[Episode 29] Today's podcast is the second in a two-part series on Clinical Hypnosis. According to the American Society for Clinical Hypnosis, hypnosis is a state of inner absorption, concentration and focused attention. Today I spoke with Dr. Elizabeth Winter about how and when to use clinical hypnosis. In the first episode, Dr. Winter and I spoke about the history of clinical hypnosis, key assumptions, goals, the client's role and types of problems that might be addressed with clinical hypnosis.Download MP3 [18:41]
References
- The American Society for Clinical Hypnosis: http://www.asch.net
- The Milton H. Erickson Foundation: http://www.erickson-foundation.org/
- Montgomery, G. H., et al (2007). A Randomized Clinical Trial of a Brief Hypnosis Intervention to Control Side Effects in Breast Surgery Patients. Journal of the National Cancer Institute, 99, 1304-1312.
- Pisano, M. (2007, November 17). Hypnosis takes patients to a calmer place. Houston Chronicle
- American College of Chest Physicians (2007, October 24). Hypnotherapy for smoking cessation sees strong results. ScienceDaily.
Transcript
Interview
Jonathan Singer: So as a clinician, how do you decide when to use hypnosis?
Elizabeth Winter: Probably the first caution is to use only to do something that you’re already trained to do. And that may sound a little bit obvious but for example, it would be appropriate for me as a social worker to use it with somebody who comes to see me for work on addictions. It would not be appropriate as a social worker for me to help someone to induce analgesia or anesthesia with an intention of my performing surgery on them. I’m not trained to do that, I shouldn’t do it. And conversely somebody who is perhaps and anesthesiologist shouldn’t be doing psychotherapy using hypnosis. So it may seem obvious, but it’s really important that you don’t work outside your field or do anything that you’re not already trained to do. Having said that, not everyone is going to want hypnosis and it’s not going to be something that I would do with everyone. If somebody specifically comes and asks for hypnotic intervention, typically I would do that as part of a broader therapeutic relationship. And it may or may not be appropriate. For example, people will sometime specifically ask if they can use hypnosis to recover memories, typically memories they think they may have buried somewhere about past abuse. Now, I won’t do that kind of work and I won’t do it for a number of reasons, the primary one being memory is not history. And the fact that you recall something in a trance state doesn’t make it true, and in fact there is a fair amount of research that suggests that people who appear to remember things in trance have a higher degree of confidence in those memories but less accuracy. So that would be a time not to use it. If someone is motivated to use it for something like habit control, or anxiety, then certainly it’s worth exploring, and you would start out by teaching the skill before you would use it for the specific purpose. And I’ll give you a quick example of that. I once heard a story of a woman who had grown up in Europe and was towards probably her middle years looking to stop smoking, and she had smoked for many many years, and she wanted to use hypnosis to stop smoking. And what she found was she really got stuck going into trance, and kind of couldn’t go into trance, and when she was asked what her first memory of smoking was, when did you start smoking, it was when she had been smuggled out of Germany in the late 1930’s early 1940’s during the second World War. She had been smuggled out, she was a Jewish woman, and when she crossed the border into Switzerland, someone gave her a cigarette, and she took the first puff of that cigarette, they said this is what freedom tastes like. And so until she knew that she had you know her belief in freedom paired with her smoking habit, then no amount of teaching her to go into trance was going to make any difference, and sometimes you find those things out as you work. So it really depends, it depends on do you have the training and the skill set to do a particular piece of work, and if you wouldn’t without hypnosis, you shouldn’t do it with.
Jonathan Singer: So you use clinical hypnosis when someone asks for it, when it seems clinically appropriate, but also with the caveat that hypnosis is used within a treatment context that is within your scope of expertise and in your scope of practice.
Elizabeth Winter: Exactly.
Jonathan Singer: Let’s say they that all this criteria had been met with a client and you decided to use it. How do you actually use clinical hypnosis?
Elizabeth Winter: The first thing I do is to help someone learn how they best go into trance. There are a number of different inductions, so probably the one people are going to be most familiar with is fixing their eyes on a particular object, and it need not be a watch, and it need not be swinging in front of ones face, I will say that quite categorically now. But there is something called an eye fixation technique and this is one of what is known as the formal inductions. And when I talk about using hypnosis and what is ethical and what is appropriate, really talking about this sort of formal induction of hypnosis. Now the eye fixation may be helpful for someone who is more visually oriented and there are other forms of formal induction, one for example is an arm levitation induction. So that would be perhaps, and this is someone who is more comfortable with more physical and more body oriented rather than visual. There’s another, which focuses more on the ability to visualize things so that may be more appropriate for someone who thinks in that way. So there are different formal inductions. To use those help somebody to learn how to go into trance. Once somebody is in trance then a clinician would add what we would think of as a utilization, which would be what is it we are trying to accomplish, it may be suggestion in a fairly direct way, so you know one might say to somebody “You will be surprised at how much more comfortable you will be when …”. “As you monitor your breathing and slow down your next breath out, you will find that you’ve become calmer, more relaxed, and so on”. A simple example of just relaxation based, but that’s the utilization part of the trance. They then within that, or following that, perhaps be a suggestion for how that comfort or whatever it is will follow that person once the trance has ended. So just because the trance ends they don’t have to stop feeling comfortable you know, that comfort can go with you, that’s the post-hypnotic suggestion part of that. And then there is a termination of that, of the trance experience, which may sound something like “You return your attention to the room in your usual way in the next few breaths and so on”. So there is usually a structure to the formal induction of trance, but the induction, you know the induction of the early trance state is really just the beginning of that. And that will be completely really individualized for the person. There are some standard forms of script, actually some really really nice publications that have standardized scripts, and you know people often make their own but there are some really nice pieces of work for different applications. Now, formal induction is not the only way to use an understanding of hypnosis in the clinical setting. Now here’s the deal, since we go into trance spontaneously, I can intentionally work with someone to induce trance sitting in my office, but I can’t stop them spontaneously going into trance in my office. What I can do is recognize it and work with it because some spontaneous trances are useful and some are really quite harmful. So if there is a trance state which is what we would think of as a negative trance, so a highly focused attention perhaps in a relational situation, that is really really negative then my recognizing when someone has gone into hat sort of highly focused state that is not working well for them, is something that can be very useful clinically.
Jonathan Singer: So would this be something that you might recognize in a couples therapy session?
Elizabeth Winter: Oh sure, an induction into a trance state doesn’t have to be intentional obviously, so couples have a well worn path into an argument, into an old disagreement, into the you always do this, you never do that, so that can certainly operate as an induction if you like, with a focused attention or perhaps even more often focused disattenion, let’s say the induction "You never…"and then the other party disappears, they are not listening after that, they defocus, they have gone elsewhere. Could you view that as a couple’s trance? Certainly. I think it’s also helpful to consider negative trances that children go into and what operates as an induction for a child in a negative way might be the “You’re stupid, you never listen, you never get this right, you’re always so clumsy…” and at that point children often defocus and go elsewhere and they’re in their trance where they can’t get anything right, so of course the don’t. I think that can be a very helpful frame for parents to understand, for teachers to understand. Now on the positive trance side for children, I think it’s helpful again for parents, teachers, families to understand when a child is not being inattentive or disobedient, but simply highly focused in their internal world. So just useful ways to use that conceptualization of trance in a way that is helpful but does not involve necessarily a formal induction of a trance state, but really the recognition of naturally occurring states.
Jonathan Singer: So it does, it sounds like there’s a distinction between these naturally occurring and these formally induced trance states, and you’ve talked about positive and negative trance states. Are there limitations or strengths to clinical hypnosis in terms of the formal work that a clinician would do, not the naturally occurring trance states, but are there strengths and limitations or contraindications in terms of the clinical usage of hypnosis?
Elizabeth Winter: I think there are times when you absolutely wouldn’t use it, and we’ve certainly mentioned you know where you’re really not trained to. You may understand trance work but you may not be appropriate for you to use it in a particular area. Contraindications for me as a social worker seeing people for psychotherapy. I typically, probably would not use hypnosis for someone who has psychotic symptoms because they’re experiencing altered states in any case and adding in another form of altered state really is probably not going to be helpful, it just isn’t.
Jonathan Singer: That makes sense.
Elizabeth Winter: So I probably wouldn’t, I wouldn’t do it. I think I’ve already mentioned that I wouldn’t do, I don’t do memory retrieval work, and again that is something to be really cautious of. Might somebody remember something during the course of psychotherapy, absolutely, memory is not a continuous thing. Might somebody remember something while they’re in trance, certainly, but I wouldn’t go fishing for it. I wouldn’t use trance if somebody said I only want to do this and nothing else, that’s like telling a surgeon all they can use is a scalpel, nothing else, no retractors, no forceps, you know you wouldn’t limit yourself in that way. One aspect of using clinical hypnosis that I think is important for people to bear in mind is that where there is a legal case going on the admissibility of your clients evidence can really be put in jeopardy by that person having done hypnosis. Not because hypnosis makes them a less credible, well literally makes them a less credibly witness, but the law certainly views it that way. You know when, if you’re a forensic, if you’re doing forensic work as a therapist or a psychiatrist, you probably would not want to be using hypnosis. And it’s appropriate if someone wants you to work with hypnosis or if you’re considering it, to bear in mind that if they have a case pending or they might have a case against an abuser for example, that their testimony could be set aside in court. If you’re thinking of using clinical hypnosis with someone to really discuss with them in a psychotherapeutic setting whether this is something they’re comfortable with, not everyone is going to be comfortable with it. And there are some real cultural differences on the use of hypnosis with some people being very comfortable and some people being extremely uncomfortable and not feeling ok with that at all.
Jonathan Singer: And you are talking about informed consent, essentially, yes.
Elizabeth Winter: Absolutely, yes, and obviously that applies to anything but particularly to this. Particularly because of the misconceptions around it. You know just because I think it’s a great idea, if my client doesn’t then we’re not doing it, it’s really simple. The obvious limitation I think for clinicians is that you don’t do hypnosis as entertainment and you don’t do it if you’re not trained, same as anything else. You really, really want to receive the appropriate training. Interestingly, training for hypnosis puts people often in a multidisciplinary kind of setting because if you go and get formal training in clinical hypnosis, you’re probably going to be… As a social worker, you’re going to be with other social workers, but you’re also going to be with physicians, with dentists, you know nosis and so on because typically those trainings are multidisciplinary. Which is actually a very very interesting you know in addition to getting the training, it’s a very interesting setting to get some learning.
Jonathan Singer: If somebody is listening to the podcast and they say ok this sounds like it would be really a useful skill for me to have as an adjunct to what I normally do in my treatment, are there other references, are there books, are there authors, are there specific places where people could go to get training that you would recommend or that you would say off the top of your head?
Elizabeth Winter: I think I would probably start with the American Society for Clinical Hypnosis, which has an excellent website and I know and also look at the Milton Erickson Foundation website. But the American Society for Clinical Hypnosis, which is fondly known as ASCH (pronounced Ash) runs a number of trainings across the country, and these are very experiential trainings. To be an ASCH approved training it has to not just have lecture content but it has to have practical, you know practical learning. So learning how to induce trance, being a recipient of that, and really is quite extensive training. There are many places that you can an online or a weekend course, or a and get a, I think you can even get a Doctorate in hypnosis, that really is not the kind of training I would recommend, I have to say. I would say start with the American Society for Clinical Hypnosis; it is one of the very few national and longstanding professional organizations for therapeutic and clinical hypnosis.
Jonathan Singer: Well Dr. Winter this has been fascinating for me and I hope for our listeners. Thank you so much for being here and talking with us today about clinical hypnosis.
Elizabeth Winter: It’s my pleasure.
-- End --
Elizabeth Winter: Probably the first caution is to use only to do something that you’re already trained to do. And that may sound a little bit obvious but for example, it would be appropriate for me as a social worker to use it with somebody who comes to see me for work on addictions. It would not be appropriate as a social worker for me to help someone to induce analgesia or anesthesia with an intention of my performing surgery on them. I’m not trained to do that, I shouldn’t do it. And conversely somebody who is perhaps and anesthesiologist shouldn’t be doing psychotherapy using hypnosis. So it may seem obvious, but it’s really important that you don’t work outside your field or do anything that you’re not already trained to do. Having said that, not everyone is going to want hypnosis and it’s not going to be something that I would do with everyone. If somebody specifically comes and asks for hypnotic intervention, typically I would do that as part of a broader therapeutic relationship. And it may or may not be appropriate. For example, people will sometime specifically ask if they can use hypnosis to recover memories, typically memories they think they may have buried somewhere about past abuse. Now, I won’t do that kind of work and I won’t do it for a number of reasons, the primary one being memory is not history. And the fact that you recall something in a trance state doesn’t make it true, and in fact there is a fair amount of research that suggests that people who appear to remember things in trance have a higher degree of confidence in those memories but less accuracy. So that would be a time not to use it. If someone is motivated to use it for something like habit control, or anxiety, then certainly it’s worth exploring, and you would start out by teaching the skill before you would use it for the specific purpose. And I’ll give you a quick example of that. I once heard a story of a woman who had grown up in Europe and was towards probably her middle years looking to stop smoking, and she had smoked for many many years, and she wanted to use hypnosis to stop smoking. And what she found was she really got stuck going into trance, and kind of couldn’t go into trance, and when she was asked what her first memory of smoking was, when did you start smoking, it was when she had been smuggled out of Germany in the late 1930’s early 1940’s during the second World War. She had been smuggled out, she was a Jewish woman, and when she crossed the border into Switzerland, someone gave her a cigarette, and she took the first puff of that cigarette, they said this is what freedom tastes like. And so until she knew that she had you know her belief in freedom paired with her smoking habit, then no amount of teaching her to go into trance was going to make any difference, and sometimes you find those things out as you work. So it really depends, it depends on do you have the training and the skill set to do a particular piece of work, and if you wouldn’t without hypnosis, you shouldn’t do it with.
Jonathan Singer: So you use clinical hypnosis when someone asks for it, when it seems clinically appropriate, but also with the caveat that hypnosis is used within a treatment context that is within your scope of expertise and in your scope of practice.
Elizabeth Winter: Exactly.
Jonathan Singer: Let’s say they that all this criteria had been met with a client and you decided to use it. How do you actually use clinical hypnosis?
Elizabeth Winter: The first thing I do is to help someone learn how they best go into trance. There are a number of different inductions, so probably the one people are going to be most familiar with is fixing their eyes on a particular object, and it need not be a watch, and it need not be swinging in front of ones face, I will say that quite categorically now. But there is something called an eye fixation technique and this is one of what is known as the formal inductions. And when I talk about using hypnosis and what is ethical and what is appropriate, really talking about this sort of formal induction of hypnosis. Now the eye fixation may be helpful for someone who is more visually oriented and there are other forms of formal induction, one for example is an arm levitation induction. So that would be perhaps, and this is someone who is more comfortable with more physical and more body oriented rather than visual. There’s another, which focuses more on the ability to visualize things so that may be more appropriate for someone who thinks in that way. So there are different formal inductions. To use those help somebody to learn how to go into trance. Once somebody is in trance then a clinician would add what we would think of as a utilization, which would be what is it we are trying to accomplish, it may be suggestion in a fairly direct way, so you know one might say to somebody “You will be surprised at how much more comfortable you will be when …”. “As you monitor your breathing and slow down your next breath out, you will find that you’ve become calmer, more relaxed, and so on”. A simple example of just relaxation based, but that’s the utilization part of the trance. They then within that, or following that, perhaps be a suggestion for how that comfort or whatever it is will follow that person once the trance has ended. So just because the trance ends they don’t have to stop feeling comfortable you know, that comfort can go with you, that’s the post-hypnotic suggestion part of that. And then there is a termination of that, of the trance experience, which may sound something like “You return your attention to the room in your usual way in the next few breaths and so on”. So there is usually a structure to the formal induction of trance, but the induction, you know the induction of the early trance state is really just the beginning of that. And that will be completely really individualized for the person. There are some standard forms of script, actually some really really nice publications that have standardized scripts, and you know people often make their own but there are some really nice pieces of work for different applications. Now, formal induction is not the only way to use an understanding of hypnosis in the clinical setting. Now here’s the deal, since we go into trance spontaneously, I can intentionally work with someone to induce trance sitting in my office, but I can’t stop them spontaneously going into trance in my office. What I can do is recognize it and work with it because some spontaneous trances are useful and some are really quite harmful. So if there is a trance state which is what we would think of as a negative trance, so a highly focused attention perhaps in a relational situation, that is really really negative then my recognizing when someone has gone into hat sort of highly focused state that is not working well for them, is something that can be very useful clinically.
Jonathan Singer: So would this be something that you might recognize in a couples therapy session?
Elizabeth Winter: Oh sure, an induction into a trance state doesn’t have to be intentional obviously, so couples have a well worn path into an argument, into an old disagreement, into the you always do this, you never do that, so that can certainly operate as an induction if you like, with a focused attention or perhaps even more often focused disattenion, let’s say the induction "You never…"and then the other party disappears, they are not listening after that, they defocus, they have gone elsewhere. Could you view that as a couple’s trance? Certainly. I think it’s also helpful to consider negative trances that children go into and what operates as an induction for a child in a negative way might be the “You’re stupid, you never listen, you never get this right, you’re always so clumsy…” and at that point children often defocus and go elsewhere and they’re in their trance where they can’t get anything right, so of course the don’t. I think that can be a very helpful frame for parents to understand, for teachers to understand. Now on the positive trance side for children, I think it’s helpful again for parents, teachers, families to understand when a child is not being inattentive or disobedient, but simply highly focused in their internal world. So just useful ways to use that conceptualization of trance in a way that is helpful but does not involve necessarily a formal induction of a trance state, but really the recognition of naturally occurring states.
Jonathan Singer: So it does, it sounds like there’s a distinction between these naturally occurring and these formally induced trance states, and you’ve talked about positive and negative trance states. Are there limitations or strengths to clinical hypnosis in terms of the formal work that a clinician would do, not the naturally occurring trance states, but are there strengths and limitations or contraindications in terms of the clinical usage of hypnosis?
Elizabeth Winter: I think there are times when you absolutely wouldn’t use it, and we’ve certainly mentioned you know where you’re really not trained to. You may understand trance work but you may not be appropriate for you to use it in a particular area. Contraindications for me as a social worker seeing people for psychotherapy. I typically, probably would not use hypnosis for someone who has psychotic symptoms because they’re experiencing altered states in any case and adding in another form of altered state really is probably not going to be helpful, it just isn’t.
Jonathan Singer: That makes sense.
Elizabeth Winter: So I probably wouldn’t, I wouldn’t do it. I think I’ve already mentioned that I wouldn’t do, I don’t do memory retrieval work, and again that is something to be really cautious of. Might somebody remember something during the course of psychotherapy, absolutely, memory is not a continuous thing. Might somebody remember something while they’re in trance, certainly, but I wouldn’t go fishing for it. I wouldn’t use trance if somebody said I only want to do this and nothing else, that’s like telling a surgeon all they can use is a scalpel, nothing else, no retractors, no forceps, you know you wouldn’t limit yourself in that way. One aspect of using clinical hypnosis that I think is important for people to bear in mind is that where there is a legal case going on the admissibility of your clients evidence can really be put in jeopardy by that person having done hypnosis. Not because hypnosis makes them a less credible, well literally makes them a less credibly witness, but the law certainly views it that way. You know when, if you’re a forensic, if you’re doing forensic work as a therapist or a psychiatrist, you probably would not want to be using hypnosis. And it’s appropriate if someone wants you to work with hypnosis or if you’re considering it, to bear in mind that if they have a case pending or they might have a case against an abuser for example, that their testimony could be set aside in court. If you’re thinking of using clinical hypnosis with someone to really discuss with them in a psychotherapeutic setting whether this is something they’re comfortable with, not everyone is going to be comfortable with it. And there are some real cultural differences on the use of hypnosis with some people being very comfortable and some people being extremely uncomfortable and not feeling ok with that at all.
Jonathan Singer: And you are talking about informed consent, essentially, yes.
Elizabeth Winter: Absolutely, yes, and obviously that applies to anything but particularly to this. Particularly because of the misconceptions around it. You know just because I think it’s a great idea, if my client doesn’t then we’re not doing it, it’s really simple. The obvious limitation I think for clinicians is that you don’t do hypnosis as entertainment and you don’t do it if you’re not trained, same as anything else. You really, really want to receive the appropriate training. Interestingly, training for hypnosis puts people often in a multidisciplinary kind of setting because if you go and get formal training in clinical hypnosis, you’re probably going to be… As a social worker, you’re going to be with other social workers, but you’re also going to be with physicians, with dentists, you know nosis and so on because typically those trainings are multidisciplinary. Which is actually a very very interesting you know in addition to getting the training, it’s a very interesting setting to get some learning.
Jonathan Singer: If somebody is listening to the podcast and they say ok this sounds like it would be really a useful skill for me to have as an adjunct to what I normally do in my treatment, are there other references, are there books, are there authors, are there specific places where people could go to get training that you would recommend or that you would say off the top of your head?
Elizabeth Winter: I think I would probably start with the American Society for Clinical Hypnosis, which has an excellent website and I know and also look at the Milton Erickson Foundation website. But the American Society for Clinical Hypnosis, which is fondly known as ASCH (pronounced Ash) runs a number of trainings across the country, and these are very experiential trainings. To be an ASCH approved training it has to not just have lecture content but it has to have practical, you know practical learning. So learning how to induce trance, being a recipient of that, and really is quite extensive training. There are many places that you can an online or a weekend course, or a and get a, I think you can even get a Doctorate in hypnosis, that really is not the kind of training I would recommend, I have to say. I would say start with the American Society for Clinical Hypnosis; it is one of the very few national and longstanding professional organizations for therapeutic and clinical hypnosis.
Jonathan Singer: Well Dr. Winter this has been fascinating for me and I hope for our listeners. Thank you so much for being here and talking with us today about clinical hypnosis.
Elizabeth Winter: It’s my pleasure.
-- End --
APA (6th ed) citation for this podcast:
Singer, J. B. (Host). (2007, November 27). #29 - Clinical hypnosis (part II): An interview with Dr. Elizabeth Winter [Audio podcast]. Social Work Podcast. Podcast retrieved from http://socialworkpodcast.com/2007/11/clinical-hypnosis-part-ii-interview.html
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