Anxiety during the stressful medical procedure of endoscopy was studied as a function of the number of prior viewings of an explicit preparation videotape and of repression-sensitization coping style. Sixty naive patients viewed a videotaped endoscopy either zero, one, or three times. Dependent measures included heart rate, behavioral ratings, tranquilizer required, and self-report. On each dependent measure, three viewings generally resulted in the least distress; one, more distress; and zero, the most distress. Most comparisons reached statistical significance. These results are interpreted as resulting from extinction and/or habituation of anxiety. The repression-sensitization factor interacted with heart rate change. Sensitizers showed a monotonic decrease in heart rate as a function of number of tape exposures. Repressors showed an inverted-U-shaped function, with one viewing producing the highest heart rate; this is interpreted as resulting from a disruption of repressing defenses by one tape exposure followed by extinction of fear by three exposures.

Slutsky, Jeffrey; Allen, George J. (1978). Influence of contextual cues on the efficacy of desensitization and a credible placebo in alleviating public speaking anxiety. Journal of Consulting and Clinical Psychology, 46 (1), 119-125.

This investigation was designed to determine the extent to which contextual cues mediated the effectiveness of systematic desensitization and a plausible placebo in alleviating public speaking anxiety. After participating in a public speaking situation that allowed the collection of self-report, physiological, and behavioral manifestations of anxiety, 67 subjects were randomly assigned to receive five sessions of either desensitization, “T scope” therapy, or no treatment. Each of these conditions was conducted in a context that either stressed the clinical relevance of the procedure or presented the procedure as a laboratory investigation of fear without therapeutic implications. Analysis of changes both between groups and within individuals indicated that desensitization reduced public speaking anxiety in both contexts, whereas the placebo was effective only in the therapeutic setting. The superiority of desensitization was most pronounced on the physiological variables. The results are interpreted as indicating support for a counterconditioning, rather than an expectancy, interpretation of desensitization.

Ascher, L. M. (1977). The role of hypnosis in behavior therapy. In Edmonston, William E., Jr. (Ed.), Conceptual and investigative approaches to hypnosis and hypnotic phenomena (296, ). New York: New York Academy of Sciences.

He does not differentiate physical and mental relaxation (Davidson & Schwartz). Insists that hypnosis treatment not include desensitization operations.
“Two studies (Gibbins et al., and Woody and Schaube) presented data that seemed to indicate that desensitization plus a hypnotic induction procedure resulted in greater fear reduction than desensitization alone. However, an analysis of the procedures employed suggests that the conclusion may be unwarranted, or at least premature. Both studies confound the hypnotic induction with added elaboration of desensitization scenes, as well as additional direct fear-reduction suggestions. In addition, Gibbons et al. further confounded their study by placing good hypnosis subjects into the hypnotic-induction group as opposed to the desensitization or control groups. Barber has pointed out that the type of method that Gibbins et al. employed in subject assignation, as opposed to random assignment, results in the inability to control for such things as previous experience, the relationship of the subject with the experimenter, and the differential effects of these factors on the subject’s attitudes, expectancies, and motivation” (p. 256).
“Finally, some individuals writing from the context of hypnotherapy, have suggested that the effects of specific imaginal behavioral techniques may be due to the possible existence of hypnosis or the trance state unwittingly incorporated into these behavioral procedures. The difficulties of such a position have been addressed by Barber, Cautela, Johnston and Donaghue, Spanos, Spanos, et al., Spanos and Barber, and Weitzenhoffer, among others. The following, as a group, have pointed out the difficulties inherent in the position that certain procedures, not otherwise associated with hypnosis, may nevertheless result in the production of a ‘trance state’ in susceptible subjects (Barber, Chaves, and Spanos) have delineated the differences between hypnosis and various behavioral procedures (Cautela, Spanos et al., and Spanos and Barber); and have presented strong arguments for suggesting that the effectiveness of hypnotherapeutic techniques are due to the inclusion of components of desensitization in the procedure rather than to the induction of a ‘trance'” (pp. 257-258).

Avila, Donald; Nummela, Renate (1977). Transcendental meditation: A psychological interpretation. Journal of Clinical Psychology, 33 (3), 842-844.

The authors suggest that Transcendental Meditation offers a great deal of promise for use in helping relationships. They also suggest that the technique might receive wider acceptance if it could be explained in other than a purely philosophical or mystical way. For that reason, in their article they offer a psychological interpretation of he TM process.

Snyder, Arden L.; Deffenbacher, Jerry L. (1977). Comparison of relaxation as self-control and systematic desensitization in the treatment of test anxiety. Journal of Consulting and Clinical Psychology, 45 (6), 1202-1203.

Relaxation as self-control and desensitization were compared to a wait-list control in the reduction of test and other anxieties. Neither active treatment differed significantly from the other, but they did differ significantly from the control treatment on several variables. Subjects in both treatments reported less debilitating test anxiety, whereas desensitization subjects showed greater facilitating test anxiety. Under stressful conditions, treated subjects were less worried and anxious, found the situation less aversive, and perceived themselves and their abilities more favorably than controls. Significant reductions in nontargeted anxieties also were found, suggesting transfer of anxiety-management skills to areas other than test anxiety,

Hemme, Robert; Boor, Myron (1976). Role of expectancy set in the systematic desensitization of speech anxiety: An extension of prior research. Journal of Clinical Psychology, 32 (2), 398-404.

The influence of expectancy set with regard to therapy outcome on the effectiveness of systematic desensitization (SD) for reducing public speaking anxiety was investigated. The 7 Ss given a high expectancy set for favorable therapy outcome were informed about psychological research that indicates that SD is effective to reduce public speaking fears. SD was administered with the standard instructions to the 11 Ss given a neutral expectancy set. This expectancy manipulation did not require deception and perhaps could be used with actual SD therapy clients. As in previous research by Woy and Efran, the expectancy set manipulation significantly modified Ss’ self-report of subjective perceptions of anxiety from pretratment to posttreatment speeches, but did not affect overt behavioral or physiological indices of anxiety. Since subjective perceptions of anxiety responses are psychologically significant behaviors, these data suggest the importance of conveying a high expectation of improvement to SD and perhaps also to other types of therapy clients. SD sessions administered to small groups of clients on consecutive days, as in this study, appeared to be as effective to reduce speech anxiety as SD sessions administered to each client individually at 1-week intervals, as in the Woy and Efran study” (pp. 403-404).

Lick, John R. (1975). Expectancy, false galvanic skin response feedback, and systematic desensitization in the modification of phobic behavior. Journal of Consulting and Clinical Psychology, 43 (4), 557-567.

This study compared systematic desensitization and two pseudotherapy manipulations with and without false galvanic skin response feedback after every session suggesting improvement in the modification of intense snake and spider fear. The results indicated no consistent differences between the three treatment groups, although all treatments were significantly more effective than no treatment in modifying physiologic
al, behavioral, and self-report measures of fear. A 4-month follow-up showed stability in fear reduction on self-report measures for the three treatment groups. Overall, the results of this experiment were interpreted as contradicting a traditional conditioning explanation of systematic desensitization. An alternate explanation for the operation of systematic desensitization emphasizing the motivational as opposed to conditioning aspects of the procedure is discussed.

Russell, Elbert W. (1974). The power of behavior control: A critique of behavior modification methods. Journal of Clinical Psychology, 30 (2), 111-136.

In summarizing the effectiveness of behavior therapy the author states, “At this point there does not appear to be sufficient evidence to demonstrate that all of the effectiveness of various types of behavior therapy is produced by non-specific, especially placebo, effects. In fact, it is more probable that many of these techniques will be found to have elements that are not due to non-specific effects and, as such, they will be the treatment of choice for certain limited problems, such as aversive therapy for autistic children or training of the mentally retarded. Nevertheless, concerning the central issue in this monograph, it is increasingly apparent that a very large proportion of the ‘power’ of behavior methods is due to non-specific, suggestion or placebo effects.
“As such, this ‘power’ is neither behavioristic, new, nor particularly threatening. It is not new since it has been known to medicine for many decades. As Shapiro states, ‘the history of both physiologic and psychologic treatment is largely the history of the placebo effect; those who forget it are destined to repeat it’. In support of the age of this problem, Shapiro also quotes from the compiler of the remedies of the Paris Pharmacologia, a century ago, ‘What pledge can be afforded that the boasted remedies of the present-day will not, like their predecessors, fall into disrepute, and in their turn serve only as a humiliating memorial to the credulity and infatuation of the physicians who recommended and prescribed them'” (p. 120-121).
“The large amount of suggestion or placebo effect in behavior therapy does raise at least two vital problems. The first problem involves the ethics of using suggestion or a placebo. Is it ethical to give the patient a false or questionable explanation for the source of the effectiveness of behavior procedures? Such an explanation would be that they are based on proven scientific behavior principles when major people in the field do not believe this and evidence is mounting that the primary source of effect is suggestion. Secondly, what will be the effect on the attitude of the general public toward professional psychology when they realize that the effectiveness of psychological behavior therapy methods is primarily a matter of suggestion? Will they not consider it a modern patent medicine? The damage that could be done to the prestige of psychology might take decades to repair. JH

Wickramasekera, Ian (1974). Heart rate feedback and the management of cardiac neurosis. Journal of Abnormal Psychology, 83 (5), 578-580.

This article describes the treatment of a chronic case of cardiac neurosis which had failed to respond to several prior medical and psychological interventions. Significant and durable symptomatic response appeared to be correlated with the application of a combination of procedures including heart rate feedback, patient- administered desensitization, and therapist-administered flooding.

Brown, H. Alan (1973). Role of expectancy manipulation in systematic desensitization. Journal of Consulting and Clinical Psychology, 41 (3), 405-411.

Expectancy, relaxation, and hierarchy content were manipulated in a 2X2 factorial design with two additional control groups. It was hypothesized that a major portion of therapeutic change following desensitization could be accounted for by the subjects’ responses to positive feedback inherent in the paradigm. Spider-phobic subjects saw either photographs of spiders or blank slides that they believed to be tachistoscopically presented pictures of spiders. In the factorial part of the design, half of the subjects believed their progress through the hierarchy to be contingent on autonomic responses; the others believed rate of progress to be random. Findings did not support the hypothesis that expectancy was the only factor in desensitization, but they did serve to clarify the role of expectancy vis-a-vis the counterconditioning elements typically discussed in the literature.

McReynolds, William T.; Barnes, AllanR.; Brooks, Samuel; Rehagen, Nicholas (1973). The role of attention-placebo influences in the efficacy of systematic desensitization. Journal of Consulting and Clinical Psychology, 41 (1), 86-92.

Systematic desensitization was compared with two attention- placebo control treatments – one taken from Paul and one currently devised as an elaborate, highly impressive “therapeutic” experience – and no treatment. It was hypothesized that (a) fear reductions following desensitization would be no greater than those associated with an equally compelling placebo treatment and (b) fear and control measure changes following the previously used attention-placebo treatment would be less than those following desensitization and the present placebo control manipulations. Both hypotheses were supported, although support for the first was more consistent than for the second.

Tori, Christopher; Worell, Leonard (1973). Reduction of human avoidant behavior: A comparison of counterconditioning, expectancy, and cognitive information approaches. Journal of Consulting and Clinical Psychology, 41 (2), 269-278.

This study was designed to compare the fear-reducing efficacy of procedures based on three major theories that have been proposed to account for the success of systematic desensitization therapy: (a) cognitive information storage and retrieval, (b) cognitive expectancy, and (c) counterconditioning. Predictions were confirmed in that the outcome measures of the high-expectancy placebo group and the two cognitive-coping groups were significantly superior to those of the counterconditioning and no-treatment groups. Thus, this experiment supports the supposition that changes in human avoidant behavior may be attributed to demand and expectancy variables rather than the conditioning of “antagonistic responses” as has been previously suggested.

Gibbons, Don E. (1971). Directed-experience hypnosis: A one-year follow-up investigation. American Journal of Clinical Hypnosis, 13, 206-207.

In a previous study, the Direct Experience (DET) group was significantly lower than the Wolpe desensitization group and No Treatment controls on Mandler-Sarason Test Anxiety Questionnaire. One year later this advantage was maintained. They concluded direct-experience hypnosis (a) takes effect more rapidly than does systematic desensitization, since the differences obtained in the original study were produced after only 3 hours of experimental treatment, (b) produces a long-term effect which, by virtue of its duration, may not be attributed to implicit posthypnotic suggestion, (c) is likely to be due to influences other than initial differences in suggestibility between groups, as no such differences had been found in initial administration of the Barber Suggestibility Scale, (d) is unlikely to be due to systematic differences in experimenter variance, as a different E worked with each subject in the original study, and (e) would be difficult to account for in terms of subject demand characteristics, since E’s handling the desensitization subjects were either enrolled in or teaching a graduate seminar in desensitization and behavior modification at the time while those handling DET subjects were enrolled in or teaching graduate seminars in hypnosis.

Davis, Daniel; McLemore, Clinton W.; London, Perry (1970). The role of visual imagery in desensitization. Behaviour Research and Therapy, 8 (1), 11-13.

Summary: a measure of visual imagery ability was obtained for 33 females who and participated in desensitization therapy for snake phobia. Visual imagery was positively related to pretherapy performance (closeness of approach to a live snake), but not to improvement. On the basis of these results and the results of two other studies, it was hypothesized that the fear of good imagers tends to be based on imagination while that of poor imagers tends to be based on sensory experience.
Most psychologists now recognize behavior therapy as effective in alleviating a wide variety of fears, but the nature of the processes underlying the various methods remains an open issue. Imagery has been of particular interest as a possible common denominator among various desensitization techniques. Lazarus (1961), for example, asserts that a “prerequisite for effective application of desensitization is the ability to conjure up reasonably vivid images,” and Wolpe (1961) claims, “it is essential for visualizing to be at least moderately clear.” London suggests that theoretically opposed treatments such as reciprocal inhibition (Wolpe, 1958) and implosion (Stampfl and Levis, 1967) may both be facilitated by repeated imagery which “produces a discrimination set such that the patient learns to distinguish between the imaginative, cognitive, affective aspects of experience, and the sensory and overt muscular aspects” (1964, p. 130). However, no systematic studies linking visual imagery to desensitization have been reported. This study examined the relationship between visual imagery and success in desensitization therapy.

Schubot, Errol David (1967). The influence of hypnotic and muscular relaxation in systematic desensitization of phobias (Dissertation). Dissertation Abstracts, 27 (n10-B), 3681-3682.

“15 snake phobic subjects had desensitization treatment and 15 matched subjects had desensitization treatment with a hypnotic and muscular relaxation induction. Rate of moving through the fear hierarchy was based on three variables fear report, report of body tension, and time of signaling anxiety. Analysis of results took into consideration initial approach (to snake) level of subjects. Both treatments were effective. However, hypnotic relaxation was significantly important in desensitization for the most phobic subjects (those who couldn’t approach closer than 5 feet, initially) though not for less fearful subjects. In fact, the most fearful subjects did not show improved approach behavior if they did not get the hypnosis relaxation treatment, though bodily tension and fear were reported as less while working on early items in the hierarchy. The Waking group, compared to the Relaxation hypnosis group, manifested significantly less improvement in approach and slower progress in desensitization. Hypnotizability was significantly correlated with improvement for the Relaxation subjects, as was vividness of imagery. In summary, hypnosis (a relaxation induction) facilitated desensitization treatment of highly anxiety snake-phobic subjects with the hypnotic relaxation induction, treatment outcome was related both to hypnotizability and to imagery vividness” (p. 3681- 3682).

Davison, Gerald C. (1965, June). Anxiety under total curarization: Implications for the role of muscular relaxation in the desensitization of neurotic fears. [Paper] Presented at the annual meeting of the Western Psychological Association, Honolulu.

I began by describing the Jacobson-Wolpe position on the use of deep muscular relaxation as an anxiety-inhibitor: these writers assume that the considerable reduction in proprioceptive feedback from muscles which are in a relaxed state is incompatible with a state of anxiety. Then I mentioned the evidence that at least modern neuromuscular blocking-agents operate solely at the myoneural junction, with no direct central effects. I went on to discuss the various studies which have used paralytic drugs, primarily d- tubocurarine chloride, to show the learning of fear-responses under complete striate muscle paralysis: the fact that these animals are able to acquire classically-conditioned fear-responses under curare was taken as evidence inconsistent with the views of Jacobson and Wolpe. Several studies were then reviewed which purport to furnish confirmatory evidence for the Jacobson position: these studies showed considerable central depression during curare paralysis. I re-interpreted these studies in the light of the over-riding importance of exteroceptive stimulation, stressing that the animals in the curare learning experiments were likewise deprived of proprioceptive feedback and yet were hardly non- anxious: the important difference was that the animals in the conditioning experiments were stimulated frequently from the environment while curarized, this stimulation maintaining an alert, often anxious state. Finally, two hypotheses were put forward as to why training in muscular relaxation does, in fact, inhibit anxiety: the one suggested that relaxing one’s muscles generates strong positive affect states, which in turn inhibit anxiety; the other hypothesis called attention to the fact that the states of muscular relaxation under curare versus under self-induced relaxation differ in the important respect that only with self-induced relaxation is there a reduction in efferent activity–perhaps this elimination of efferents, rather than afferents, inhibits anxiety.


Eimer, Bruce. N. (2000). Clinical applications of hypnosis for brief and efficient pain management psychotherapy. American Journal of Clinical Hypnosis, 43 (1), 17-40. (July)

ABSTRACT: This paper describes four specific clinical applications of hypnosis that can make psychotherapy for pain management briefer, more goal-oriented, and more efficient: (1) the assessment of hypnotizability; (2) the induction of hypnotic analgesia and development of individualized pain coping strategies;
(3) direct suggestion, cognitive reframing, hypnotic metaphors, and pain relief imagery; and (4) brief psychodynamic reprocessing during the trance state of emtoional factors in the patient”s experience of chonic pain. Important theoretical and clinical issues regarding the relationship between hypnotizability to the induction of hypnotic analgesia are presented, and attempts to individualize pain treatment strategies on the basis of assessed differences in hypnotizability and patients” preferred coping strategies are described. Some ways are also presented of integrating direct hypnotic suggestion, COGNITIVE-EVALUATIVE reframing, hypnotic metaphors, and imagery for alleviating the SENSORY and AFFECTIVE-MOTIVATIONAL components of pain, with an exploratory, insight-oriented, and brief psychodynamic reprocessing approach during trance for resolving unconscious sources of resistance to treatment, and reducing the emotional overlay associated with chronic pain. Some basic assumptions underlying the use of this approach are discussed, and a brief step-by-step protocol is outlined.

Wickramasekera, Ian (1998). Secrets kept from the mind but not the body or behavior: the unsolved problems of identifying and treating somatization and psychophysiological disease. Advances in Mind-Body Medicine, 14, 18-132.

The identification and therapy of somatoform and psychophysiological disorders are major problems for medicine. This paper identifies three measurable risk factors (Wickramasekera 1979, 1988, 1993a, b, 1995) that are empirically associated with somatoform and psychophysiological disorders. These risk factors are high hypnotic ability, low hypnotic ability, and high Marlowe Crowne scores. Patients who are positive on one or more of these risk factors (all of which can constrict consciousness) have a high likelihood of having somatoform and psychophysiological disorders and should be studied with the additional risk factors proposed in the High Risk Model of Threat Perception (HRMTP). Treatment of patients should begin with the Trojan Horse Role Induction procedure (Wickramasekera 1988), which enables patients, who might otherwise resist psychological interpretations of their physical problems, to recognize that unconscious threat perception could be driving their somatic symptoms, an understanding that reduces their resistance to psychotherapy. A case study is presented of a patient without identifiable pathophysiology or psychopathology to account for somatic symptoms that were largely resistant to standard medical therapy. The patient was positive for several of the psychosocial and psychophysiological risk factors of the HRMTP and after experiencing the Trojan Horse Role Induction showed improvement in somatic symptoms.

Kessler, Rodger; Dane, Joseph R. (1996). Psychological and hypnotic preparation for anesthesia and surgery: An individual differences perspective. International Journal of Clinical and Experimental Hypnosis, 44 (3), 189-207.

Multiple reviews indicate that psychological preparation for surgery can provide psychological, physiological, and economic benefit to the patient. Research demonstrating that hypnosis adds to this benefit is both limited and encouraging. The content and status of this literature, however, are confusing, with little coherent theoretical basis to account for the contradictions and inconsistencies across multiple studies whose methodologies often limit generalization. A model is presented regarding pertinent individual differences that include patient coping styles, prior medical experiences, and hypnotic ability, as well as differences in types of coping demanded by different surgical procedures. This model (a) helps explain some of the confusion, (b) offers a theoretical focus for patient assessment as well as development and selection of preparation strategies, and (c) clarifies future research goals.

Ganaway, George K. (1995). Hypnosis, childhood trauma, and dissociative identity disorder: Toward an integrative theory. International Journal of Clinical and Experimental Hypnosis, 43 (2), 127-144.

It is contended that prevailing exogenous trauma theory provides in most cases neither a sufficient nor a necessary explanation for the current large number of diagnosed cases of dissociative identity disorder (multiple personality disorder) and related dissociative syndromes purported to have arisen as a response to severe early childhood physical and sexual abuse. Relevant aspects of instinctual drive theory, ego psychology, object relations theory, self psychology, social psychological theory, sociocultural influences, and experimental hypnosis findings are drawn on to demonstrate the importance of adopting a more integrative theoretical perspective in the diagnosis and treatment of severe dissociative syndromes. Further cooperative experimental and clinical research on the etiology, prevalence, and clinical manifestations of the group of dissociative disorders is strongly encouraged.

Sarbin, Theodore R. (1995). On the belief that one body may be host to two or more personalities. International Journal of Clinical and Experimental Hypnosis, 43 (2), 163-183.

The belief in the validity of the multiple personality concept is discussed in this article. Two scaffolding constructions are analyzed: dissociation and repression. As generally employed, these constructions grant no agency to the multiple personality patient. The claim is made that the conduct of interest arises in discourse, usually with the therapist as the discourse partner. In reviewing the history of multiple personality and the writings of current advocates, it becomes clear that contemporary users of the multiple personality disorder diagnosis participate in a subculture with its own set of myths, one of which is the autonomous actions of mental faculties. Of special significance is the readiness to transfigure imaginings into rememberings of child abuse, leading ultimately to the manufacture of persons. The implications for both therapy and theory of regarding the patient as agent in place of the belief that the contranormative conduct is under the control of mentalistic faculties are discussed.

Cardena, Etzel (1994, August). Domain of dissociation. [Paper] Presented at the annual meeting of the American Psychological Association, Los Angeles.

NOTES: Dissociation (a French term) exists when two or more mental contents are not integrated. Dissociation includes a wide variety of behaviors and experiences.
Three Concepts: 1. nonconscious or nonintegrated mental models or processes 2. alteration in consciousness when disconnection from self or environment is experienced 3. defense mechanism
Explanation of these three concepts:
1. Within nonconscious or nonintegrated mental models/processes there are three types: (a) absence of conscious awareness of impinging stimuli or ongoing behaviors (broad, vague, not useful, because we are unaware of physiological processes most of the time) (b) co-existence of separate mental systems or identities that should be integrated (Meyers, 1903, said the memorability of an act is better proof of consciousness than its complexity). Examples: dissociative amnesia (Walter Reed Hospital patient); or in hypnosis telling a person that their hand is going to begin raising on its own (c) ongoing behavior that is inconsistent with person’s verbal report. May be part of #2. Example: commisurotomized patients – woman who wanted to smoke couldn’t get her hand to lift cigarette to her mouth. Example of student, being criticized, breaking out into a rash while saying that she felt calm.
Often repression and dissociation are confused. When dissociation is used as in (c) above, they are indistinct; they are the same. Freud used the terms for the same thing. When we talk about a dissociated memory, it is same as repression.
2. Alteration in consciousness (disconnection from the self or environment is experienced). In this case we talk about an experiential event. Caveats: Some use it to refer to *any* kind of alteration of consciousness. Braun, 1993, reported that mystical experiences are dissociative; I maintain that many people feel most in contact with the self during mystical experience. Same with drugs: it may not involve primarily separation, disengagement, from self or environment. As you listen to me, you may disengage at times. I think the only legitimate use of “dissociation” is a radical alteration of consciousness; like Tart’s altered states of consciousness, like out-of-body experiences. In clinical situation, distraction or dreaminess is usual; but if a patient disengages and starts reliving a situation, it is legitimately regarded as dissociation.
3. Defense mechanism – a theoretical construct, referring to intentional disavowing things that would cause anxiety or pain. Clinical observations of people in traumatic events, rape, people may have out of body experiences; explained as the person sending the ego somewhere else because they can’t bear the pain. But, you get this separation in non-traumatic circumstances (in meditation, revery, etc.)
Alternative Paradigm:
Janet’s theory which explains cognitively how dissociation occurs, without necessarily proposing an intentional process.
For further elaboration of these comments, see Cardena, E. (1994). The domain of dissociation. In S. J. Lynn & J. W. Rhue (Eds.) Dissociation: Clinical and Theoretical Perspectives. New York: Guilford Press

Frankel, Fred H. (1994, October). Working with the concept in a clinical setting. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, San Francisco.

NOTES: I have concerns about the construction of the Diagnostic and Statistical Manual (DSM) as a whole. It was initially a research document, but it has come to dominate clinical diagnostic practice, and worse, it governs what treatment third party payers will compensate.
Dissociative Identity Disorder (DID) to replace Multiple Personality Disorder (MPD) may well change the way the condition is viewed, and we may see fewer alters in each person.
I have difficulty understanding the precise nature of dissociation–especially with its powers to produce amnesia. The dissociative disorders are part of the legacy of hysteria; though some parts of hysteria are represented in other DSM categories. The influence of environmental factors and imagination were suspected when the diagnosis was hysteria; everyone knew the picture was complicated, and subject to contagion, etc. The DSM makes little attempt to take that into account in the section on Dissociative Disorder.
Questions we must address: 1. How voluntary is clinical dissociation? To what extent can we expect the patient to claim agency for it, e.g. if it is claimed that a crime was committed by an alter? 2. To what extent does the clinical manifestation of dissociation overlap with absorption and attention? 3. How does morbid preoccupation with images differ from regression? How much is the patient the willing agent of that kind of behavior? 4. To what extent are flashbacks remembering or imaginings? 5. How do we control for contagion or imitation on the dissociative disorder inpatient units? 6. Could we be creating things to fit our theories? 7. Are other diagnoses being displaced here? The dissociative disorders being put on center stage may lead us to do disservice to the patient in dealing with their other life crisis. 8. If the shock of the trauma is associated with impaired perception, altered attention, and memory problems, how dependable are the reports that are ultimately retrieved–perhaps decades later? 9. What do we in truth understand by the word dissociation? Is it a psychological event with underlying physiology, or just a metaphor?
Psychiatry is subject to diseases rising and falling, e.g. the disappearance of hysteria itself.
Spiegel, David (1994, October). Acute stress disorder and dissociation in DSM-IV. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, San Francisco.
NOTES: Starting with the theme on hysteria introduced by Frankel (1994), and Cardena (1994) on trance disorder [Spiegel notes that] in the West our problem is of individuality, so fragmentation of personality is our disorder. There is cultural content in the delusions of schizophrenia, and cultural content in dissociative disorders. We have further evidence of trauma being involved in dissociation. Trauma is the experience of being made into an object, and the core problem is helplessness (not anxiety or fear), and discontinuity in experience. Dissociation permits people to retain control of their minds when they have lost control of their bodies. The discontinuity of dissociation reflects the discontinuity of experience.
[This presentation included the material presented at an earlier meeting and is not reported in full here.]
The difficulty is the problem of lack of identity rather than too many identities.

Spiegel, David; Koopman, Cheryl; Classen, Catherine; Freinkel, Andrew (1993, October). Dissociation, trauma, and DSM-IV Acute Stress Disorder. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington Heights, IL.

NOTES: This represents a progress report on the research in our laboratory, which is different from traditional approaches that link childhood trauma to current problems. We say if there is a link between dissociation and trauma, one should find the symptoms in people who have trauma.
Earthquake Research:
They examined data from Loma Prieta earthquake; Stanford had $164 million damage. Oct 1989. [Presents data that he has presented before.] There was a drop in dissociative symptoms over 4 months. McFarlane found that numbing was the best predictor of later PTSD symptoms, and we find that too.
Most trauma researchers have focused on anxiety because that is what they are interested in; they have ignored dissociative experiences, because such symptoms are designed not to be noticed.
Andrew Frankel and Cheryl Koopman studied 15 journalists who saw Robert Alton Harris’ execution–volunteers who reported on the execution, to whom the event did not personally threaten. 40% reported depersonalization experiences, 2/3 felt detached or estranged from others, 27% had problems remembering everyday activities, etc. Dissociative symptoms were especially high in TV journalists, lowest in radio journalists, and in the middle range in newspaper reporters.
Oakland Fire Research:
Koopman & Classen looked at immediate psychopathology and later problems. They studied people of low, medium, and high exposure as defined by distance from the fire, which related strongly to both dissociative and anxiety symptoms.
There were strong relationships between the Mississippi PTSD scale scores and anxiety and dissociative symptoms (.50 and .59 respectively). People who reported recent life stress in the intervening period had higher PTSD and dissociative symptoms. The combination of initial dissociation and subsequent stress was additive in their relationships to PTSD.
People who had higher dissociation scores tended to do higher risk things (e.g., cross police barriers). This may explain how clinicians see patients who appear to get themselves re-victimized.
Law Office Shooting Research:
We followed up on the 1993 shooting of 14 people (8 fatally) in a law office in San Francisco. Survivors filled out dissociation questionnaires in the office (N = 36). They had high scores on the Impact of Event Intrusion Scale. The more they thought they or colleagues were in danger, the higher their scores on anxiety and dissociation measures and on Impact of Event scale.
Dissociation Definition:
These studies led to a project, with Etzel Cardena, in trying to revise DSM-IIIR, which doesn’t capture the symptoms [of post traumatic dissociation]. In DSM-IV there will be the diagnosis of 308.3 Acute Stress Disorder, characterized as: A. Same as DSMIIIR, except it doesn’t require that the trauma be “unusual” B. Requires 3 of 5 dissociative symptoms. C, D, and E are classic dissociative symptoms F, G, and H are delimiting factors (e.g., causes significant impairment, length of time, not due to other factor).
Also, the multiple personality disorder (MPD) diagnosis has been changed to Dissociative Identity Disorder. The problem for these patients is not in having more than one personality, but not having one _functioning_ personality.

Van der Hart, Onno; Spiegel, David (1993). Hypnotic assessment and treatment of trauma-induced psychoses: The early psychotherapy of H. Breukink and modern views. International Journal of Clinical and Experimental Hypnosis, 41 (3), 191-209.

The role of hypnotizability assessment in the differential diagnosis of psychotic patients is still unresolved. In this article, the pioneering work of Dutch psychiatrist H. Breukind (1860-1928) during the 1920s is used as early evidence that hypnotic capacity is clinically helpful in differentiating highly hypnotizable psychotic patients with dissociative symptomatology from schizophrenics. Furthermore, there is a long tradition of employing hypnotic capacity in the treatment of these dissociative psychoses. The ways in which Breukink used hypnosis for diagnostic, prognostic, and treatment purposes are summarized and discussed in light of both old and current views. He felt that hysterical psychosis was trauma-induced, certainly curable, and that psychotherapy using hypnosis was the treatment of choice. Hypnosis was used for symptom-oriented therapy, as a comfortable and supportive mental state, and for the uncovering and integrating of traumatic memories. For the latter purpose, Breukink emphasized a calm mental state, both in hypnosis and in the waking state, thereby discouraging emotional expression, which he considered dangerous in psychotic patients. In the discussion, special attention is paid to the role and dangers of the expression of trauma-related emotions.

Frischholz, Edward J. (1992, October). Dissociation. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington, VA.

NOTES: there are two approaches for studying dissociation 1. phenomenological: describe difference types of dissociative phenomena, e.g., forgetting, multiple personality disorder or MPD 2.theoretical: explain the physiological/ psychological processes by which things become associated/disassociated, e.g., Freud (repression) vs. Janet (dissociation).
Two types of dissociation: 1. dissociation of awareness (amnesia, unconscious cognitions) 2. dissociation of volition (loss of executive control over behavior, psychological automatisms)
Normal Dissociation is characterized as: 1. content is narrow and specific 2. duration is brief 3. awareness of loss of material exists 4. control can be re-established
Abnormal Dissociation is characterized as: 1. content is broad (self-identity) 2. duration is extended 3. no awareness of loss of material exists 4. no re-establishment of control
The most widely used measure is Dissociative Experience Scale (Bernstein & Putnam) which has .84 to .96 test-retest correlation (Bernstein & Putnam, 1986; Frischholz et al.)
Mean Scores for DES MPDs 55. DD NOS 40.8 Students 23.8
He advocates a cutoff score above 40 as indicating abnormal dissociative experiences (that would yield 6% false negatives). Above 65, suspect faking or over- reporting of dissociative experiences.
Factor Analysis of the DES would associate the following items: 1. Absorption Factor: 2, 14, 15, 17, 18, 20 (normal dissociation) 2. Amnesia Factor: 3, 4, 5, 8, 25, 26 (pathological dissociation) 3. Depersonalization/Derealization Factor: 7, 12, 13, 14, 27, 28
Correlations of DES with other tests:
Tellegen Ambiguity Jenkins
Absorption Tolerance Activity DES Total .39 .24 .04 DES Amnesia .24 .22
See Table from AJCH in July 1992, which replicates a study by Nadon Table 2 r = .12 with hypnotizability (Nadon reported .18).
One could use both the DES and hypnotizability scores to distinguish between different clinical groups. For example, dissociative patients reverse amnesia while schizophrenics don’t.
One could distinguish real MPDs vs Simulators based on Special Hypnotic Phenomena: with Real MPDs half show the hidden observer phenomenon, therefore they hide their MPD; simulators show the hidden observer phenomenon 100% of the time. Another item that discriminates is the Orne Double Person Hallucination item. MPDs 50- 62% show it, but 92-80% [incorrect percentage in these notes?] of simulators do experience the hallucination. Of these 70-75% of the MPDs are able to distinguish the hallucination; only 45-40% of simulators are able to distinguish the hallucination. Real MPDs know, can tell difference between a hallucinated person and the real person whereas simulators maintain they can’t tell who is the real person.
It’s not true that MPDs are extremely high in hypnotizability. They score in 8-10 range. The MPDs score 1 SD above normals but they are not off the end of the scale.
These are good ways of testing whether someone is faking MPD. We have replicated this many times, getting better replication of MPD simulators than high hypnotizable simulators.
Another method for distinguishing true MPDs from simulators involves demonstration of the Einstellung (learning set) effect.
Looking at Water Jar Problems, patients learn to solve the problems the long way. They teach personality A how to solve problem by long solution method (four trials of B – A – 2C); on the fifth trial, 95% of Ss solve the problem by the long method, the Einstellung (learning set) effect. Switch to personality B and give the same test. If there were no transfer, people immediately see A-C, which is a short method for solving the problem. It has been observed that 50-60% of MPDs do not show Einstellung effect; they immediately see the short solution.
Have done this also with retroactive interference word learning model.
Effect of context. Kohlenberg (Behavior Therapy Journal) selectively reinforced one personality of an MPD, which then ‘came out’ more often; during extinction the frequency of seeing that personality went back to baseline.
I used Greenspan’s and Erickson’s learning without awareness paradigm. When a low baseline frequency personality emerged, I’d reinforce the person; when a dominant personality came out I’d start yawning, look out the window, etc. During extinction the frequency went back toward normal baseline level, but not all the way. These indicate you can shape the appearance of one personality, but not that it’s iatrogenic.
Can also do this with schizophrenics, normal highly hypnotizable subjects.

Spiegel, Herbert; Greenleaf, Marcia (1992). Personality style and hypnotizability: The fix-flex continuum. Psychiatric Medicine, 10, 13-24.

Since Mesmer, there has been much confusion about the inter-relationship between an individual’s degree of hypnotizability, the personality style of the individual, and the importance of the therapeutic strategy. Empirical and experimental research supports the hypotheses that there are: 1) biopsychosocial components of hypnotizability on a continuum ranging from ecologically insensitive (not modifiable by external stimuli) to ecologically sensitive (very modifiable by external stimuli); 2) biopsychosocial components that can be measured to identify an individual’s degree of hypnotic capacity and responsivity; 3) distinct personality styles which correlation with low, mid-range and high hypnotizability on a _fix_ (ecologically insensitive) – _flex_ (ecologically sensitive) continuum; and 4) different clinical syndromes which correlation with these categorical distinctions. We propose that measuring hypnotizability and personality style is a way to clarify diagnosis and choose appropriate treatment strategies to maximize existing biopsychosocial resources of an individual with a specific problem in a particular context.

Frischholz, Edward J.; Braun, Bennett (1991, August). Diagnosing dissociative disorders: New methods. [Paper] Presented at the annual meeting of the American Psychological Association, San Francisco.

Five new methods which have proven useful in the differential diagnosis of dissociative disorders from other psychiatric syndromes are identified. The first method involves the use of the Dissociative Experiences Scale, a self-report questionnaire which significantly discriminates dissociative psychopathology from normal dissociative experiences. The second method involves the use of various measures of hypnotizability (e.g., Hypnotic Induction Profile; Stanford Hypnotic Susceptibility Scale, Form C; self-ratings of hypnotizability) in discriminating between various psychiatric groups. The third method involves the use of qualitative responses to individual test items (e.g., instructed posthypnotic amnesia) to discriminate between different psychiatric syndromes. The fourth method involves the use of an implicit memory test to measure the amount of between-personality state amnesia in patients suffering from Multiple Personality Disorder. The fifth method involves the use of special hypnotic phenomena (e.g., the Orne double person hallucination and the Hilgard hidden observer item) to discriminate between dissociative disorder patients and subjects simulating dissociative psychopathology. (ABSTRACT from Bulletin of Division 30, Psychological Hypnosis, Provided by former Editor, James Council.)

Five new methods have proven useful in the differential diagnosis of dissociative disorders. The first method involves the use of the Dissociative Experiences Scale, a self-report questionnaire which significantly discriminates dissociative psychopathology from normal dissociative experiences.
The second method involves the use of various measures of hypnotizability in discriminating between various psychiatric groups.
The third method involves the use of qualitative responses to individual test items (e.g., instructed posthypnotic amnesia) to discriminate between different psychiatric syndromes.
The fourth method involves the use of an implicit memory test to measure the amount of between-personality state amnesia in patients suffering form Multiple Personality Disorder.