to letting go of old, mistaken goals.] you've had the pain of a burn, that you learned What a relief! To be free of the burden of to be cautious with fire. trying to be the best, or perfect (or superior). Your imperfect mistakes, have been perfect It's so much easier, so much more satisfying, so opportunities for a wealth of learnings, that natural, to accept yourself as human, and in the have formed an indispensable foundation to process of improving and growing. No need to build on. So don't be mistaken about mistakes; compete with anyone -there's no way to meathe more unpleasant it is, the more pleasant will sure who's the best anyway. be your learning. And I wonder if you'll be surprised, at how And yet so many people are afraid to try, for attracted you will now become, how enthusifear they'll make mistakes. And when they do astic you'll become, about the goal of coopermake a mistake, they try to cover it up for fear ating and working together and making a conpeople will think less of them, or think they're tribution, instead of trying to be perfect (or weak or stupid. But I'd like you to appreciate superior). And I wonder if you'll notice how the fact, that mistakes are not only tolerable, spontaneously, how automatically you can find but are actually desirable, because we learn yourself cooperating with people, and thinking through making mistakes. in terms of making a contribution. It will feel Have you ever been around someone who like such a relief - like becoming a member of was afraid to admit they had made a mistake? the human family. And because your uncon- [Brief pause for response] They're very tense 1 26 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS and defensive, so they find it hard to grow and rationalemotive therapy. Individual paraimprove. What I'd like you to consider is the graphs (themes) may be regarded as modules benefit, of having the courage to be imperfect. for use with patients who have particular diffi I wonder if you've had the experience, I culties. (Ed. ) certainly have, of finding that when you see people make an error or mistake, that you can SUGG ESTIONS actually feel relieved, to see that they're human too . Most people feel more willing to have a Day by day you will increasingly do what you relationship with someone who seems human, enjoy doing rather than what other people rather than perfect. And if someone does critthink you ought to do in life. It would be nice if icize you for making an honest mistake, it's other people approved of what you do, but it is probably because they are insecure. not necessary to your happiness for you to be I wonder if you might even find it an interloved and approved of by almost everyone for esting growth experience, to tell friends about almost everything you do. You know what it is some mistakes you make, or about mistakes that makes you happy, that makes life enjoythat you have made, instead of trying to hide able and this is what you should do. and cover them up. In fact, wouldn't it be As each day passes, you will become increasfascinating, as a way of giving you practice ingly competent as you try to better your own allowing yourself to be human and imperfect, if performance. Do things because they bring your unconscious mind were to arrange for you pleasure and rewards, but give up the notion of to make some minor mistakes? And while your trying to be thoroughly competent, adequate unconscious mind may take a kind of pleasure and achieving. Try to do rather than do perin letting you be human, I don't know at first, fectly. Accept failures as undesirable but not if it will make you a little nervous, or if it will, dreadful. You are a worthwhile, valuable in some strange sort of way, seem more fun and person because you exist as a human being, not almost amusing, to find that you can make an because of how well you do something. You are occasional silly mistake. Or maybe it will just worthwhile in yourself, quite apart from your give you the feeling of, "Welcome to the human performances. race." But deep inside, you can begin to get the Day by day you will find it easier and easier feeling, that it really is all right to be human, to accept that you are a fallible human being, and to make some mistakes, so that you can and therefore, likely to make mistakes. You learn and grow more rapidly. will be able to learn from your mistakes and be increasingly successful as a result. Because you can accept that as a human being you are fallible, you will find it completely unnecessary Suggestions Derived from to blame yourself for anything, for self-blame RationalEmotive Therapy is completely unhelpful and destructive. When conditions are not as you would like H arry E. Stanto n , Ph . D . them to be, you will be able, wherever possible, to change them for the better. When for the Hobart, Tasmania, Australia moment, things cannot be changed, you will be able to accept them calmly, realizing that anger I N D ICATIONS and frustration would be making you miserable for nothing. It would be nice if things were These suggestions may facilitate cognitivegoing the way you want, but if they are not, it perceptual changes and be particularly helpful is not terrible, horrible or catastrophic. You with patients who operate on the kinds of will be able to accept the situation and deterirrational assumptions targeted for change in minedly work to improve it. EGOSTRENGTHENING: ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 127 Day by day you will become more and more sorbed in some persons or things outside yoursuccessful in feeding positive, happy thoughts self. To make our lives happy and fulfilling we into your mind. You will accept more and more need a purpose, and you will be able to find strongly that you are responsible for your emosuch a purpose for yourself. tions, that you decide whether to be happy or miserable. It is not external events that make you happy or sad, but the attitude you take to these events. Your misery is caused by your Suggestions for Raising irrational thinking and the negative sentences you speak to yourself. Self-Esteem Gradually you will find less and less need to worry about future problems and dangers, many H elen H . Watki ns, M.A. of which are quite imaginary. You will be able Missoula, Montana to determine the real dangers about the things you fear and see what the probabilities are of their actually occurring. Most of the things we I N DICATIONS worry about never happen, so we make ourselves miserable for nothing. Day by day you The following suggestions were prepared for will find yourself becoming more and more sucuse with patients with low self-esteem. The cessful in overcoming such pointless worry. suggestions should be given following hypnotic As each day passes, you will become increasinduction and deepening. These suggestions ingly able to face up to the difficulties and may be used in an office setting. It is also responsibilities of life. You will be able to recommended that the session be tape recorded determine for yourself what the truly necessary for later use by the patient at home. The activities of life are, and, no matter how unsuggestions labeled as "night tape" are for use pleasant they may be, you will be able to by the patient immediately before going to perform them unrebelliously and promptly. As sleep. It may be helpful in the "night tape" to you do so, you will feel an ever growing sense use a lengthier induction-deepening process of happiness and accomplishment. that may include such things as progressive With every passing day, the irrationalities of relaxation and going down a long staircase for the past will influence your life less and less. deepening. During the deepening process, the You will reject more and more strongly the idea author also suggests, "For the present, you will that the past is all important and you will not fall asleep, but will listen to the sound of realize very powerfully that just because somemy voice until the tape is finished." The "day thing once strongly affected you, there is no tape" suggestions are for use in tape-assisted reason why it should continue to do so indefiself-hypnosis during the day. (Ed.) nitely. You are a different person now from the one you were in the past and you can now successfully cope with things which may have N I G HT TAPE SUGG ESTIONS previously upset you. With ever increasing frequency, you will be T H E SAFE ROOM. You can see that in front of us able to accept people and things as they are, is a hallway. And as you look down the hallseeing that compromise and reasonable soluway, you can see a door. That door is a door to tions are necessary. You will be able to give up a room of your own choosing, in which you will the notion that it is catastrophic if perfect feel safe and comfortable. [Pause] As we come solutions to life's problems are not found. closer to the end of the hallway, you can see the As each day passes, you will find yourself door more clearly. This door will keep out all making definite attempts to become vitally abthe negative messages, the words, the behav- 128 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS iors, that you perceived from your world as a entity, that exists because it becomes a kind of child, which made you feel bad about yourself. spokesman, for that life energy, for that There's no room here for such negative meshealing energy, for that essence, which is you. sages. That nurturing part of you is capable of Look at the door very carefully, [pause] even healing, both mind, and body. It is capable of the doorknob . And know that this is a room of helping, healing those parts of you that are not your own choosing, in which you will feel safe, happy, that don't feel good about themselves. and comfortable. Early positive messages and And it is possible for that nurturing self, to seek experiences enter, but all negative messages out other parts of you, that are not happy, and must stay outside. And now I want you to open help them, help them become happier, help that door, and then close the door behind you. them become more worthwhile in their own And look around that room, this safe room, eyes, and most of all, help them to feel loved that you can visit any time you wish, by just from the inside, not from the outside world. closing your eyes. Look around, and enjoy To help this process, it is worthwhile for you what you see there. [pause] to think about that nurturing part within you, Now I'd like you to sit, or lie down someplace and perhaps to visualize that process going on, in that safe room, wherever you will be comas you go about your daily business. Visualize fortable. And listen carefully to whatever I say the process of that nurturing part helping out to you. There is a life energy inside of you. It is those, that are not so happy inside, in a way that unique to you. It is your life energy, not anyone comes naturally to you, in your mind's eye. And else's. It is the energy from whence you came. as you continue to do this, thinking about the Life energy has only one purpose: to help you nurturing part, you will stimulate that aspect of reach your potential as an organism. It is proyou, and it will become stronger within you. tective; it is healing. And since it is healing and As you go to sleep tonight, you will have a protective, it is therefore loving. I want you to healing dream, [pause] a healing dream to heal experience that life energy of yours, by feeling a mind, body and spirit. And that healing, nurlight above your head, a light from which issues turing part will know, what you need in a healing warm streams of energy, warm streams of endream. And that healing dream will not only ergy, that surround you like an imaginary cohave an effect tonight in your dream, but will coon, soft and pliable, that lets you move about, affect you during the day as time goes by. And that protects you, like a cocoon. as healing progresses, you will come to feel bet Feel that life energy also penetrating every ter about yourself, stronger, more selfcell of your body, surrounding you, and peneconfident, and therefore happier. And when you trating you. This is your life energy. It reprefeel happier and better about yourself, the world sents your true self, your natural self, your will respond to you in more positive ways. essence - whatever you wish to call it. It be And now, in a moment I'm going to sign off, longs to no one but to you. It is protective; it is and you will find that you will drift into a healing, and therefore loving. Within that life natural sleep pattern, and when you awaken in energy are no negative messages; they cannot the morning, you will be aroused just naturally exist there. Feel that positive life energy, from this sleep pattern. I'm signing off now. coursing through every cell of your body, sur Sweet dreams. [Silence. Tape is left openrounding and protecting you. That life energy ended, allowing the patient to drift off to has sometimes been expressed within you, persleep.] haps as a still inner voice, that many of us ignore; words of wisdom inside of us that we DAY TAPE SUGGESTIONS don't always listen to, but are really there to protect us. That still inner voice is a nurturing Allow yourself to drift and float, drift and part of you. And that nurturing part is an float. And listen to the sound of my voice, and EGOSTRENGTHENING: ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 29 what I'm going to be saying to you. Self-esteem little bit, while you check out those messages is the way you think and feel about yourself. from the past. [Pause for about one minute.] The more positive the feelings, the higher your Now let's take a trip into your past, and find self-esteem; the more negative the feelings, the out what faces go with those messages. Imagine more negative your self-esteem. Self-esteem that you are sitting in a pink compartment on a affects the quality of your life. A high selftrain, looking out the window. As you look esteem can make you feel productive, capable, around your compartment, for you are the only lovable, happy. Low self-esteem makes you person sitting there, you notice that the comfeel unproductive, miserable, worthless, inpartment is pink all the way around, the ceiling, competent, unlovable. With low self-esteem, the walls, the furniture, so that you can almost you may even be outwardly jovial, or you may feel the pinkness. The pinkness is strangely act confident to the world, or you may be relaxing. That train will take you on a round highly successful in your work. But inside, you trip into your past, all the way back to your cringe and say to yourself, "Boy, if that world birth, and then return to the present. out there only knew what I'm really like, they Now the train begins to move along, and pick wouldn't want to get to know me. They'd up speed. But you have a control switch in front probably just go away." And so you carefully of you, and by moving that switch, you can polish up your cover, your facade, and stay on control the speed of that train. You can even the alert, for fear you will be found out. What stop if you wish, to get a better view of some a miserable way to live. How do people get this incident you want to study more carefully. way? Perhaps you want to look at the people in those Well, let's take a trip, through your brain, scenes, and understand them better, and yourwhere all of those notions are stored. Think of self. See them as human beings, with human an area in your brain, containing all the expefaults, limitations and emotions. No one can be riences you have ever had in your lifetime. That perfect, neither you nor I, nor any of the people area is not exactly a depository of what hapin those scenes. In a while, I will sign off, so pened, but of what you learned from those that you can go on this trip at your own speed. experiences; that is, how you perceived them. When the train reaches birth, take in a deep For example, suppose at the age of two you breath, and get in touch with the energy from spilled a glass of milk and you heard someone whence you came. That energy from whence say, "Bad girl or bad boy ! " From this experiyou came is your essence. It is protective, it is ence, you might get the idea that you are bad, loving, it is your life energy, and it belongs only even though the person saying that did not to you. Feel its power, its warmth, its protecmean that exactly. They were just upset at tiveness. Feel it as warm streams of energy, having to clean up the milk, and didn't want surrounding and penetrating you. It will give you to do it again. you strength on the trip back. But as a child, you can't help but think con From birth, the train will head back on its cretely; that is, literally. You conclude, "I am return trip over the same scenery. However, on bad, or worthless, or I can't ever make it," or the return trip, you will be able to change your whatever that negative idea is. Therefore, the attitude toward these scenes, if you wish. You brain is always full of distortions from child can even open a window and do something to thinking, which is just normally concrete and change the event, [pause] because on that reliteral. turn trip, you are full of life energy, which Check out that brain right now. Maybe you helps you to be more confident and selfcan see, or hear, or sense the messages that are assured. Take the time you need for your trip; there. They may not all be negative, but they make it meaningful to you. Remember, you are always a product of child thinking; that is, don't have to accept any more of those negative the perception of the child. I'll be silent for a messages from the past. [pause] You can leave 1 30 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS them back there. [Pause] When you return to to base any final decisions, and you will always the present, take a deep breath, and slowly want to check out these new ideas to make sure open your eyes to become alert. Have a good, that they are practical, just as you would check meaningful trip for yourself. Remember, you out information from any other source. You deserve it. This is [therapist's name] signing off. will also continue to be aware that sometimes [Stop speaking and leave the tape open-ended.] the best decision is a decision to wait or to secure additional information before acting. But nevertheless, you are going to be surprised and pleased at how much more clearly and Suggestions to Facilitate creatively you are going to be able to think, and Problem Solving at how much more confidently and effectively you will be able to deal with the issues and Don E. G i bbons, P h . D . problems which lie before you. I NTRODUCTION It is my own belief that the process of The Serenity Place incubation may be facilitated by direct suggestion - if only because the subject is thereby D . Corydon H a m mond, P h . D . made more confident that an effective solution Salt Lake C1ty, Utah will be forthcoming. At the conclusion of an induction, the following suggestions may be given. I N DICATIONS SUGGESTIONS This is a permissive, indirect egostrengthening method designed to increase patient In the coming days and weeks, your thoughts coping abilities . It is useful with anxious pawill often turn to the consideration of important tients, for patients with premenstrual syndecisions you have to make, and important drome, and with patients who are bright, inproblems for which you have as yet found no sightful and self-directed. Along with induction solution. Even when you are not consciously and deepening, this procedure may be tape thinking about these topics, your mind will conrecorded for use in tape-assisted self-hypnosis. tinue to deal with them so that, when your at The open-ended conclusion allows the patient tention returns to them once more, you are going to remain in a deep trance for as long as to be surprised and delighted at how many poneeded, which can often produce profound tentially useful ideas you are able to come up feelings of calm and tranquility. Encourage the with; and some of these ideas are even likely to patient to allow the image to spontaneously catch you by surprise at times, emerging into appear, rather than searching consciously for your awareness while you are thinking of somethe most ideal place. The process for arriving at thing else. They might even enter your dreams at the serenity place may be individualized, for night, or you might wake up with some of these example, through taking an elevator down and new ideas in mind; but regardless of how they finding the special place when a door opens, make their appearance, they are going to be very floating there on clouds, or simply finding helpful and beneficial to you. oneself there. Present the suggestions slowly Of course, You will always try to make sure and restfully. Commas are placed to suggest that you have sufficient information on which brief pauses. EGOSTRENGTHENING: ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 3 1 SUGG ESTIONS can be aware of actual feelings, with a correct sense of proportion, free from the distortions Now, as you continue to relax, more and of a mood or set of circumstances. {Pause] As more deeply, just allow yourself to float across you rest in this place, things come into proper time and space. And in a moment, your unconperspective. [Pause] And in this special place, scious mind is going to suddenly take you, to a independent of anything that I say, you can very special place, that's associated with trereceive what you most need right now. Your mendous feelings of peacefulness, and tranquilunconscious mind knows what you most need. ity, and safety, and happiness. It may be a place And I don't know exactly how you'll receive you've been before, or some special place that that. It may be that you gain a new perspective, you find yourself in for the first time. And you or just find yourself feeling differently. [Pause] can just allow such a place to spontaneously Or maybe, before awakening, you'll receive come into your awareness now. And as you from your unconscious, a special gift, of an find yourself there, give yourself the opportuexperience or a memory that gives you the nity, to experience all the refreshing feelings of understanding or the perspective or the feelings calm, and contentment, and security, and hapthat you most need right now. [Pause] Or piness, associated with this wonderful place. perhaps, you may hear, what you need. It may And I'm not really sure whether you'd rather be that you hear a still voice, maybe a voice in just sit and rest back, and look at everything your mind, or seeming to come from deep around you, or if you'd rather walk around inside you, saying what you most need to hear, some, and explore this special place, that's here giving you the suggestions you most need to right now, just for you. And I don't know for receive right now. [Pause] sure, the things that will stand out most for And in a moment now, I'm going to stop you - whether it will be the sounds in this talking. And you can remain in this special special place, or the beauty of it. Perhaps you'll place of yours, for as long as you need. You can especially enjoy the sensations and feelings as remain in this place of contentment, and hapyou touch things, and maybe even the smells piness, and tranquility, for as long as you need, will be unusually pleasant. recharging your batteries, and soaking up these And I wonder if you've already begun to nofeelings, receiving what you need. And there's tice the fact, that as you just experience, and something that's going to be embedded and enjoy this special place, you soak up and absorb remain in your mind: you will know, that you these tranquil feelings. And you can just allow can return to this special place of yours, whenthese feelings of deep contentment, and peace, ever you need or want to. You will know, that and calm, to flow, all through you, to all parts whenever you need to rest, or replenish your of you, allowing all of you to experience these strength and energy, that you can put yourself soothing feelings. And as each moment passes in into a deep and peaceful hypnotic state, and this special place, these wonderful, invigorating return to this place. feelings increase, and become more a part of And when you're ready to awaken, you can you. And you can savor this place, and your drift back across time and space, bringing these enjoyment of it can be heightened, with every wonderful feelings, and this sense of perspecmoment that you spend here. And as you rest tive with you. And you'll awaken feeling well; here, and recharge your batteries, this experirefreshed, alert and clear-headed. And what ence may remind you of other places and expeyou have experienced can remain with you, riences, where you've felt happy, and contented, after you have awakened. Now, as I stop and filled with peaceful feelings. [Pause] speaking, you can continue in this place, And in this place of serenity and security, receiving what you need, for as long as you things can come into perspective. [Pause] You like. 132 HANDBOOK O F HYPNOTIC SUGGESTIONS AND METAPHORS EgoStrengtheni ng Suggestions The I nevitability of Change Richard B. Garver, Ed . D . Robert C . Mas h m a n , P h . D. Del Mar, Cal1forn1a San Anton 1o, Texas I N DICATIONS I know you have a conscious memory of what you have experienced and learned, but These are nonspecific suggestions for change your unconscious mind has a much more comintended to activate the client's own abilities in plete record of everything that you have ever selecting and implementing a necessary change. learned or experienced of any significance since They are intended to potentiate the effect of you were born. I want to ask your unconscious subsequent suggestions. These suggestions demind to review all of that material, and it can fine change as pervasive, positive, and uncondo that much more quickly and completely than sciously determined. In addition, they redefine you could do it consciously. Review all of your feelings of anxiety and confusion as signs of learning and experiences; scan all of them and positive unconscious activity. Discomfort is select only positive experiences and feelings. reframed as an epiphenomenon of natural, Review them, and strengthen them, and begin normal unconscious work. to make them available to you as your inner strength to cope with whatever you need to cope with now. And although you won't be SUGG ESTIONS aware of most of this consciously, it will be going on beneath the surface, just as your Now change is something that exists unconscious mind works on problems and conthroughout the universe and it is particularly tinues to operate beneath your awareness most characteristic of biological life. You may or of the time. Perhaps you will be more aware of may not know that every seven years almost all some of this, a small sample of it surfacing into of the molecules that make up your body are your conscious awareness - perhaps an expericycled through. So that every seven years you ence, a positive experience, that gives you a are actually a completely new person. There are good feeling. It may be one that happened last certain patterns that remain and that is why you week, last month, last year, or many years ago, are still recognizable to yourself and others. but the thought of it makes you feel good about Psychological change usually begins below yourself. Then, perhaps occasionally a good awareness . . . from what might be described as feeling will surface, just a positive feeling, a a seed of change, a potentiality for change. A feeling perhaps of being secure, confident, seed can be planted in our early or late childhappy; or perhaps this feeling may be unathood or perhaps even today, or it can be tached to any particular experience, just a good inherited as part of the genetic wisdom of our feeling and you can enjoy it again, a feeling of species. Up until recently developmental psyinner strength. You'll begin to feel much better chologists have paid attention mostly to childabout yourself, and you will have the inner hood and adolescence, but it is now docustrength it requires to pursue some positive mented and recognized that adults go through strategies that we have talked about, and where developmental stages as well . . . throughout some of these may have been threatening betheir entire lives. And there is remarkable confore, now they will represent a challenge to you, sistency across people as to what the developand you will feel positive about taking a bit of mental stages are . . . and the order in which a risk in meeting this challenge, and feeling they appear, although each individual manigood about it. fests the developmental issue differently. EGOSTRENGTHENING: ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 133 This remarkable consistency in terms of adult SUGGESTIONS development suggests that these particular changes come about as a result of a potentiality Understanding, more and more, that it is your that is inherited, a seed that we inherit from our ease and comfort that are important [said as the parents and even the species that preceded us. client readjusts his/her physical position], and And when the conditions and the timing are in order to get more comfortable, you will shift correct, these seeds can develop and germinate your position when you would like. It is imporbelow our awareness in our unconscious tant to recognize that when you go through life, mind . . . and when that happens we may have you will arrive in a certain situation, and you will a sense that something is going on below the find the most comfortable position for yourself, surface. the most comfortable point of view, the com In the days, weeks and months that follow, fortable understanding, and then you will feel you may have a strange feeling, a sensation, an good for a period of time. experience. If that should happen, you can take But at some point the situation will change a pleasure in knowing that your unconscious little bit, or you will change yourself, and it will mind is working for you, that there is a necesrequire an adjustment to remain comfortable. sary and useful change developing . . . and There is no one position, no point of view, there after that change is completed and has become is no one understanding that will allow comfort part of your mental processes, that change will forever . . . And so what is necessary to mainemerge into consciousness in the form of a new tain your comfort as you proceed through your feeling or a changed behavior and you can life is the ability to adjust your position from understand -yes -that's what's been going on time to time . . . to see things a little bit differall along. ently, or to hear things in a way that is particularly useful, and to notice that your feelings can evolve and that, even though the same situation may present itself, the feelings that you have in Change Is Necessary for response will be evolutionary. Comfort Robert C. Mas h man, Ph . D . An Abstract Tech nique for Del Mar, Caftforn�a EgoStrengthening IN DICATIONS B . J . Gorman, M . B . , C h . B . These are further nonspecific suggestions for change intended to activate the client's own abil I NTRODUCTION ities in selecting and implementing a necessary change. Intended to potentiate the effect of sub One means o f circumventing . . . critical facsequent suggestions, these suggestions utilize the ulty, which seems to be operative to some client's own experience of a need for a physical degree under all therapeutic situations, is to readjustment in the hypnotic session as a metgive suggestions in an indirect or abstract manaphor for the process of readjustment in life. It ner, in such a way that no direct suggestion is is discomfort that informs us of the need for made, and therefore, the critical faculty is less change. The suggestions redefine discomfort as likely to be activated. I have found that a a useful, unavoidable, and periodic part of life, modified form of Dr. John Hartland's excellent and encourage flexibility and adaptability. egostrengthening ( 1 971), delivered in this ab- 1 34 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS stract manner, has been very effective. The cess fat or flesh; greatly increased resistance to general technique which I have used, altered, of all forms of infection or disease and an increascourse, to suit each patient, is as follows . . . . ingly great measure of control of both the au This approach was first initiated when a tonomic nervous system and the hormone patient commented upon the fact that certain glands which, between them, control all the words which I had used, such as "exactly" or functions and conditions of the body. "precisely" [e.g. , from Hartland's ego Good health means not only physical health strengthening suggestions] had made him feel but also a healthy attitude of mind in which the that I was setting too high a standard for him. nerves are stronger and steadier, the mind calm I therefore dropped the authoritarian approach and clear, more composed, more tranquil, and now, almost exclusively, allow the patient more relaxed, more confident. to choose from the material which I present to It can mean a greater feeling of self-esteem, a him that which he needs. According to the greater feeling of personal wellbeing, safety, circumstances, I may also soliloquize about security, and happiness than has ever been felt such words as autonomy, wealth, happiness, before. etc. I have given in some detail the wording for It can mean complete control of the thoughts "health, " "success," and "motivation" to illusand emotions, with the ability to concentrate trate the mode of presentation which I have better and utilize all the vast resources of the found most successful. memory and the full intellectual powers of the subconscious mind. It can mean the ability to sleep deeply and T H E TECH N IQU E refreshingly at night and to awake in the morning feeling calm, relaxed, confident and You are now so deeply relaxed that your cheerful - and ready to meet all the challenges mind has become very receptive. In this state of of the new day with boundless energy and deep relaxation the critical part of your conenthusiasm. scious mind is also very deeply relaxed so that The words good health can mean to you any you can accept any ideas you wish to accept for or all of these things and more. These words your own good. have tremendous power. I want you to let them Because I wish you to remain in this sink deeply into your subconscious mind, which uncritical state, I am not going to give you any always does reproduce in you your dominant direct suggestions with regard to any of your thoughts. particular problems; I am only going to ask you The next word I would like you to think to think about certain words and their meanabout is success. It may mean a sense of ings and associations for you. I want you to recognition, satisfaction and achievement in think lazily of these words, to turn them over in your chosen field in life; a happy, fulfilling sex your mind, to examine them, to let them sink life; a closely-knit, loving family circle; the deeply into your subconscious mind until they ability to make firm friends and mix easily in a become woven into the very fabric of your social setting, or the confidence and skill to substance and of your selfimage. speak well in public. The first word I wish you to think about is the It may mean the ability to set and achieve word health, and I want you now and always to goals in life which are realistic, worthwhile and couple it with the word good. What can the progressive, and the motivation and determinawords good health mean? They can mean a sense tion to achieve those goals. It may mean the of superb physical wellbeing, with strong heart confidence to enable you to throw off your and lungs, perfect functioning of all the organs, inhibitions, to be spontaneous, to express your nerves, glands and systems of the entire body; feelings without fear or hesitation. firm, strong muscles, bones and joints; smooth, Success may mean wealth in terms of money healthy, elastic skin and the absence of any exand the things that money can buy, or security EGOSTRENGTHENING: ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 35 for yourself and your family. It can also show to egostrengthening is to utilize experiences, itself in the attitude of mind which gives inner particularly of mastery, in the personal life happiness regardless of material possessions or history of the patient. We may view the patient circumstances. as having internal resources waiting to be It could mean the ability to overcome some tapped and utilized. This more indirect and particular problem; perhaps even some probexperiential style was characteristic of Dr. lem about which I do not know. Milton H . Erickson's method for enhancing Whatever the word success means to you, I esteem and self -efficacy. The example modeled want you to use this word as an emotional here is one of moving from dependence to stimulus to produce in you all the feelings independence, as well as gaining mastery. Other which go with success. early life experiences that may serve as a source Finally, I want you to think of the word of positive age regression include learning to motzvation. What can it mean? It can mean the walk, to talk, to read, to ride a bike, to roller desire, determination and driving force to skate, to swim, to drive a car, to skip rope, and achieve a certain objective. It can mean a to multiply and divide. The next contribution gradual but progressive strengthening of one's by Dr. Murray-Jobsis provides an excellent desire to be in charge of one's life; to destroy example of this approach in her suggestions the old recordings of habit patterns; to play about learning to crawl and walk. Hypnotic new music instead of old; to cease being a induction and trance-deepening should have puppet of one's early conditioning and to bebeen done prior to facilitating these expericome a creator of a new, healthy, happy, ences. successful script in the play of life. It can mean the gradual but progressive building of a stronger and stronger desire to LEARN I NG TO F E E D ONESELF stop [e.g., overeating or smoking, etc.] until the desire is so great that it is much stronger than It might be interesting to allow your mind to the desire to [e.g. , eat, smoke, etc.], and there is drift back through time, as if you're growing therefore no difficulty, hardship or discomfort younger and smaller, and smaller and younger. in [e.g. , losing weight, giving up smoking, etc.] . Allowing yourself to orient back to when you We have all been conditioned since birth to were a small infant. Just imagining as if you associate words with feelings. Words are therewere a very small infant again, who still has to fore the tools which we are going to use to probe fed by other people. And I'm not sure if duce the feelings and results which we want. And you'll actually remember it exactly as it was, or these words are health, success, and motivation. if you'll only imagine it as if you were a baby again, and it doesn't really matter. But I'd like you to find yourself in a high chair, or sitting and being fed. You are so small Learning to Feed You rself: An that someone else is feeding you. And it can be Exam ple of Age Regression to a very nice experience, to be fed. But when Experiences of Mastery you're completely dependent on someone else, it can also be rather frustrating. Sometimes they may feed you too fast, and you really D. Co rydon H a m m o nd, P h . D . haven't had a chance to swallow the last bite Salt Lake Ctty, Utah before the next bite is already being put into your mouth. And your cheeks fill up with the INTRODUCTION AN D I N DICATIONS food. And it's frustrating because you really can't tell them, except to push it out with your One method of egostrengthening is through tongue. And at other times you feel full, and the use of direct suggestions. Another approach you really don't want any more, but they keep 136 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS trying to feed you, even though you keep beginning to explore and understand ourselves turning your head away. At other times, the more fully. And in that understanding an acperson who is feeding you can get distracted ceptance of self, coming to know and underwith something. And you're really hungry, and stand and accept our strengths and our limitayou want that next bite that's sitting out there in tions. Coming to access our strengths and our the spoon, but it's not moving toward your sense of power without apology or fear, mouth. And it's so frustrating to not be able to without worrying whether our strengths please get it. [Pause] . or displease others. And acknowledging to our And a little later, as you get a little bigger, selves our right to achieve our own personal you begin trying to feed yourself. And you take best self. And at the same time acknowledging hold of that spoon or food, and maybe at first our need to accept limitations. Learning to you thought it would be easy. But you quickly discriminate between those limitations that can find that it won't go where you want it to go. It be changed through growth and learning, and looked so easy. You want to get that food into those limitations that may be an inevitable part your mouth, but somehow your hand won't do of human existence. And coming to an accepexactly what you want it to do. And you really tance of our total selves with our strengths and can't quite figure out how to do it, how to get it our limitations. Knowing that we have a right there. You keep missing, and dropping the and an obligation to be our best self. But also spoon, and you really can't get it up to your knowing that no one should ask us to be or do mouth. Sometimes it almost gets there, and more than our best self. then oh, it missed again! And finally someone helps you, and takes over and feeds you, and it must have seemed like such a relief. And I'm EXPAN D I NG MASTE RY sure at first, that you must have felt very discouraged. You must have thought you'd And perhaps beginning to explore and exnever be able to feed yourself, like you saw pand the possibilities of competency and masother people do. But you really wanted to do tery that are available to us, continuing to things for yourself. And you didn't give up, and explore and expand our boundaries for compeother people encouraged you. And before you tency and mastery. And perhaps traveling back knew it, you could do it yourself. And what a into past experiences, traveling back to some of feeling that is, to master things that seemed the earliest times in childhood and infancy, to impossible, and be able to do things for oursome of our earliest attempts at growth and selves, without depending on others. There was mastery. a time when it seemed impossible to be able to do that for yourself, and now you don't even LEARNING TO CRAWL AND WALK. Perhaps rememthink about it. [A bridging association may bering and reexperiencing some of those early now be made to the patient's problem.] months of existence, of first beginning to crawl. Crawling across the floor. Feeling the excitement and the wonder of lifting the body off the Ego Building floor and beginning to move. Feeling the strength and the power and the mastery of joan Murray-jobsis, P h . D . finally beginning to be able to move, not having Chapel Ht!C North Caroltna to simply lie there waiting for someone to come. But being able to move, physically G E N E RAL M ESSAG ES moving about, beginning to be able to explore things. And perhaps seeing the patterns beneath And it begins to become easier to imagine the fingers as the hands move across the floor traveling through time and space in trance, crawling, the pattern of the carpet or the floor. EGOSTRENGTHENING· ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 137 And feeling the excitement, the challenge, the GLAss METAPHOR. And most of us remember the mastery of being able to move about for the story of the glass filled to the halfway mark, first time. And then perhaps reaching up to a and how one person can look at that glass with chair or a table and pulling ourselves upright great sadness and dismay, saying, "Oh, how and standing for the very first time on two feet. awful, the glass is already half empty," and And feeling once again that sense of mastery another person can look at that same glass with and excitement, struggle and accomplishment. a great sense of joy and happiness and say, And then still later taking that very first step, "How wonderful! The glass is still half full." and wavering, and falling, but getting up again, And of course in both cases, the glass and the and taking another first step, and falling. And liquid are exactly the same, but the perceptions so many steps and so many falls and failures. are dramatically different. And since how we But always finding within ourselves the feel about our existence is influenced by how we strength, the determination, to persevere, to perceive our existence, then isn't it reasonable endure all those falls and hurts and failures. always to choose to perceive the fullness and And always getting back up and trying again. satisfactions of life, and to distance from what And from those first wavering steps we learned ever losses, discomforts, or dissatisfactions eventually to walk, and skip, and run, and may be an inevitable part of our existence? And jump, and after a while we hardly had to think in so many ways we can add to our sense of joy about it at all. in life by choosing to perceive the fullness of And in those early months of existence, we life, perceiving all of the positives that are sent were still free, not yet weighed down with those to us throughout our days, all of the positive later fears of failure and of humiliation. And responses, the compliments, the affirmations, somehow as infants we knew instinctively that all of the kind words and the smiles. Allowing struggle and failure are a natural part of life ourselves to perceive them and perhaps disand growth. And we knew that it is not avoidtancing away from whatever inevitable negaance of failure that leads to competence and tives there may be. And most of us have in the growth; but rather it is learning from our past placed far too much emphasis on whatever failures, and perseverance, and willingness to negative or critical comments we've received in take risks that allow us to grow and succeed. our daily lives. And most of us have been And even as the child learned to walk with trained in a false sense of modesty to dismiss steadier and steadier gait, so also can we as the positive comments that have come to us. adults learn to walk through life - steadier and And isn't it better wherever possible to help steadier, less fearful of our missteps and setourselves really focus on those positive mesbacks. So also can we as adults enhance our sages and to dismiss or take less seriously some capacity for persevering our failures and exof the inevitable negative messages we get in pand our capacity for taking risks. And in so our daily lives. many ways, we can rediscover our �apacity for And perhaps also beginning to allow ourgrowth, perseverance, risk-taking, allowing selves to perceive the joys in nature more fully, ourselves to move more freely and positively really noticing when there is a beautiful blue toward enhancing competency, mastery, sky and high white clouds, or really noticing the growth, development. scenery on the way in to work as we drive. Or when we take a walk, really noticing the trees, EXPAN DING JOY and the sky, and everything in nature. Seeing the beauty that is around us, beginning to allow And in similar fashion, beginning to explore ourselves to expand our capacity to see, and and expand our capacity for joy in living. feel, and hear the beauty in nature. And in our Beginning to explore all the ways in which we personal interactions, seeing, and hearing, and can experience joy in our everyday lives. feeling the beauty in our associations with loved 1 38 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS ones, family, close friends, all of the good ning is worthwhile, and we set our own stanmessages that come our way, perceiving them dards of approval. fully, expanding our capacity to perceive the And similar to freeing ourselves from dejoy in everyday living. structive competitions, we also can expand the possibilities of freeing ourselves from destructive forms of anxiety. Again as we begin to FRE E DOM FROM DESTRUCTIVE examine the past, looking at the origins of our COMPETITION AND ANXI ETY anxiety, we discover that anxiety hangs on us as if it were a weight around our neck, weighing us THE COMPETITIVE GAMES I N OUR FAMILY OF ORIG I N . down and making it difficult for us to function. And in addition to expanding our capacity for joy, for experiencing joy in living, we can also MOUNTAIN METAPHOR. And One of the ways we begin to explore the possibility of freeing ourcan begin to help free ourselves from these selves from destructive forms of competition destructive anxieties is to begin to see our and destructive forms of anxiety. And very anxiety as if it were a mountain. And when we often we learn our patterns of competition in stand close to that mountain, it seems overour early years, in our early years with our whelming. But we can imagine getting into a car family. And sometimes we learn that we must and driving some distance from that mountain. always lose. Sometimes we compete for moth And when we are far enough away, we can er's approval and discover that mother's apstop, get out of the car, and turn around and proval costs us father's love. Or sometimes we look back, and from this distance that mouncompete for father's approval and discover that tain seems much less overwhelming. And from in winning his approval we lose mother's love. this distance we can begin to imagine different And so we begin to discover that we lose by ways of getting beyond that mountain. Perhaps whatever action we take. And sometimes we we discover a path around one or the other side compete with brothers and sisters for parents' of the mountain. Or perhaps we discover a love. And sometimes we discover that in wintunnel through the base of the mountain. We ning our parents' love, we lose the love of our might even discover that we can fly over the brother or sister. And again there's the feeling mountain. But in any event, from this distance of somehow always losing. And in some famithat mountain of anxiety seems much less overlies things are so destructive and mixed up that whelming. And we begin to discover that some everyone competes, and no one wins. of the anxieties become insignificant; some And we begin to notice that the rules of even disappear. And those that remain become competition are unfair, that the rules of the much more manageable from this perspective. game are loaded. And the only way to deal with Everything does indeed become easier. this destructive kind of competition is to step out of the game, refuse to play the game, and REFRAMING ANXIETY. And then we may notice instead of seeking approval from others, we that anxiety consists of several component begin to set our own standards of approval. We parts. And some of these component parts of learn to step out of the destructive game, and anxiety are really quite positive, consisting of set our own standards of approval. We begin to excitement and challenge and interest and enget a sense of self, and to be able to define ergy, the kind of energy that gets us "up" for a values, and to set our own standards. And then performance. And when we think about it, we we begin to let go of the old habit of automatbegin to realize that life would be very boring if ically competing, and we begin to judge we had no challenge, and if we had no anxiety whether the competition is fair. And we begin at all. Even as children we sought challenge and to discriminate, and select the competitions that excitement: riding roller coasters, learning to are meaningful, and to determine whether win-ride a bicycle. And without these challenges life EGOSTRENGTHENING: ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 39 would be dull and boring. So it's really only the with such grace and beauty it made his sad excessive levels of anxiety that we experience as heart flutter. He thought, if only I could be just destructive, the excessive levels of anxiety that a little beautiful with just a fraction of that interfere with our performance. And these exloveliness. Then all of a sudden, he happened to cessive levels of anxiety can be managed by look down into the water beside him and bedistancing, while at the same time beginning to hold! There was a mirror-image, a reflection, allow ourselves to experience and even enjoy of himself. No longer was he the ugly duckling; the healthy, moderate levels of anxiety - to he too was a swan, a creature of stately eleenjoy the challenges. Redefining the moderate gance. levels of anxiety as energy, and interest, and The ugly duckling, transformed into a beauexcitement. And then with this new perspective, tiful swan, can symbolize the growth and everything becomes easier. changes in all of us. When there are emotional hangovers of ugliness from the past, when we might have been like an ugly duckling at least to ourselves in some ways, through loving care The Ugly Duckli ng Metaphor and affirmations we also change, and we become transformed. . . . Our destiny is to be Roy L. Ru m mel, Ph . D. fully and completely alive, full of loving our Dayton, Ohto selves and loving others, and we grow and develop toward that destiny . . . . Now relax, Once upon a time a mother duck sat hatching and let this picture of the ugly duckling transher eggs. One egg was larger; it was the last to formed into a beautiful swan inspire and enerhatch. Her duck friends said, "Be careful about gize you toward a richer, more abundant life, as that egg; it's probably a turkey. Turkeys'll give you take a few moments of silence to reflect you nothing but trouble. Why not spend your about the growth and transformations taking time and energies mothering your new babies place inside yourself. . . . That moment of that are hatched. Forget that big, old turkey silence begins . . . now. egg." The mother duck was determined to follow her best instincts, however, and she kept sitting on it, and it finally hatched. There it was, not a baby turkey, but a big, gangly The Prominent Tree Metaphor duckling. Now she's got this big, awkward kid, along Alcid M. Pel letier, Ed . D . with all her beautiful brood! In the barnyard Grand Raptds, Mtch tgan her friends continued to make many a snide remark about this peculiar and ugly creature, I N DICATIONS but like God, with nurturing devotion in her heart, she kept loving them all, giving her A metaphor like this may be subtly disguised mother duck's best. Time went on. Her big as a "deepening" technique ("to help you go still fellow got bigger and bigger, but so often he deeper"). During trance "deepening," before felt like an outcast. His ugly appearance was therapeutic work is usually done, patients are shunned by all his peers, and the gangs and less likely to engage in the defensive monitoring cliques in the barnyard shot him down with and editing of suggestions. This type of metamany slings and arrows of adversity. . . . phor may be particularly useful with patients Finally, one spring day, after what seemed an who have been through trauma, deprivation, eternity, he was moving around the pond near and difficult life circumstances. In such cases the castle, and over across the way he spotted you could also discuss the early process of the this magnificent, regal-looking swan floating tree's growth from a seed, encountering the hot 1 40 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS sun, learning to bend before the strong winds, thesis. Imagine the energy going through the being weighed down by the rains and snow, the cambium layers of the tree to the roots which animals that may try to devour it, learning to obtain nitrates from the soil. Imagine, the grow around obstacles, the process and periods whole being, exchanging within itself, to give of growth and latency, and the development of life, strength and health to the whole being. a hard outer bark to protect the tenderness Nineteen . . . twenty, as you admire that tree, within. (Ed.) imagine yourself like that tree, tall and strong, firmly rooted and grounded. You, like that tree have been made stronger by the vicissitudes of I NTRODUCTION life. Like the tree's branches you reach out for help and energy. You too, can offer shelter and One should discuss which fantasized scenes help to others. Within you, are the various most relax a patient. This method avoids using functional systems to make the whole you guided imagery which may exacerbate patient stronger and healthier. But now, think deeply, phobias or allergies. A prominent tree can be you are more than that tree. You can think, you introduced in any nature scene. For the present have mobility, you can be discreet, you can example let us say a fairly intelligent patient has make decisions, you can love and be loved, you selected a walk through a field of moderately can do so many, many things that tree cannot tall grass . . . . The therapist counts 20 steps, do. Sense your power, your strength, your pausing occasionally to call attention to tall abilities. Be grateful for you. Think of all you blades of waving grass, colors, gentle breezes, are! Now please, relax deeper and deeper as you etc . , to deepen the trance. contemplate your strength. [At this point, if it is necessary, the therapist may utilize other T H E METAPHOR egostrengthening suggestions.] . . . Ten . . . eleven . . . twelve, now see to your right or your left stands a tall strong tree. Thirteen . . . fourteen, the tree is so fascinating The Seasons of the Year: A that you walk around admiring it. Fifteen . . . Metaphor of Growth sixteen, hear the birds singing in the tree. The sound of the birds singing along with the sound Lawre nce R. G i nd hart, Ph . D . of the wind through the leaves and the wind through your clothing is so relaxing. Seven I NTRODUCTION A N D I N DICATIONS teen . . . eighteen, see the tree, how fascinating, how tall and strong. Examine it carefully. This metaphor was designed for a patient Notice the outcropping of the roots reaching who wanted to "grow up," and may serve as an out across the soil and disappearing into the indirect method for facilitating personal ground. Imagine the roots spreading deep into "growth. " Repetitions have been excluded from the ground to firmly anchor the tree. See how the written version, but should be included in tall the trunk is with a few twists and turns, the presenting this to a patient. (Ed. ) scars and rough edges that are the result of the tree's struggle to survive against the wind, the hail and the storms of life. The struggle to T H E M ETAPHOR survive made it stronger. Notice how high and far the branches reach into the sky. Imagine the March is now, [patient's name] , the time for branches offering shelter to the birds and shade beginning the growth that has ceased for so to man. You know the leaves obtain energy long - through the long cold winter. As you from the sun through the process of photosyn-wonder, as you understand, as you listen to my 1 42 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS your mind, put it into the cloud. As you do so, Some force is preventing you, a force emayour unconscious mind will put in other reasons nating from a huge black statue in the center of of which you are unaware, causing the cloud to the room. This statue, powered by a brilliant become increasingly dark. When you have put jewel embedded in its forehead, is the embodiin every reason you are able to think of, it will ment of all the negative forces of failure and be inky black. defeat within you. It has been placed in the Look at the black cloud containing all these room as the guardian of the treasure, making negative programs and, as you do so, someall other guardians unnecessary. where behind it you will see a source of light. At To free this vast storehouse of your potential first quite dim, it will become increasingly so that you can become the person you are bright. That light is really a sun, the sun of your capable of being, you must first overcome the own desire to be free of everything that has negative tendencies, the forces of failure and been preventing you from living life to its defeat, within you which are acting to prevent fullest. this, these tendencies being personified and The light grows stronger and brighter until it embodied in the guardian statue. begins to burn away the black cloud. As this is Go to the statue and knock the jewel from its happening, you will become increasingly aware forehead. As it lies on the ground, its lustre of the warmth of the sun so that, as the cloud fades, so that it looks dark and ugly like a piece burns away completely, leaving no trace o f of coal. This can be stepped upon and crushed either cloud o r anything i t contained, you will into black dust. Its power gone, the statue may be able to bask in this warmth, feeling the sun's then be pushed so that it falls and breaks into rays penetrating every cell of your body, many pieces. bringing a wonderful sense of self-assurance You are now free to gather up as many of the and self-confidence. treasures as can be carried, taking it with you as you retrace your steps up the passage to the entrance. There is no need to attempt to take all T H E PYRAM I D the treasure, for you will be able to return to this treasure room whenever you want to. No Imagine yourself back in ancient Egypt, matter how much you may take, or how many standing in the desert before the cave-like entimes you return, the room will never be empty. trance to a large pyramid. As you enter, you Step outside into the warm sunshine, and find yourself in a downward sloping passagereturn to the world of your everyday life with way, well lit with torches. Feeling a sense of the treasures you have gathered. These treasecurity and confidence, you follow this passures, which can be anything you want them to sageway as it takes you deeper and deeper into be, will reveal themselves in new habits, new the heart of the pyramid. ideas, and new directions. At the very end of the passage is a vast On any occasion when you feel a lack of storeroom filled with treasures of all descripconfidence in your ability to do something, tions. This is the storehouse of all the vast think of the pyramid and the treasures it conuntapped resources, all the potential for good tains. As you do, you will feel a sense of and for achievement, which you have not yet confidence, strength, and power surging turned to your advantage. All of this treasure is through you, filling you with the certainty that rightfully yours, for it has been stolen from you you are capable of accomplishing the task through force of circumstance. However, unabout which you were doubtful. less you carry it back into the world outside to enjoy and to share with others, it will eventually T H E LAKE be sealed up within the room and lost forever. Naturally, you attempt to gather this trea INDICATIONS. This image may feel more comsure, for it is rightfully yours. Yet, you cannot. patible to a patient who enjoys the mountains EGOSTRENGTHENING: ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 43 and certain leisure activities like swimming, has brought you as far as this mountaintop, canoeing or rowing. Imagery of walking in the further progress towards your objective is mountains may be used for deepening before blocked, for all along the mountainside are using this symbolic imagery experience. The numerous barriers and obstacles. These reprepatient may be asked to give a head nod or sent everything standing between you and the ideomotor signal when he/she is engaging in attainment of your goals. using some method to get across the lake, and Bend down and pick up a handful of snow. when the other side is reached. Patients may Examine this. You will find it to be soft and also be asked to verbalize which activity they powdery, comparable, in a way, to your own have selected for crossing the lake. (Ed. ) determination which has, at times, lacked firmness and strength. suGGESTIONS. See yourself standing on the Add more snow, packing it more tightly in shore of a lake, looking out over the water. your hands, compressing it into a snowball Where you stand, it is a dreary and depressing which is firm, round, and hard. As you do so, scene, the water rough and treacherous, feel your own assertiveness and determination whipped into waves by wind and rain. Yet, the becoming stronger and firmer too, as hard and other side of the lake is quite different, with as firm as the snowball being prepared for its people enjoying the bright sunshine and lively trip down the mountainside. Walk over to a atmosphere. This is the shore of health and very steep incline at the side of the mountain normality. and gently roll the snowball down it, straight at Visualize yourself crossing the lake in some the obstacles below. Quite slowly the snowball way that requires considerable effort. Rowing a rolls down the mountainside, growing in size as boat, paddling a canoe, or even swimming it does so, until it attains the proportions of a would be possibilities. Not only are the waves large boulder. It then becomes an avalanche, and wind to be combatted. Other obstacles will sweeping everything before it as it continues on attempt to impede your progress from the shore its journey to the bottom. of dreariness to the shore of brightness, but The way is now clear. As all obstacles have these you overcome. If the distance seems too been swept away, you can begin to descend the great, or your efforts are exhausting, you can mountainside where your courage and determiuse the islands dotting the surface of the lake as nation have gone before to clear a path. As you temporary resting places. imagine yourself striding purposefully down When you finally reach the bright shore, as the mountain, you will know that, in your own you will, you feel a tremendous surge of confimind, your determination is continuing to dence, a belief in your ability to live your life as grow, as did the snowball, until it will become you want to, coping effectively and happily sufficiently strong to sweep away every obstacle with whatever your environment provides. in its path. You will then be able to attain whatever goals in life you have set, just as easily as you can now imagine yourself descending that mountainside. Increasing Determination: The Snowball Suggestions for Emotional H. E. Stanto n , Ph . D . E n richment Hobart, Tasmania, Australia Don E. G i bbons, Ph. D. Picture yourself standing at the top of a tall I NTRODUCTION AND I N DICATIONS snow-covered mountain, looking down into a valley below. In this valley is the place you have Many people consistently go at life with such been attempting to reach. Though your journey an air of grim determination that they eventu- 1 44 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS ally lose, or at least severely blunt, their cabeginning to breathe more rapidly in anticipapacity to experience joy and a zest for living tion of the joys which will soon be yours; for not merely abandoning their sense of childlike soon your entire body will be quivering with wonder, but also the deeper, richer experiences pleasure and tingling with delight. As you of fulfillment which are characteristic of the continue soaring farther and farther into fully functioning adult. . . . trance, your ability to respond to experience of The following postinduction suggestions are every kind is becoming infinitely keener. Your not designed to induce excessive or inapproentire body is becoming exquisitely more sensipriate affect, nor are they intended to elicit tive and more responsive with every breath you strong emotion merely for its own sake. Rather, take. they are designed for use as a set of "toning up" You are beginning to breathe even faster exercises for sufficiently suggestible subjects now, as your capacity for experience multiplies who are familiar with their aims and purposes: itself over and over. And the higher you climb, as a means of strengthening and heightening the the higher you want to climb and the stronger capacity for positive emotional response, and the effects of my words become. as a method of counteracting occasional ten And as your entire body continues to grow dencies toward depression when such tendenmore sensitive and more responsive with every cies are primarily the result of habit or of breath you take, you are also becoming more failure to maintain a sufficiently optimistic free, more open, and more accepting of every outlook on life. When combined with approtype of experience. You are becoming totally priate suggestions of time expansion, these sugand completely free, as your responsiveness gestions may also be useful as a means of continues to grow and your breathing comes providing a temporary substitute for persons still faster in anticipation of the joys which will who are presently addicted to mood-altering soon be yours. And the higher you go, the drugs. They may also be used as a method of higher you want to go and the stronger the pain control by allowing the subject to experieffects of my words become. ence the opposite emotions. A similar approach And now, as your responsiveness and sensihas been employed for this purpose by tivity continue to increase within an atmosphere Sacerdote ( 1 977). of total freedom, we are beginning to release all of the vast, untapped resources of feeling and emotion which lie within you. Probing the SUGG E STIONS depths of your innermost self, and releasing every wonderful, positive emotion for your Now, as you continue to listen to my words, exquisitely tuned body to savor and experience you find yourself being mentally transported to to the fullest. the center of a large, green meadow which lies And the higher you go, the higher you want at the foot of a tall mountain. But this is no to go and the stronger the effects of my words ordinary mountain looming up before you; for become. this is a mountain of pure joy, and you are Great waves of pleasure, ecstasy, and delight about to climb all the way to the top of it. are gushing forth from the innermost depths of Now you are beginning to climb the mounyour being like water from behind a bursting tain of joy. And as you climb, you can feel this dam, overwhelming you completely as your joy coursing through every fiber of your being, breathing comes still faster and your heart as the level of j oy within you continues to rise. begins to pound. Now, you are about to be transported to But there is never any sense of strain or greater heights of pleasure than you ever fatigue; for the heights which you are able to dreamed possible. As you continue soaring achieve in trance are truly without limit. And farther and farther into trance, you are already the higher you go, the higher you want to go EGOSTRENGTHENING: ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 45 and the stronger the effects of my words be Each time you climb this mountain of joy, come. you will be able to tap into more of this vast You are being guided all the way to the peak potential, and the joy which you are able to of the mountain by the sound of my words experience in your everyday life will be correalone; and as I continue, you will feel wave spondingly enhanced. after wave of ecstasy building up from the depths of your being and rolling endlessly forth like breakers upon an ocean shore. Each successive wave, as it comes crashing forth, will Stein's Clenched Fist Tech nique carry you still higher, leaving you ever more sensitive and more responsive to the one which D . Corydon H a m mond, Ph. D. is to follow. Salt Lake C1ty, Utah And the higher you climb, the higher you want to climb and the stronger the effects of my I N DICATIONS words become. The waves of joy will come faster and faster This is an egostrengthening and hypnotic until they finally blend together into one vast conditioning technique that can give patients a tide. And when they finally fuse together and valuable coping method for altering problembecome one, they will carry you up to an atic emotional states. Unconscious resources ultimate peak of joy which is the fulfillment of within the patient (e.g., feelings of confidence, all existence. And then you can sink back, happiness, calm, spontaneity) are accessed and happy and fulfilled, and able to experience joy then conditioned, so that they may be evoked more fully in your everyday life. by the patient whenever needed. This technique And each time this exercise is repeated, your may be used for coping with anxiety, anger, capacity to experience joy will become greater, cravings (smoking, food, alcohol, drugs), with and your ability to live joyfully will be correcompulsive disorders, in nailbiting, and with spondingly enhanced. psychosomatic disturbances. In a sense, this Now, as you continue climbing on and on, method is like the behavioral methods of you begin to sprint; for you are determined to thought stopping and thought substitution, reach the peak as soon as you can. And with which can often be made more powerful and every step, your speed increases. Running and automatic through hypnotic conditioning. Failrunning, breathing faster and faster, nearly ures may occur if this technique is used when bursting with delight as the level of joy within unconscious adaptive functions are being you continues to rise. And when you finally served which need to be examined through sink down upon the peak, a final burst of joy exploration techniques (e.g., ideomotor signalwill explode within you like a rocket. Now you ing), or when strong hostility requires exploraare very near the peak. Almost there. Now! tion and abreaction. The verbalizations mod And as you sink down upon the peak and the eled below are mine, but they are modeled after joy begins to subside, it is followed by a Dr. Calvert Stein. boundless feeling of peace and tranquility, confidence and calm. You feel just as secure as a little baby nestled in its mother's arms. And as T H E TEC H N IQ U E a result of having tapped into this vast potential for experiencing joy, you will be much more [First, identify the resource and feeling state able to respond joyfully in everyday life situaneeded by the patient. Following induction and tions; and each new day will contain new deepening, the patient may be told:] Now I treasures of joy for you to discover and to want your unconscious mind to search through experience. your memories and identify a time when you 146 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS felt (e.g . , confident, happy, peaceful and calm, need to do is clench your dominant hand into a healthy, accepted, competent, strong). fist, and this same kind of memory and feel Just allow your inner mind to identify a time ings, will come back into your experience. when you felt , no matter how brief [Identify two other experiences where the the experience, or how long ago, and no matter patient felt these same types of feelings, going how intimate or personal the experience, bethrough the same procedure and suggestions.] cause it isn't necessary to tell me anything about And now you can feel pleased, and feel a it if you don't want to. And when your unconsense of confidence in knowing, that you have scious mind has identified that experience, just learned a method for recapturing these feelings, allow your "yes" finger to float up. whenever you need them . Your unconscious [After an ideomotor response:] Good. Now mind has memorized these feelings, these expe I'd like your unconscious mind to take you back riences, and they will remain just beneath the through time to that experience. Just allow surface, as inner resources. And because of this yourself to drift back to that experience, and conditioning, they will be readily available, when you are there, allow your "yes" finger to whenever you need them. All that you'll need to float up again. [Following an ideomotor redo is to clench your hand into a fist, sponse:] Good. And as you enjoy that experias these memories, and positive feelings, wash ence again, you can begin to sense those feel-back over you. ings associated with it - feelings of And I'd like you to demonstrate this for And when you're aware of experiencing those yourself now. In a moment, I want you to feelings again, allow your "yes" finger to float squeeze that (right, left) hand into a confident up to signal me. [Pause for response] That's fist. And as you do so, notice, just notice how right. And notice how those feelings get stronone of these same wonderful memories, and ger, as you enjoy that experience again, in these same feelings, come back into your expecomplete privacy. [Pause] rience. Go ahead. [Pause] And enjoy this expe And now as you feel these feelings, I'd like rience. [Pause] And the stronger you clench you to close your dominant hand into a tight that fist, the more vivid the feelings become, do fist, and as you do so, these positive feelings they not? [A double check] And I'd like you to become even stronger. That's right, just close appreciate, your own ability, to recapture these your dominant hand into a tight fist, as a sign feelings, whenever you wish, knowing that they and symbol of confidence and determination. are always there, just beneath the surface for This is the hand that you trust and depend on. you. And as you clench it tightly, feel the feelings of Now allow that fist to relax, and allow becoming even stronger. And when yourself to drift into an even sounder, and you're aware of feeling those feelings even more deeper hypnotic state. [Deepen the trance.] strongly, just nod your head to let me know. And now you're going to have an opportu That's right, and just continue enjoying that nity, to learn another method, which will allow experience, and these good feelings, allowing you to even more effectively neutralize the them to fill you, and to flow all through you. feelings of , and replace them with And as you continue experiencing these feelfeelings of and . In a mo— ings, take several deep, refreshing breaths, ment, I'd like you to permit yourself to rewhile your unconscious mind memorizes, all of member an unpleasant experience, that made these wonderful feelings. Because in the future, you feel . It doesn't have to be so whenever you close your dominant hand into a unpleasant that it makes you miserable. I don't tight fist like this, you will feel once again, these want you to be that uncomfortable. But allow feelings of and , flowing just enough of an unpleasant memory to come back over you and filling you. Whenever you back, so that you begin to feel some of those want to experience these feelings again, all you feelings of [Pause] And when EGOSTRENGTHENING: ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 47 you're experiencing some of those unpleasant remain with you, far longer than you might feelings, signal me with your "yes" finger. expect. All right. And now I want you to enjoy You now have a method for controlling your discovering something, very interesting. I want own feelings, and for creating this same sense you to notice, how these negative feelings can of wellbeing, whenever you need to. So whenbe transferred and displaced, into your ever you feel (negative feelings), just close your nondominant, (left, right) hand, as you close it (nondominant) hand into a fist. As you do so, into a fist. Close your (left) hand into a fist, and you'll feel all as you do so, be aware of how those unpleasant those unpleasant feelings and sensations feelings and sensations funnel down, through flowing, and funneling, and concentrating into your shoulder, your arm, your forearm, down your hand. And after a short time, into your (left) fist. Allow all those unpleasant when it feels as though all those unpleasant feelings and sensations, those negative emofeelings are locked up in that hand, then you tional and physical knots, to flow down into can neutralize them. You can get rid of them, your fist, condensing and concenand then replace them with positive feelings, by trating there. Lock them up tightly in that fist, simply squeezing your (dominant) hand into a keeping them there until you're reasonably sure tight fist, while you open your that all of them, or the majority of them, are in hand, and let go of all the unpleasant feelings that fist, where you yourself have displaced and and sensations . And I want you to really enjoy, transferred them. You may not always be able all the positive feelings, and wonderful memoto keep unpleasant feelings from appearing in ries that flow over you, and that will increase, your mind or body, but you'll be able to the tighter you squeeze that fist. transfer them into your fist, where And after a minute of two of clenching that you can control them . And when it feels as if all fist, you'll discover that those pleasant, good those unpleasant feelings, are collected into feelings, will remain with you . Almost as if, by that fist, j ust nod your head to signal me. clenching that fist, you've infused Good. Now, since you're the one who put your whole being with so many, good feelings, those feelings into that (left) fist, you're the with so much of those natural endorphin subperson who can remove and neutralize them. stances from your brain, that for a long time, And I want you to observe how easy it is, to get there's just nothing to bother you, and nothing rid of those feelings, and replace them with to disturb you. positive feelings. I want you to squeeze your (dominant) hand into a strong, confident, happy fist. And as you do so, allow your (nondominant) hand to relax, letting go of all Suggestions for those unpleasant feelings. That's right. Just EgoStrengthening move those fingers around, allowing all those unpleasant feelings to flow out of your hand, as j o h n H artland, M . B . if they were just evaporating, or falling onto the floor. And you'll discover that the unhappy memory disappears, and is replaced by a posi I N DICATIONS tive one. And you can enjoy that happy memory again, in complete privacy, with that The suggestions that follow are the original happy fist tightly closed, as a symbol of confiego-strengthening method, pioneered by the dence, and strength, and determination. Enjoy late John Hartland. Although they are extaking several extra deep, relaxing breaths, as tremely general, highly directive and authoriyou just luxuriate in these positive feelings for a tarian, they may nonetheless be useful with while. [Pause] And these good feelings will patients who are dependent and submissive to 148 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS authority. Clinicians may also find certain confatigued . . . much less easily discouraged . . . cepts and ideas useful to adapt for individual much less easily depressed. Every day . . . you patients, and to modify into a more permissive will become so deeply interested in whatever form. (Ed.) you are doing . . . in whatever is going on around you . . . that your mind will become completely distracted away from yourself. You SUGGESTIONS will no longer think nearly so much about yourself . . . you will no longer dwell nearly so You have now become so deeply relaxed . . . much upon yourself and your difficulties . . . so deeply asleep . . . that your mind has beand you will become much less conscious of come so sensitive . . . so receptive to what I yourself . . . much less preoccupied with yoursay . . . that everything that I put into your self . . . and with your own feelings. mind . . . will sink so deeply into the uncon Every day . . . your nerves will become scious part of your mind . . . and will cause so stronger and steadier . . . your mind calmer deep and lasting an impression there . . . that and clearer . . . more composed . . . more nothing will eradicate it. Consequently . . . placid . . . more tranquil. You will become these things that I put into your unconscious much less easily worried . . . much less easily mind . . . will begin to exercise a greater and agitated . . . much less easily fearful and appregreater influence over the way you think . . . hensive . . . much less easily upset. over the way you feel . . . over the way you You will be able to think more clearly . . . behave. you will be able to concentrate more easily. You And . . . because these things will rewill be able to give up your whole undivided l main . . . firmly imbedded in the unconscious attention to whatever you are doing . . . to the part of your mind . . . after you have left complete exclusion of everything else. Consehere . . . when you are no longer with me . . . quently, your memory will rapidly improve . . . they will continue to exercise the same great and you will be able to see things in their true influence . . . over your thoughts . . . your perspective . . . without magnifying your diffifeelings . . . and your actions . . . just as culties . . . without ever allowing them to get strongly . . . just as surely . . . just as powerout of proportion. fully . . . when you are back home . . . or at Every day . . . you will become emotionally work . . . as when you are with me in this much calmer . . . much more settled . . . much room. less easily disturbed. Every day . . . you will are now so very deeply asleep . . become . . . and you will remain . . more . that . everything that I tell you that is going to happen and more completely relaxed . . . and less tense to you . . . for your own good . . . will happen each day . . . both mentally and physically . . . . . exactly even when you are no longer with me . . as I tell you. And every feeling . . . that I tell you that you will experience . . . you And as you become . . . and as you rewill experience . . . exactly as I tell you. And main . . . more relaxed . . . and less tense each these same things will continue to happen to day . . . so . . . you will develop much more you . . . every day . . . just as strongly . . . confidence in yourself . . . more confidence in just as surely . . . just as powerfully . . . when your ability to do . . . not only what you you are back home . . . or at work . . . as when have . . . to do each day . . . but more confiyou are with me in this room. dence in your ability to do whatever you ought During this deep sleep . . . you are going to to be able to do . . without fear of failure . . . . feel physically stronger and fitter in every way. without fear of consequences . . . without un You will feel more alert . . . more wide necessary anxiety . . . without uneasiness. Be-awake . . . more energetic. You will become cause of this . . . every day . . . you will feel m uch less easily tired . . . much less easily more and more independent . . . more able to EGOSTRENGTHENING· ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 49 'stick up for yourself . . . to stand upon your gave you a strong sense of pride and accomown feet . . . to hold your own . . . no matter plishment, and meant a great deal to you at the how difficult or trying things may be. time. It may have been graduation from high Every day . . . you will feel a greater feeling school, or the day you got your first driver's of personal wellbeing . . . a greater feeling of license, or almost anything else you can think personal safety . . . and security . . . than you of, as long as it was something you really felt have felt for a long, long time. And because all good about when it happened. Take your time, these things wrll begin to happen . . . exactly as and as soon as you have thought of a situation I tell you they will happen . . . more and more which fits this description, you can signal me by raprdly . . . powerfully . . . and completeraising the index finger of your right [or left] ly . . . with every treatment I give you . . . you hand. will feel much happier . . . much more content[After the subject has responded:] All right. ed . . . much more optimistic in every way. Now let yourself get in touch with the feelings You will consequently become much more able of achievement and satisfaction which you were to rely upon . . . to depend upon . . . your-feeling when you were actually in that situation. self . . . your own efforts . . . your own JUdg-Let yourself go back and experience those ment . . . your own opimons. You will feel feelings once more, and feel them growing even much less need . . . to have to rely upon . . . or stronger as I speak. Growing and growing, and to depend upon . . . other people. becoming clearer and stronger and more intense with every passing second. And all the time I am speaking to you, until the trance is over, these feelings are going to continue growing Suggestions for stronger by themselves. SelfReinforcement And when the trance is ended, your normal, everyday mood will return. And of course, you Don E. G i bbons, Ph . D . will have no need to balance things out by feeling bad, just because you have been al INTRODUCTION A N D I N DICATIONS lowing yourself to feel so good. But because you have been able to recapture and to The following suggestions are designed to strengthen these feelings of pride and accomassist an individual in developing a greater plishment, and the sense of deep personal satcapacity for selfreinforcement so that he will isfaction that goes with them, it will be much be less dependent on external sources of reeasier for you to feel good in the future over all ward - and hence, better able to determine the the things you do that you ought to feel good course of his own conduct. Of course, nuabout, and to give yourself a pat on the back merous concrete applications are possible. whenever you have it coming. SUGG ESTIONS Visualization of the Now I would like to help you to experience the feelings of satisfaction and achievement Idealized Ego-Image which come with the attainment of an impor Mau rice H . McDowell, Th . D. tant goal, so that you can learn to practice and Salem, Oregon strengthen these feelings and apply them to the attainment of other goals in your life. First of I NTRODUCTION all, I would like you to think of a time in the past when you had just achieved something that Normally, I ask patients to read the first four was very important to you - something that chapters of Maltz's Psycho-Cybernetrcs. If they 1 50 HANDBOOK OF HYPNOTIC SUGGESTIONS AND METAPHORS read the first four chapters, they normally will Cycle of Progress continue to read the rest of the book, and this makes an excellent background for therapy. Douglas M. G regg, M . D . After deep hypnosis has been obtained, the San 01ego, California following suggestions are given to each patient. As you continue to relax, just letting yourself SUGG ESTIONS drift down deeper and deeper relaxed . . . you relax completely throughout every fiber of your Each person has several selfimages. Your being; relaxing physically, emotionally, menobvious, conscious selfimage is largely a retally and spiritually. And as you relax so comflected image of how you feel significant people pletely in this fashion , concentrating your have reacted to or treated you. If you have felt mind, listening to each word that I say, you let that they treated you as a just, honorable, and each suggestion take complete and thorough decent person, you will tend to think of youreffect to help you, deeply and automatically, on self in those terms. If, on the other hand, you both the conscious and unconscious levels of have felt that they regarded you as a bad, lying, mind activity. You extend the principles of thieving, untrustworthy person of little value, relaxation and concentration which you now you will tend to think of yourself in those experience into your everyday life so that in terms. every situation, and in every circumstance in You also have precise selfimages: How you which you find yourself, whether alone or with feel that your father feels toward you. What others, you relax and you concentrate your your mother would say about you if she were mind, automatically; no matter what you are present now. Or, how would your favorite doing, you find that more and more, day by teacher evaluate you? How do you think the day, you relax and you concentrate your mind. teacher you most dislike would evaluate you? If you are doing something for fun or relax What would your best friend say about you? ation, you relax and you enjoy it more . . . you [These various images were sometimes disconcentrate your mind casually and comfortcussed with the patient for clarification. If any ably and get more out of what you are doing. If traumatic materials were elicited, a temporary you are doing something that involves work or amnesia was often instilled for follow-up at a some serious project or activity, you relax and later time.] apply yourself more thoroughly, more effec Now I want you to go way deep into your tively; you concentrate and do a better job. own mind and visualize the real you, the kind And so, every day in every situation and in of a person you really are and can really every circumstance in which you find yourself, become. I want you to look at it very carefully you relax and you concentrate, more and more and to study it thoroughly and lock it into your and more. As you relax and concentrate, you conscious mind so that we can discuss it when I evaluate everything thoroughly and completely; alert you. you reach decisions easily and readily; you act I shall count to three, and the visualization efficiently and effectively; and you build your will immediately appear in your mind. As soon self-confidence, your selfreliance, your selfas you have completed the visualization, please acceptance, and your self-esteem. You become lift your right index finger to signal me that you a stronger individual; you become selfhave completed your part of this project and sufficient. As this occurs, you feel more relaxed are willing to be alerted. . . . and you are capable of greater concentration. [This technique has been used with over one Just drifting down now . . . way down . . . hundred college students in their search for deeper relaxed. And you realize that as you are identity. It has been very helpful to a majority more relaxed and as you are capable of greater of the students.] concentration, you evaluate things even more EGOSTRENGTHENING: ENHANCING ESTEEM, SELFEFFICACY, AND CONFIDENCE 1 5 1 thoroughly and completely; you reach decisions concentrate your mind more and more. Helping even more easily and readily; you act even more you as you learn to relax, deeper and deeper efficiently and effectively and you continually relaxed . . . as you learn to concentrate your build your self-confidence, selfreliance, selfmind more and more intensely, more and more acceptance, and self-esteem . . . growing stroncompletely, just drifting deeper relaxed. ger and more capable every day in all situations. As you do this, you feel even more relaxed and you are capable of even greater A Brief EgoStrengthening concentration. As you drift down deeper relaxed, you let all of these suggestions seat Suggestion themselves deeply, permanently in your unconscious mind. And as you apply these principles Wi l l iam T. Reardon, M . D. in your life automatically every day, in every Wt!mtngton, Delaware situation and in every circumstance in which you find yourself, whether alone or with others, You will be able to tolerate the persons, you relax more and more deeply, you concenplaces, or things that used to disturb you and trate your mind more and more sharply and annoy you. You will be able to adjust yourself intensely, you evaluate thoroughly and comto your environment, even though you cannot pletely, you reach decisions easily and readily, change it. you act efficiently and effectively, and you continually build your self-confidence, selfreliance, self-acceptance, and self-esteem. And A Futu reOriented Suggestion you continually find that you are capable of more relaxation and greater concentration and P. Oystragh so on in a cycle of progress that grows, that Bandt, N.S. W., Australta deepens, strengthens and reinforces itself every day as you grow and become that person that . . . and as this begins to happen, every day you have always admired; the person you have you will find yourself better able to . . . [inalways wanted to be: self-sufficient. clude relevant suggestions] . . . and achieve for All of these suggestions are now implanted yourself that picture of yourself that you have deeply, firmly and permanently in the deepest in your mind's eye. As you want to be, as you reaches of your unconscious, and they are part can be, and as you will be. of your entire being to be used automatically by You will be able to stand up for yourself, you to make your life more effective, more stand on your own feet and state your opinion productive, more useful and happier as you or suggestion without embarrassment, without learn to relax more and more, as you learn to fear and without anxiety. � 6 ANXIETY , PHOBIAS , AND DENTAL DISORDERS I NTRODUCTION Anxiety and Phobic Disorders LERE ARE M�-�-�.IHOJ:>s_for disorders. Occasionally, direct suggestions for relief of anxiety_qr effectiY.e...{e.g., Horowitz�1970;MarkS: 1 968; 1965). When direct suggestions are ineffective, there are many other suggestive hypnotic techniques that may be productive. The patient may be may be ac.£_omp]ished to a tranquil feeling distant regression or age progression to more peaceful scenes _..A!!