80. Гипноз как измененное и регрессированное состояние сознания. М. Гилл (80. Hypnosis as an Altered and Regressed State of Consciousness. Merton M. Gill)
( A revision and condensation of a paper published in the Internati onal Journal of Clinical and Experimental Hypnosis, 1972, 20: 224-237. Supported by Research Scientist Award. National Institute of Mental Health, K5-MH-19: 436)
University of Illinois, Chicago, USA
The paper deals with four main topics: 1. A general characterization of hypnosis as an altered state of consciousness; 2. A more specific characterization of this altered state as a regressive one, arguing that dissociation and role are concepts subsumable under regression; 3. A restatement of some of the differences between my views and Kubie's (1961), emphasizing psychological rather than psychophysiological factors and insisting that transference phenomena play an essential role in both induction and the hypnotic state; and 4. A discussion of major differences in perspective on psychology, and whether one is an experimenter or a clinician, which inevitably lead to the disagreement about whether hypnosis is an altered state.
The principal justification for dealing with hypnosis in a symposium on the unconscious is that the simplest and most readily persuasive demonstration of the reality of unconscious psychic processes lies in the phenomena of posthypnotic suggestion. Freud (1912) referred repeatedly to how this shows that an unconscious motivation can actively influence behavior.
Freud's earliest psychotherapeutic activities employed hypnosis and it was through these experiences that he first gained insight into such central psychoanalytic concepts as unconsciousness, repression and transference.
This paper, however, instead of focusing directly on the light which hypnosis can shed on the concepts of unconsciousness and the unconscious (see my other paper in this symposium for the distinction) will summarize the current psychoanalytic theory of hypnosis, namely that it is an altered and regressed state. In particular this view will be defended against the argument that hypnosis is not appropriately designated an altered state of consciousness.
Hypnosis As An Altered State
It is not easy to say how comprehensive and in what dimensions a change in a person must be to justify concluding that an alteration of state has occurred. While personality dimensions seem in general to be continua rather than dichotomies, an altered state must be a distinct qualitative shift with its own boundaries. It must show a reasonably unique grouping of phenomena, though of course any individual phenomenon seen in a particular altered state can occur in many other contexts. This configural point often seems lost sight of by the antistatists.
Before specifying these dimensions I note that there is much evidence in the phenomena of hypnosis that some massive change is coming about. This evidence lies in the distinction between the transitory transitional phenomena most usually appearing during hypnotic induction but occasionally to be seen as hypnosis is terminating too (Orne and Evans, 1966) and the phenomena of the established state. Emotional outbursts are dramatic instances of such transitional phenomena, though spontaneous changes in body image are more common (E. Hilgard, 1965). The unexpectedness of these changes to both hypnotist and subject makes most unlikely an explanation in terms of demand characteristics (Orne, 1959). They are rather to be seen as instances of deautomatization and thus as transitional indications of disequilibrium which disappear as reautomatization in the established state takes place (Gill and Brenman, 1959).
The second major line of evidence that hypnosis is an altered state lies of course in the hypnotic phenomena themselves. I will restrict myself to organizing the phenomena in terms of Rapaport's (1951a, 1951b, 1957) conceptualization of the dimensions of an altered state of consciousness, phrasing them in the direction of a change to a more regressed state.
I should first make clear however my own understanding that the phrase "state of consciousness" is not equivalent to a characterization in terms of nature of consciousness only. Consciousness is only one dimension of a state of consciousness. In fact state of consciousness is, in the ordinary usage, equivalent to state of the psyche.
The changes in the several dimensions are these:
a. A diminution in reflective awareness. The redistribution of attention is another way of conceptualizing the empirical referent.
b. A diminution in voluntariness. This is what Hilgard (1965) called the subsidence of the planningfunction, and referent is the hypnotic subject's disinclination to take initiative.
c. A change in thought functioning toward more primary process organization (Orne's (1959) demonstration of primary process thinking, which he calls "trance logic", deserves special mention. It is of no small import that trance logic is one of if not the only finding so far which clearly separates the genuine subject from the simulator). Here belong the availability of visual memories and dream and fantasy production, the reduction in reality testing and the reorganization of the defenses, resulting for example in the capacity for amnesia.
The changes in reflective awareness, volition, and thought organization are all in the direction of and conceptualizable as repression, and hence are indications that we are dealing with a coherent state.
There are two more phenomena that deserve mention.
d. One is role behavior. While this would perhaps be best discussed as an aspect of susceptibility I mention it here as one more indication that the various ego functions are reorganized in a way which requires us to see them as comprising a state rather than an incoherent miscellany.
e. And last, suggestibility. In the past it would have been easy to say that hypersuggestibility is an index of transference, that is a regressive alteration in interpersonal relations paralleling the regressive alteration in ego functions.
But there has been a good deal of unrest recently about whether hypnosis really is accompanied by an enhanced suggestibility. The experimental literature is complex and hard to integrate. (E. Hilgard, 1967; Rosenhan, 1967)
I believe further investigation of the matter will clarify that the central phenomenon is a regressive alteration of the relation with the hypnotist, that this may and often does take the form of subservience with hypersuggestibility, but that it can and does sometimes take other forms including the contrary form of stubborn negativism, a phenomenon the clinician is more likely to see.
A third line of evidence for regarding hypnosis as an altered state is that there are related conditions that are clearly altered states. Brenman and I (1959) considered these states of such value in understanding hypnosis that the subject of our book was hypnosis and related states.
Fugue, traumatic neurosis, and multiple personality are altered regressive states which show manifestations similar to hypnosis, a similarity given added significance by the greater incidence of hypnotizability in such states. One could also point to the probable greater incidence of hypnotizability in hysterics than in the general population; and at least some kinds of hysterics show episodically clearly altered states of consciousness.
There even seems some evidence that there is a relationship between hypnosis and sleep after all. There have been some reports (Cobb et a 1., 1964, 1965 and Evans et a l.,1 1966, 1969) of a similarity between responses to suggestions given in sleep and post-hypnotic behavior, a similarity which in Evans' words is given "added significance because both tend to occur with the same subjects".
Hypnosis as Regressed State
Though the evidence that hypnosis is a regressed state is mainly clinical, the recent study of the personality correlates of susceptibility by J. Hilgard (1970) offers important confirmation.
Her major finding is the association between the capacity for intense involvement in some activity and hypnotic susceptibility. Despite relatively low correlations, the finding is a striking and original one.
The intense involvement is described essentially with activities and things, rather than with people. This is not to say that involvements with people are described as not intense but rather that they are relatively little dealt with in this work.
An intense involvement, whether with activities or people, bespeaks a capacity for the surrender of self to something on the outside on the one hand and mergiug with that something on the other. Stated otherwise, it is an ability to yield something of one's autonomy. In terms of the psychoanalytic model of progressive autonomy with increasing maturation, such a surrender of autonomy is regressive.
I argue that the concept of regression is not only compatible with the finding but suffices to cover it and that additional concepts like dissociation and role involvement are descriptive and subsumable under regression.
Since the regression is a regression in the service of the ego, it of necessity excludes some aspects of ordinary ego functioning and thus implies dissociation, if by dissociation is meant a lack of integration of what might otherwise be synthesized. By its very definition, regression implies diminished integration.
Furthermore, the existence of such a regression implies more than an isolated fragrrent of functioning. It implies rather an organized entity - what Brenman and I (1959) have referred to as a subsystem within the ego. It seems to me such a subsystem could also be called a role and that its regnancy might well be called role involvement-
The term regression often connotes pathology but it need not, and of course to call hypnosis pathological would fly in the face of the finding that hypnotic susceptibility is more characteristic of normal than of disturbed personalities. For the regression is a regression in the service of the ego and the capacity for such regression is a mark of health. As Hartmann (1958) put it, "the nor-mal ego must be able to must".
Dr. Hilgard sees a relationship between the subjecst' involvement and the concept of transference too. I agree. Like involvement with something nonpersonal, transference is involvement with another person with some surrender of self and fusion. The subjecst' compliance and loss of initiative, his awaiting directives from the hypnotist, are evidence of this kind of relationship.
Recognizing that my generalization is only sketchily supported by these remarks, I see Dr. Hilgard's finding as the first clearcut empirical demonstration of a relationship between personality and hypnotic susceptibility which confirms the psychoanalytic view that hypnosis is a state of regression in the service of the ego and that that aspect of this regressive state which comprises the subject's relationship to the hypnotist is what we call transference.
A Disagreement with Kubie's Views on Induction and Transference
I turn now to Dr. Kubie's (1961) views of the process of induction and transference in hypnosis. Though his writings seem to me sometimes ambiguous on the subject Dr. Kubie sees the essence of induction in psychophysiological changes. He believes hypnosis can be induced without a hypnotist. But I find it noteworthy that he frequently refers to the state resulting from induction by nonpersonal means as hypnoidal and that he stresses that though there may be no external hypnotist there is an internal one, even if only in the shape of a guardian angel.
Brenman and I did say in our book that the hypnotic regression could be initiated either by sensory-motor manipulation or by a regrsesive tie to the hypnotist. But by sensory-motor manipulation we meant something quite different from Kubie's subject suspended in a tank of water, encased in a plastic bubble high above the gravitational field, or in a respirator which takes over breathing- We meant something more akin to what psychoanalytic theory calls an ego apparatus; our notion of deautomatization of such apparatus is a psychological rather than a physiological concept and what we had in mind in speaking of the loss of reality moorings was not a "partial afferent isolation" but a psychological disorientation in time and space with an ensuing search for a strong figure to take over the protecting and guarding functions.
Since I differ with Dr. Kubie's emphasis on psychophysiological considerations, so must I inevitably differ with him on the role of transference in hypnosis. He belittles its importance as a primary phenomenon in hypnosis, though he concedes that in any interpersonal relationship there must be transference. To me transference is crucial in hypnosis. The hypnoidal states he de-scribes are doubtless regressive states and, since there furthermore is always an introjected object to which a helpless human being will turn, there are surely some major resemblances between these hypnoidal states and hypnosis. But for me hypnosis does require an outside hypnotist and the transference is of the essence.
I distinguish two kinds of transference in the hypnotic subject and I was pleased to see that Dr. Hilgard seems to find this distinction plausible. The first kind of transference is the one underlying the hypnosis itself. It is the existence of the capacity for this transference which makes the real characteristics of the hypnotist so apparently unimportant at first, because this transference is present from the beginning and is a predisposition evoked but not created by the hypnotist.
Only as a relationship with the hypnotist as a real person develops over time do we see the second kind of transference, that complex amalgam of feelings and attitudes, in part justified and in part unjustified by the real relationship with the hypnotist. This is the kind of transference we see developing in therapy.
The nature of the transference on which hypnosis is based is still not known, nor even whether it differs from person to person. As we inquire for such material in a subject, are we getting the second kind of transference, the first, or some unknown mixture of the two? Research in hypnosis has so far failed to clarify the distinction between what we might call the primary transference and the secondary transference, though it has clarified some ego characteristics of the way a susceptible subject functions.
The State, Anti-State Dispute
Every one of the phenomena cited and all the arguments given have been disputed by those who reject the idea of an altered state. Instead of trying to counter these arguments as such, I will offer what I believe to be some of the reasons standing in the way of a resolution of the dispute.
1. The unfortunate connotations of the term "trance" to describe the altered state.
"Trance" sounds mystical and unscientific. Furthermore it suggests a close relationship to sleep, which is at least questionable. It is therefore especially unpleasant to those who want to make hypnosis scientific and rid it of its dubious aroma. I don't like the term either and much prefer the term state, but surely the connotations of the term "trance" have no bearing on whether hypnosis is an altered state.
2. Important differences in general psychological perspective between those who hold the altered state view and those who do not.
a. The intrapsychic. To be able to seriously entertain a state view, one has to be seriously interested in the intrapsychic - the world of subjective phenomena or meanings. Though I reject the idea that hypnosis is no more than a subjective sense of change and though I believe anything said by a subject has to be critically appraised like any other datum and not taken at face value, I believe that some of the data most conclusive to the state point of view are most readily seen in the subject's report.
b. Intrapsychic organization. It is not only whether one takes the intrapsychic seriously but also the view one has on the nature of the intrapsychic which will influence one's position on the state concept. Does one see the intrapsychic as a piecemeal collection of attitudes, expectancies, and motives or does one see the intrapsychic as organized according to dimensions? I have already indicated that the state view proposes an integration in which the ego functions of reflective awareness, volition, thought organization, and the mode of object relationship are central. Since the state concept of necessity implies organization, those who do not see the intrapsychic as a coherent organization will not be likely to accept a state concept.
c. The developmental point of view. Those who take seriously an organized psyche are likely to see the nature of this psyche as determined in part by the organism's history - and in a sense the psyche is in part a record and precipitant of this history. They will therefore find congenial the possibility that the psyche may have latent modes of organization which can become active under certain circumstances, and that hypnosis may be one of these, expressed as a regression in the service of the ego.
Of course the anti-statists do not totally ignore the organism's history but they seem concerned with it not much more than with the way some of the manifestations of hypnosis in a particular person reflect the history of his ideas of what happens in hypnosis.
d. Is the organism only reactive or active too? Those who see the organism as essentially reactive in a moment-to-moment way will of course more likely stress the external stimuli to which the organism is considered to react. Those on the other hand who consider the person to be an actor as well as a reactor and who see his actions as a function of intrapsychically organized systems, like goal-directed motivations, are much more likely to accept a state concept. And they will look for changes in spontaneously initiated integrated behavior as a sign of an altered state.
3. Whether one holds a state or anti-state view may depend on whether one is essentially a clinician or an experimentalist.
a. The manipulability of variables. There is a reciprocal relationship with the general psychological perspectives we have just listed. For in general,, and only in general, an expermienter, seeking to manipulate isolable variables will believe that he can do this much more easily with external than with intrapsychic behavior. He will be less likely then to concern himself seriously with the psyche. And similarly, one who does not take the intrapsychic organization very seriously is more likely to approach the study of human phenomena in the fashion of an experimenter.
b. Individual versus group. The clinician deals with the individual, rather than a group. The clinician is obviously therefore in a better position to see and explore detail, idiosyncrasy and individual difference. The phenomena which lead to the altered state concept are those which emerge more sharply in the intensive study of the individual rather than the averaged commonalities of the group.
c. Depth of hypnosis. The clinician usually deals with an hypnosis of greater depth in the conventional sense of the demonstrability of the usual hypnotic phenomena. Because the phenomena - especially the intrapsychic ones - that mark hypnosis as an altered state are more prominent in the deeper states, the clinician is more likely to see them.
d. Depth of involvement. The clinician deals with a more deeply involved subject, deep now in another sense. The subject is more involved because he has much more at stake than when he is in an experiment. In these circumstances he is again much more likely to show the evidence of an altered state. The frequency of emotional outbursts on induction is related to whether the context is therapeutic or experimental. Of course one has to distinguish what is a function of the therapeutic situation and what of the hypnosis. Anecdotal evidence suggests that hypnosis adds to the involvement brought about by therapy alone.
e. Opportunity for spontaneity. The clinician gives the subject much greater opportunity for the appearance of spontaneous manifestations. I refer not to the old-fashioned removal of symptoms by authoritarian suggestions but to hypnotherapy which so far as that is possible in the hypnotic state, attempts to use techniques of psychoanalytically oriented psychotherapy and to give the patient as much autonomy in the relationship as possible. Again I believe that these are the circumstances in which evidence of altered thought organization will especially appear.
4. The non-specificity of techniques of induction. If there were a well-delined and specific technique for inducing hypnosis, one could at least be sure of the manipulation required to produce the altered state. But both sides of the issue are murky. Hypnosis can come about without any apparent induction procedure and hypnosis induced by a tape recording in a group may be a very different phenomenon from hypnosis induced in a one-to-one emotional, ly meaningful relationship. It is difficult then to compare an allegedly non-hypnotic state which may be hypnosis with an allegedly hypnotic state which may not be genuine hypnosis.
5. Individual differences in susceptibility. The fact that one person can be hypnotized and another not seems somehow incompatible with the idea of an altered state. It is as though we were told some people sleep and others do not. But it is true that people differ enormously in depth of sleep and length of sleep. They differ widely in their susceptibility to drugs and toxic deliria, for example, while the related states occur in only a small fraction of the population. An altered state then does not have to be a universal nor an unlimited potential and to see hypnosis as an altered state is by no means its complete characterization.
6. The different degrees of hypnotizability. If hypnosis is a qualitative reorganization, should it not be an all-or-none phenomenon? The question is not easy to answer. Hilgard (1965) has demonstrated that factorial analysis of susceptibility data shows a strong general factor as well as others varied enough to reflect individual idiosyncrasies. One could argue that only the deep and "complete" hypnosis should be called an altered state but that would have the grave disadvantage of isolating phenomena that seem to belong together. Is it not possible for a regression to be limited to one sector of functioning, to be confined perhaps to motor phenomena and still be a qualitatively altered state?
The several dimensions of depth. If it is true that there are several dimensions of hypnotic depth and that, depending on individual proclivities, on induction techniques, and possibly on other factors, hypnoses differ from one another in the several dimensions of depth, this all may be another reason that the dispute about state is unresolved. For again the disputants may be talking about different data. The so-called trance dimension of depth is especially under attack by the anti-statists, but it is not clear how crucial this dimension is to the state concept.
From my point of view, to work without a state concept is to fragment the phenomenon of hypnosis and tear it out of its place in an overall conceptual scheme.
Some people are doubtless pro-statist because of mystical attitudes or because they are sloppy in their methods and conceptualizations. Those of us who try not to exclude any valid approach to the organism - including subjective phenomenology and inferred constructs like unconscious motives - must cling to the scientific method as a major safeguard against self-deception and must be doubly cautious about our reasoning and our experimental controls (Dr. Robert R. Holt, who kindly read and criticized the paper, suggested this appropriate caveat).
The argument of state versus anti-state recapitulates the old question of who is responsible for hypnosis - the hypnotist or the subject. Though it would seem obvious that it takes two to tango, people seem to persist in singling out one or the other partner as the whole show. The state view lays special stress on the subject, while the "motivational" view sees the behavior as essentially shaped by the hypnotist.
Hypnosis is not a condition in which the subject's behavior is determined moment to moment and point for point solely by the interaction between hypnotist and subject. Rather it is a condition in which a general alteration takes place, after which any of the subject's behavior becomes not only a function of his state but of his interaction with the hypnotist too. Hypnosis requires for its understanding state, trait, interactive, and of course developmental concepts, too.
One of the most difficult problems in the conceptualization of hypnosis is that of specificity. All the characteristics that I have given as comprising the hypnotic state occur both singly and in cmobination in many other conditions. What then is specific about hypnosis? In my view it is that the state is brought about in the context of a relationship with a hypnotist, is either explicitly or implicitly accepted by both participants as designed to give the hypnotist various kinds of temporary control over the subject's physical and mental functioning, and is to be terminated at a signal from the hypnotist. I believe, for example, that it is the implicit recognition that hypnosis is defined as a state brought about in a particular interpersonal context which leads Kubie to designate a related condition brought about without a hypnotist as "hypnoidal" rather than "hypnotic". So too for all the other related states which have a kinship to hypnosis but are not hypnosis.
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