Trance and Treatment


CHAPTER 3: THE HYPNOTIC INDUCTION PROFILE (HIP)

Rationale for a Clinical Test Ceremony versus Measurement

CEREMONIES

There are literally hundreds, perhaps thousands, of more or less acceptable induction techniques that have been used over the past two centuries to elicit trance compliance, e.g., eye fixation on fixed or moving targets, eye closure, body sway, touch by the hypnotist, evoking numbness, paresthesias or paralysis, etc. Most of the traditional induction ceremonies are thoroughly documented and described by Weitzenhoffer (I957) and Wolberg (1948), and require no further elaboration here.

What is relevant here is a clarification of the difference between the phenomenon of hypnosis itself and the ceremony that presumably elicits it. Trance phenomema may occur spontaneously, or in response to a myriad of ceremonies of induction, as long as the subject has trance capacity and is not aesthetically offended by the ceremony.

By definition, a ceremony is an action usually performed with some formality but lacking in deep significance. If the subject interprets the cues properly and conforms to what is expected, the trance ensues. The three overlapping phases described earlier , the aura, the psychophysiogical enhancement, and the plunge, are, in effect, the common denominator usually apparent in all induction ceremonies.

There are large numbers of ceremonies for trance induction from different cultures that attract attention in the West, and deserve mention here. Our hypothesis is that these ceremonies elicit trance concentration in people who have trance capacity. For example, Chinese acupuncture employs a needle; Japanese acupuncture, Shiatsu, employs finger pressure. Transcendental meditation, Zen meditation, the relaxation response (Benson 1975), some forms of biofeedback, yoga, primal therapy (Janov 1970), religious conversion, faith healing, laying on of hands, voodoo, are just some of the many other occasions that can elicit trance experience. Although we have not been able to make careful comparative studies, we do have some data on the hypnotic component of acupuncture, which is reported in Chapter 17. Until recently the clinical literature has largely ignored the assessment of hypnotizability. In its place there frequently has been reference to so-called "deepening techniques" (Erickson 1967), under the assumption that everyone is hypnotizable. These "deepening techniques" have, in our experience, been of little value. In general, if the setting is appropriate for both the patient and the therapist, the transformation into trance occurs quickly and to the person's optimal capacity. Repetition as a learning factor is usually of minor importance (Perry 1977).

What appears to be a "deeper" trance elicited by alleged methods is better understood as: clarifying the patient's motivation or the relevance of hypnosis in the first place; correcting misunderstandings or aesthetic preferences of the patient; altering expectations of the patient, the therapist, or both. Ceremonial repetitions provide a face-saving way to make these readjustments, and the trance then seems "deeper," although it is the same when measured. In other words, the secondary issues which inliuence the context of the trance experience are clarified, but the patient's actual trance capacity remains essentially the same. "Clarifying the context" is probably a more precise label than "deepening techniques."

From one point of view, the Hypnotic Induction Profile (HIP) can be regarded as another ceremony. But it is also more than just that: It is a measurement of hypnotizability in which a systematized sequence of instructions, responses, and observations are recorded with a uniform momentum in a standardized way, as the subject shifts into trance to the exent of his ability, maintains it, and then exits in a prescribed manner. It differs from traditional clinical induction techniques in that it is a measurement procedure and, in effect, the hypnotist is the measuring instrument. It differs from the research scales in being brief and clinically appropriate.

Once a Profile score is determined, the disciplined HIP procedure is no longer necessary. In general, subsequent inductions can be selfgenerated by the patient, or signaled by the therapist. The time for the shift into trance is a matter of a few seconds. The HIP is briefer and better standardized on a clinical psychiatric population than any other clinical scale.

MEASUREMENTS

What makes hypnosis a useful organizing concept in understanding its various ceremonies is the development of techniques for measuring a relatively stable trait -- the capacity for hypnosis or hypnotizability. There are clinicians (Erickson 1967) and researchers (Barber 1956; Sarbin and Slagle 1972) who maintain that there are no reliable differences in hypnotic capacity. However, the preponderance of research in the last two decades, including our own, indicates that hypnotizability is a stable and measurable trait (Hilgard, E.R. 1965; Orne 1959; Morgan et al. 1974; Perry 1977; Spiegel, H. 1976). This evidence provides an opportunity for the clinician to use the phenomenon in a more disciplined and knowledgeable manner.

Several well-standardized scales of hypnotizability, hypnotic capacity, or hypnotic susceptibility have been developed (Weitzenhoffer and Hilgard 1959; Shor and Orne 1962; Barber and Glass 1962) with statistical reliability in mind. They were constructed as the summation score of a number of independent items which on testing proved highly intercorrelated (Hilgard, E.R. 1965). The Harvard Group Scales (Shor and Orne 1962) were designed so that the subjects themselves could score them, allowing for group administration, but they correlate highly with scores obtained on the same subjects using the Stanford Hypnotic Susceptibility Scale. These measures are lengthy to administer, requiring approximately one hour.

There was a need for a briefer measure of hypnotizability which would be practical and appropriate to the pressures of clinical work, and yet reliable and valid as a measure of the hypnotizability trait. Given the growing recognition among researchers that trance capacity is an important concept, it became imperative to introduce this kind of thinking into the field of clinical practice, which was still dominated by the concept of altering hypnotic "depth" or considering all patients to be good candidates for hypnosis. One such clinical measurement has been introduced as an adaptation of the Stanford Hypnotic Susceptibility Scales (Weitzenhoffer and Hilgard 1963). It requires approximately twenty minutes for administration. Like the parent scale, this is an additive measure with a series of ideomotor and challenge items. From a clinical point of view there remained a need for an even shorter test of hypnotizability which would provide systematic information and at the same time facilitate the therapeutic atmosphere.

The longer laboratory measures were not employed by busy clinicians and raised the additional problem of the development of fatigue during the testing. Context and motivation are critical factors in any psychological measurement. Tests standardized with subjects volunteering for the sole purpose of hypnotic experimentation measure different dimensions than those standardized on people presenting themselves for treatment (Frankel and Orne 1976). In this clinical context the assessment of hypnotizability is incidental to the treatment encounter and motivation is likely to be greater because the patient is seeking help with a personal problem rather than exercising curiosity. In this sense, paid volunteers for experimentation have a significantly different motivational set.

Tests standardized on college student populations often reflect concern with only a limited sample of age and education, whereas the concern of the clinician must relate to the wide range characteristics of a patient population. Some earlier tests identified hypnotizability as "susceptibility," a description which offended many patients and hampered their cooperation. Presenting hypnotizability as a capacity or talent serves to avoid this impediment to patient acceptance. The traditional use of sleep terminology in earlier tests was also misleading and did not convey the therapeutically useful mobilization of concentration which characterizes trance. Some of the challenge items, such as hallucinating an insect, at times proved to be aesthetically disturbing to patients seeking relief from symptoms. Since hypnosis is an expression of integrated concentration, factors which impair concentration such as drugs, psychopathology, and neurological deficits should be taken into account, and were not in the standardization of the laboratory measures.

A chemical analysis of food, no matter how accurate, in no way identifies and differentiates gourmet from institutional cooking. The unique gourmet quality is missed by the analytic measurement, yet it is a quality identified by the trained palate. No measurement of hypnotizability is the same as the entire phenomenon itself, and any test will reflect the context of the experience and have inherent limitations and advantages. Given the fact that any test is at best a sampling and imposes distortions on the data it measures, and given the above considerations, it seemed necessary to develop and standardize a test within the clinical context.

The Hypnotic Induction Profile was developed during the past decade in an effort to resolve these difficulties. It consists of three major components: a biological measurement, the eye roll (Spiegel, H. 1972), which records presumed biological trance capacity; an ideomotor item, hand levitation; and a subjective discovery experience, the control differential between hands. The test yields information regarding a subject's hypnotizability sufficient to make a clinical decision regarding the role of hypnosis in treatment.

The HIP was developed in the hopes of creating a scale with rich relationships to treatment outcome and psychopathology factors as well as hypnotizability per se. We will present data regarding relationships between performance on the test and such factors as personality traits and degree of psychopathology.

The relationship between the HIP and the Stanford Hypnotic Susceptibility Scale is currently being studied in a college student population. The association appears to be a mild one. In due course, these findings will be published.

INTRODUCTION TO THE HYPNOTIC-INDUCTION PROFILE

The Hypnotic Induction Profile was developed to provide a useful measure in the clinical setting. It evolved out of a need for a rapid induction and testing procedure which could be easily integrated into the clinical diagnostic interview, so that trance capacity might then be quickly employed in treatment.

The HIP postulates that hypnosis is a subtle perceptual alteration involving a capacity for attentive, responsive concentration which is inherent in the person and which can be tapped by the examiner. A rapid procedure, the HIP takes five to ten minutes to administer. It is both a procedure for trance induction and a disciplined measure of hypnotic capacity standardized on a patient population in a clinical setting.

The HIP assesses a single trance experience as it flows through the phases of entering, experiencing, and exiting. The test also establishes a structure for this sequence. The specific point in time at which the shift from customary awareness into trance takes place varies from person to person. However, the trance experience is punctuated, tapped, and divided into phases by the ten individual items lettered A through L on the HIP score sheet (Figure 3-1). Six of these items (D, G, H, I, J, L) are used for rating the subject's trance capacity and for scoring the HIP according to the induction or profile-scoring method. Item D is the sum of items B and C. The remaining four items (A, E, F, K) round out the clinical picture and establish the procedures for entering and exiting trance and for subsequent self-reporting. Scoring these four items is optional, since they are not part of the HIP summary scores.

This technique induces the subject to enter the hypnotic trance quickly under observed, specified conditions, and then to shift out of trance on signal. At the same time, the HIP teaches the subject to use his own cuing system for entering and exiting trance. Thus, as the examiner observes and measures trance capacity, the subject can learn to identify the trance experience in order to initiate and use it independently (self-hypnosis) in the service of relevant goals. The trance experience can be divided into four phases for measurement (see Table 3-1). The first is a pretrance or preinduction phase which lasts until eye closure. The second is the induction or entering phase in which instructions are given for the individual to shift into formal hypnosis. The shift may take place in response to the examiner's directions and, as part of this induction ceremony, instructions are given for induction responsivity. The induction ceremony and- formal trance are termintated with the opening of the eyes, but hypnotic trance persists and the third phase begins. Phase three is a postinduction or postceremonial phase in which the person may actually experience five responses to the instructions given as part of the ceremony: dissociation, signalled arm levitation, control differential, cut-off, and float. It is important to note that what are often called posthypnotic phenomena actually represent the experience of hypnosis. "Posthypnotic" is a traditional label which can be confusing. A more appropriate label may be "postceremonial" or "postinduction."

Item J (cut-off) of phase three is the exiting procedure. Although the subject is out of formal trance and his eyes are already open, this period of postceremonial trance response must be terminated by the examiner touching the subject's elbow. A fourth postexperiential, nontrance phase is comprised of self-reports by the subject.

Measurements of up-gaze (Item A), the eye-roll sign (Items B, C, and D), and instructed arm levitation (Item E) supply an evaluation of inherent potential or capacity for success in initiating and sustaining the trance experience. They also comprise the induction procedure. Actual success in maintaining the trance experience, once it has been effected through specific instructions, is tapped by dissociation (Item G), signalled arm levitation (Item H), control differential (Item I), cut-off (Item J), and fioat (Item L). These five measurements, taken together, rate the degree to which the subject can attentively focus: they comprise the induction score (see Table 3-2 ).

The profile score is a statement of the relationship between a person's potential for trance and his ability to experience and maintain it.

Table 3-2: THE ITEMS OF THE HIP INDUCTION SCALE

Dissociation "Spontaneous," uninstructed. Score positive (1 or 2) if subject reports that the arm used in the preparatory levitation task feels "less a part" of the body than the other arm, or if that hand feels "less connected to the wrist" than the other hand.
Signaled Arm Levitation (Lev) Score positive if, on the instructed signal, the arm rises to upright position. Positive scores vary from 1-4, depending on the number of verbal reinforcements necessary.
Control Differential (CD) "Spontaneous," uninstructed. Score positive (1 or 2) if subject feels less control over the arm used in the Lev item. The examiner's questions do not indicate which arm is expected to be less controllable.
Cut-Off Score positive (I or 2) if, on instructed signal, subject reports normal sensation and control returning to arm used in Lev item.
Float Score positive (I or 2) if subject reports having felt the instructed floating sensation during the administration of the Lev item.

GENERAL CONSIDERATIONS

The HIP is best described as an objectively scorable, interpersonal hypnotic interaction which also serves as an induction technique. In order to obtain results comparable to the standardization data, momentum or rhythm must be established and maintained during the interaction; there should be no long silences or pauses during test administration, nor should the pace be so rapid that the subject does not have a chance to attend to his experience. If administered correctly, the test requires five to ten minutes.

The HIP requires of the operator a degree of expertise and familiarity with the test which is not required by other tests of hypnotizability. The examiner himself is the instrument, and if he is not finely tuned the HIP will not be valid. Persons new to the HIP should not expect to be able to master the technique immediately. They should be aware that several, perhaps many, practice administrations are a requisite to valid clinical or experimental application.

These qualities of the HIP have been preserved because the test is primarily a clinical instrument and was developed in the course of clinical practice. In the clinical setting, especially during the initial encounter in which the HIP is usually used, rapport must be encouraged and nurtured. Although the HIP items and even the wording of the test (insofar as this is possible) should be the same in each case, the particular responses of the subject must be acknowledged and woven into the fabric of the interchange.

In the following two sections the administration and scoring of the HIP are presented. Read the instructions given by the examiner for a single HIP item, and then the accompanying directions. To learn what it is the hypnotist observes and scores at this point, look up the item in the following section on scoring. When the connections are clear between the administration of the test and the behaviors and experiences to be observed, read the administration section from beginning to end without interruption. With the concurrent scoring by the examiner in mind, this uninterrupted reading should begin to communicate a sense of the rhythm of administration.

The physical setting can enhance the psychological one. Shifting into a state of peak responsiveness is in a sense "shifting gears" and the physical arrangement may reflect this. For example, during an initial clinical interview, the clinician may be seated in his customary place across the desk from the patient (or subject), or in an armchair across the room. But at the time of induction the clinician shifts his position, moving to another seat slightly forward and to the left of the patient. During the induction procedure he should be close enough to establish comfortable physical contact with the patient, as shown in Figure 3-2. After completing the procedure, the examiner may return to his customary seat if he wishes.

Throughout these instructions it is presumed that the subject's left hand will levitate. If the examiner sits to the right of the subject, right should be substituted for left in the examiner's instructions to the subject. In general, the subject should be seated comfortably, with a place to rest his arms and legs. Some testers find that the use of a footstool enhances the initial floating sensation which many subjects experienceduring hypnosis. If an armchair is not available, have the subject sit next to a table, placing his arms on the table, legs relaxed, and feet fiat on the floor. Or ask the subject to imagine that his elbow is resting on an imaginary air cushion.

Until the examiner is comfortable with the procedure, he may find it helpful to keep the book open to the How to Administer section and next to the scoring form. Since this is an interpersonal interaction, eye-to-eye contact helps sustain the subject's attention even though the examiner may be referring to the instruction manual.

Copyright 1978 Herbert and David Spiegel...Reprinted With Permission


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