Freud's Rejection of Hypnosis: Perspectives Old and New:Part III of III-Toward Healing the Rift: Enriching Both Hypnosis and Psychoanalysis

As Freud developed his own ideas, he abandoned the use of hypnosis. This change led to more than a century of disengagement between hypnosis and psychoanalysis, characterized, with notable exceptions, by mutual avoidance, dismissiveness, and incomplete appreciation of each by the other. Earlier communications challenged the foundations of Freud's rationales and their perpetuation. Here, contemporary instances in which hypnosis and psychoanalysis are used together are reviewed briefly before exploring possibilities/opportunities for their mutual enrichment and enhancement. The judicious incorporation of insights and assets from each into the other can be implemented without violating the standard approaches and practices of the modality into which they might be imported. Examples are offered as food for thought, stepping-stones toward a rapprochement long overdue.

Freud's Rejection of Hypnosis, Part II: The Perpetuation of a Rift

Freud's rejection of hypnosis gave rise to a rift between clinical hypnosis and psychoanalysis that has endured for over a century. A review of Freud's rationales (Kluft, 2018a/this issue) demonstrates that while some stemmed from what he considered advances, others appear strongly influenced by his promoting the superiority of his "psycho-analysis" at the expense of hypnosis. Mainstream psychoanalysis continues to endorse the perpetuation of rationales Freud asserted nearly a century ago, and an oral lore of related supportive statements. This oral lore proves difficult to sustain upon closer scrutiny. It bypasses concerns that, if studied in depth, would demonstrate significant shortcomings. Problems encountered in this oral lore include: (1) the importance of information unavailable to Freud; (2) the ongoing impact of certain errors of Freud's thinking; (3) the distorting force of Freud's compelling drive to be a "conquistador" of the mind and create a heroic theory; (4) the implausibility, upon inspection, of certain long-accepted assertions about Freud's motivations; and (5) Freud's discomfort with his own dissociative symptomatology. It is argued that the "oral lore" promulgated in connection with Freud's rejection of hypnosis, like Freud's decision to reject hypnosis itself, is not firmly grounded and deserves careful reassessment.

Freud's Rejection of Hypnosis, Part I: The Genesis of a Rift

Modern psychoanalysis begins with Sigmund Freud's study of hypnosis and the treatment of the grand hysterics of the fin de siècle. In the process of developing his own paradigm, Freud came to reject the use of hypnosis and turned his attention away from the severe hysterias. These decisions began what has become, notwithstanding noteworthy exceptions, over a century of estrangement and disengagement between the fields of hypnosis and psychoanalysis. The current communication reviews the 75 archived Psychoanalytic Electronic Publishing resources from Freud's scientific work and correspondence in which reference is made to hypnosis. A close examination of Freud's stated rationales for abandoning hypnosis suggests that both the ideas he developed and the rift between hypnosis and psychoanalysis that they created may prove to have been problematic as well as innovative. They and their consequences merit thoughtful review and critical reconsideration.

Reconsidering Hypnosis and Psychoanalysis: Toward Creating a Context for Understanding

Sigmund Freud developed what became psychoanalysis in the context of his experiences with hypnosis and the treatment of the grand hysterics of his era, conditions largely classified among the dissociative disorders in contemporary systems of diagnosis. He rapidly constructed understandings of the human mind and human distress that replaced the concept of dissociation and a model of pathology that was passive (associated with reduced psychic cohesion), with the paradigm of an active defensive process he termed repression, and an understanding that psychological discomfort was the outcome of intrapsychic conflict. In short order Freud repudiated hypnosis, initiating the schisms that subsequently separated the study and practice of hypnosis from the study and practice of psychoanalysis. It is timely to reexamine these schisms anew, challenge the basis of the arguments thought to justify them, and explore whether these schisms have deprived psychoanalysis and hypnosis alike of the potentially helpful ideas and approaches each might offer the other. This contribution invites students of hypnosis and psychoanalysis alike to put aside both traditional and stereotypic notions of each other's field of endeavor, revisit the origins, rationales, and outcomes of these schisms that have divided them, and explore their commonalities and their differences from fresh perspectives.

Weaponized sex: defensive pseudo-erotic aggression in the service of safety

Problematic sexual behaviors are frequently encountered in the treatment of patients suffering Dissociative Identity Disorder and related forms of dissociative disorders. These may include unfortunate patterns of ready acquiescence or submission to overtly or potentially aggressive or sexual approaches/encounters, subtle and/or overt seductive signaling and behaviors, and even overt sexually provocative patterns of verbalizations and actions. This paper discusses the possibility that in some instances, sexual behavior has become weaponized; that is, deployed in circumstances under which assertiveness and/or aggression or other self-protective measures might be expected, probably because such behaviors were not within the range of the possible or were not understood as potentially successful for some victims of trauma. Clinical manifestations are described and discussed. An animal model in which sexual behaviors substitute for aggressive behaviors is described. A speculative hypothesis is offered, postulating that in some cases, such patterns in traumatized humans might represent an epigenetic response to exogenous trauma. Exploration of this model may lead to improved understandings and approaches to trauma victims who manifest such behavior, hopefully destigmatizing them further, facilitating reduction of their shame and guilt, and supporting their recoveries. Clinical interventions are suggested.

Perspectives on Pathways to Induction: Confronting Unexpected Challenges

In clinical practice, the process of induction may prove more complex and nuanced than its presentation in workshop training would suggest. The relatively straightforward cognitive and instrumental educational domains address defining the concept of induction and instructing workshop participants about how inductions can be performed. However, in work with patients, factors relevant to the attitudinal domain of education become increasingly salient and speak to the importance of how the person inducing hypnosis relates to the person in whom hypnosis is to be induced and how that person goes about crafting a constructive rather than formulaic approach to the induction of hypnosis for a unique individual. Considerations relevant to relational issues and the optimization of inductions in a clinical context will be addressed. These include assessing aspects of hypnotic talent and individual preference, identifying distressing dynamics, attention to the clinician's manner of speech, patience, achieving congruent expectations about how help is given and received, attention to shame dynamics, relational dimensions, contributions from self-psychology, collaboration with other caregivers, and issues related to autohypnosis and spontaneous trance in the clinical setting.

The Wounded Self in Trauma Treatment

The potential role of hypnosis in the treatment of trauma is both venerable and underappreciated. This article underscores the importance of the wounded-self concept by proposing a Kohutian perspective complimentary to the cognitively-driven model of Alladin (2014a, 2014b) discussed elsewhere in this issue. It explores selected topics that demonstrate (1) the importance of considering the wounds to the sense of self experienced by trauma victims and their implications for individualization of treatment in planning a psychotherapy; (2) the possibility of enhancing access to memories using shame alleviating techniques with minimal suggestive properties; (3) the use of hypnosis to facilitate less disruptive processing of traumatic materials; and (4) the importance of hypnosis in enhancing the safety of the trauma patient between sessions. Absent contraindications, the circumspect use of hypnosis as a facilitator of trauma treatment deserves consideration for inclusion in the mainstream of contemporary trauma treatment.

Approaches to difficulties in realerting subjects from hypnosis

Recent studies have demonstrated the importance of identifying and addressing failures of realerting or dehypnosis. In parallel with the exploration of the adverse consequences of hypnosis in workshop settings, a number of techniques for effecting realerting subjects from hypnosis were collected. Some of these techniques are well-known, some were developed by applying techniques developed for other purposes to the task of realerting, and some were developed by the author when other known techniques proved unsuccessful or were rejected by subjects requiring dehypnosis. This article reports 15 techniques, three of which are foundational and designed to orient the subject to becoming realerted, and 12 more specific approaches to achieving dehypnosis. When appropriate, the particular opportunities of and the potential difficulties and relative contraindications for each technique are discussed.

Enhancing workshop safety: learning from colleagues' adverse experiences (part II--structure/policy)

Findings summarized in Part I demonstrated that more adverse events occur during hypnosis workshops than had been previously appreciated. 93% went unnoticed and unreported during those workshops. Shortcomings in dehypnosis/realerting preceded most adverse events. Recommendations prioritized detecting, minimizing, preventing, and correcting those failures of alerting and dehypnosis. Part II proposes 13 additional protective measures, including curtailing common but potentially problematic practices. Further protective measures are proposed to monitor the effectiveness of participants' dehypnosis; oversee what transpires in experiential workshops; help faculty members become aware of the areas in which their skills require improvement; establish policies to delineate the range of issues acceptable to address in demonstrations; and clarify procedures for dealing with problematic faculty and adverse events in workshops.

Enhancing workshop safety: learning from colleagues' adverse experiences (part I--structure/content)

Recent studies demonstrate that unwanted responses to hypnosis during training workshops are not uncommon, and usually are covert (Kluft, 2012). Adverse events usually occurred subsequent to inadequate realerting from previous experiences of hypnosis. Inadequate realerting almost invariably was associated with unsuccessful permissive instructions for dehypnosis. Further, workshop faculty tended to accept partial dehypnosis as adequate dehypnosis. This article, the first of two related communications, offers 13 suggestions for minimizing workshops participants' risk of experiencing adverse events. It recommends safer replacements for techniques and stances often associated with adverse outcomes, and advocates using measures of alertness, such as the Howard Alertness Scale (Howard, 2008) to identify those at risk for unsuccessful realerting and the problems associated with it. Additional safety-related recommendations are communicated in Part II.

Hypnosis in the Treatment of Dissociative Identity Disorder and Allied States: An Overview and Case Study

Hypnosis played a prominent role in the first successful treatment of the condition now known as dissociative identity disorder (DID) by Antoine Despine in the 1830s, and continues to be employed in its treatment in the twenty-first century. Despite its venerable history as a therapeutic modality for this condition, controversy has often compromised the acceptance of hypnosis by the healing professions. In this article, it will be argued that given the nature of hypnosis and that hypnotizability, a genetically mediated capacity, is high in dissociative disorder populations, it is inevitable that hypnosis will play a role in the treatment of DID patients, whether this is acknowledged or not. Thereafter, the roles hypnotically facilitated techniques might play will be reviewed, and the application of several of these techniques in the treatment of a DID patient will be illustrated.

Issues in the detection of those suffering adverse effects in hypnosis training workshops

Enhancing safety in hypnosis workshops is an issue of significant concern in the progress and promulgation of hypnosis as a facilitator of treatment. In general, hypnosis is a safe modality, but occasional adverse effects are encountered in its use in clinical, research, and professional workshop settings. To develop and implement modifications designed to reduce the number and/or severity of such unfortunate incidents in workshop settings, it is necessary to establish an awareness of the nature and implications of these adverse events. This article describes 9 categories of problem presentations known to have been generated in workshop settings. It also discusses a particular constellation of factors that--without imputing blame to either faculty or to workshop participants--creates powerful forces that minimize the likelihood that adverse effects will either be recognized by faculty or reported by workshop participants.

The older female patient with a complex chronic dissociative disorder

Dissociative disorders are rarely considered in the diagnostic assessment of older women, despite the fact that the existence, appearance and characteristics of certain dissociative disorders in older populations has been known and described since the 1980s. This communication reviews the core phenomena of Dissociative Identity Disorder and related forms of Dissociative Disorder Not Otherwise Specified, the natural history of their phenomena from youth to old age, and describes common presentations of Dissociative Disorders in older women. It also reviews the treatment of complex chronic dissociative disorders and discusses alternative approaches to their psychotherapy in the older female patient. It is crucial to recognize and respect the importance of appreciating individual differences among older dissociative patients and to individualize their treatments accordingly.

Treating traumatized patients and victims of violence

This chapter presents a thorough exposition of treating traumatized patients and victims of violence, addressing many aspects of trauma and victimization critical to a vast proportion of the work that mental health professionals find themselves doing.

An overview of the psychotherapy of dissociative identity disorder

Dissociative Identity Disorder (DID) is identified and studied with increasing frequency. However, the controversy that often surrounds DID can make it difficult to approach its treatment in a circumspect manner. This paper will provide an overview of DID treatment as it is practiced by those experienced and skilled in the treatment of this group of patients. The treatment of DID resembles the treatment of other traumatized populations in that it is stage-oriented, beginning with supportive and strengthening work. Various stances toward the treatment of DID are reviewed, and specific issues that arise in the psychotherapy of DID are addressed, such as pragmatic arrangements, informed consent, work with alters, and the use of specific techniques, such as hypnosis. The employment of therapeutic modalities and ancillary therapies is discussed. The heterogeneity of DID patients is reviewed, and the characteristics of three general groups of DID patients, high, intermediate, and low in both function and prognosis, are explored. Considerations in the matching of DID patients to either exploratory or supportive treatments are discussed, and observations are made about both trauma work and the supportive psychotherapy of DID.

Treating the traumatic memories of patients with dissociative identity disorder

OBJECTIVE

The author uses clinical experience informed by research findings to suggest approaches to the treatment of the traumatic memories of patients with dissociative identity disorder.

METHOD

Recent findings in the treatment of patients with this disorder and current considerations with regard to memories of childhood trauma are used to develop recommended approaches.

RESULTS

Treatment of traumatic memories appears crucial in the recovery of patients with dissociative identity disorder, even though the reported memories may not be historically accurate. Criteria are available for determining whether a patient with the disorder is able to undertake such efforts, and methods such as fractionated abreaction have been developed to make the process less unsettling.

CONCLUSIONS

Despite the difficulties posed by the vulnerability of patients with dissociative identity disorder to decompensation when working with traumatic material and the vicissitudes of autobiographical memory, modern therapeutic approaches allow the processing of such patients' traumatic material in a manner that reduces the likelihood of disruptive events and the misuse of recovered material.

The physician as perpetrator of abuse

Although the exploitation and abuse of patients is forbidden by every code of medical ethics, physicians are in a power position vis-a-vis their patients, and this power may be misused. The spectrum of abusive physician behaviors includes doctors functioning as agents of control, exploiting physicianly perogatives, acting out personal problems in the medical setting, allowing subversion of their judgment, deliberately delivering suboptimal care, dehumanizing care, and sexually exploiting patients. Guidelines for the treatment of patients with such prior experiences are offered.

Enhancing the hospital treatment of dissociative disorder patients by developing nursing expertise in the application of hypnotic techniques without formal trance induction

Many symptoms suffered by dissociative disorder patients are unresponsive or incompletely responsive to medications. This poses a unique challenge to the staff of specialized dissociative disorder units, in which many such patients who require hospital care suffer serious distress that may not respond predictably to the pharmacological interventions that are available. However, the majority of their symptoms are dissociative in nature, and dissociative disorder patients generally are quite hypnotizable. Anticipating the need for nonpsychopharmacological interventions that we could use in the absence of the treating psychiatrist, we taught the unit's nursing and social work staff to rely on the inherent trance-proneness of these patients to utilize hypnotic techniques without the formal induction of hypnosis. Their implementation facilitated crisis resolution, led to a greater sense of safety on the part of the patients, enhanced the staff's sense of mastery, and minimized the need for emergency sedation and restraints.

Hospital treatment of multiple personality disorder. An overview

MPD patients are not rare. They frequently need hospital treatment. This brief and necessarily incomplete communication has attempted to share what is generally known and accepted with regard to their inpatient care. Such knowledge, however, even though it represents the current state of the art, is, like all state-of-the art knowledge, preliminary with regard to what remains to be discovered and developed. It is anticipated that within the next decade the increasing recognition of such patients will result in their becoming commonplace within most psychiatric hospital settings, drawing the attention of more and more hospitals and psychiatrists alike to the study of their care. At that point, the concentrated attention and endeavors of large numbers of skilled mental health professionals and administrators will, in all likelihood, bring fresh insights and offer new approaches that will enrich and perhaps supplant the observations and advices offered in this contribution.

Clinical presentations of multiple personality disorder

It is hoped that this discussion of MPD will discourage stereotypic thinking about this condition and encourage the inclusion of MPD in virtually all differential diagnoses. The major thrust of what has been learned about the natural history of MPD is that most patients with this condition spend most of their lives not manifesting their MPD in classic manner. The typical presentation of MPD is the tip of a rather large iceberg. Covert and other nonclassic presentations are much more characteristic. An appreciation of this will help the clinician approach the diagnosis of MPD with a heightened sensitivity to the possibility of encountering it within his or her practice.

Playing for time: temporizing techniques in the treatment of multiple personality disorder

The treatment of multiple personality disorder (MPD) is often a prolonged and grueling enterprise, which imposes taxing demands upon the therapist and the patient alike. It becomes quite important to pace the therapy, lest the already beleaguered patient become both acutely and chronically overwhelmed. The majority of the extant literature on the use of hypnosis for the treatment of MPD addresses the processes of accessing the alters, abreacting traumata, arranging reconciliations among the alters, and facilitating integration. This communication discusses the necessity of titrating the amount of discomfort the patient must endure against the patient's resources and capacity to achieve mastery and self-efficacy. Several hypnotherapeutic techniques for offering respite and temporary asylum are explained and illustrated: alter substitution, the provision of sanctuary, distancing maneuvers, bypassing time, bypassing affect and/or memory, attenuating affect and/or memory retrieval, and rearranging the configuration of the alters by bartering or "shuffling the deck."

Treating the patient who has been sexually exploited by a previous therapist

Patients who have experienced sexual exploitation by a previous therapist constitute an increasingly recognized clinical population. Although some of these patients were transiently overwhelmed or mildly disturbed when exploited, the majority were severely symptomatic and the victims of incest or other previous abuse. Many demonstrate a constellation of four factors that predisposes them to revictimization or the sitting duck syndrome: severe symptoms, idiosyncratic dynamics, atypical socialization that discourages self-care, and cognitive difficulties. The experience of such exploitation is not benign, although the sequelae vary considerably. The treatment of such patients is facilitated by arranging the therapy in a way that maximizes safety and clear communication. The importance of hearing the patient' own reconstructions, pacing the treatment to the patient's tolerance, and respecting the patient's agenda cannot be overemphasized. A cluster of issues that appear central to the treatment of such patients includes addressing their helplessness, their ambivalence about the exploitive therapist, their difficulties with trust, their guilt, their depression and pressures toward self-harm, their confusion over sexuality, their post-traumatic and dissociative features, their severe symptoms and the diagnostic confusion this involves, and the countertransference pressures upon the therapist.

The postunification treatment of multiple personality disorder: first findings

The treatment issues encountered in the unified multiple personality disorder (MPD) patient have received little attention in the literature to date. This study reviews the therapy records of 91 such patients and identifies seven recurrent areas of concern: (1) coping with the psychophysiologic changes associated with unification, (2) coping with the psychologic changes associated with unification, (3) working through, (4) abandoning autohypnotic evasions, (5) modifying adaptive and coping mechanisms, (6) interpersonal adjustments, (7) and major life changes. Some therapeutic approaches are indicated.

An update on multiple personality disorder

Within the last decade, multiple personality disorder has been diagnosed, treated, and studied with increasing frequency. A growing body of literature suggests that this condition is not a rarity but that its manifestations, often coexisting with or obscured by other phenomena, frequently go unrecognized for years within the mental health care delivery system. The author reviews recent advances in the understanding of the etiology, diagnosis, and treatment of multiple personality disorder. The thrust of the contemporary literature is that it is a difficult-to-diagnose condition that usually follows severe child abuse, that it is most parsimoniously understood as a chronic dissociative posttraumatic stress disorder, and that it has an excellent prognosis when intensive and prolonged psychotherapy with an experienced clinician is available.