We now must turn the flow diagrams into neurobehavioral models, like Helen Crawford is attempting to do.
COMMENTS FROM THE AUDIENCE:
Kenneth Bowers: The people flowing out from the neodissociation camp are going in different directions. I think that ideas are directly activated, Helen Crawford and John Kihlstrom would think it involves more effort on the part of the hypnotized Subject. Irving Kirsch agrees that at some level the words have to be processed, but doesn’t imply great effort. There is some kind of preattentive processing in hypnosis, the kind of processing which allows you to turn when you hear your name, in normal circumstances. Does it still make sense to talk about the field of hypnosis research or theory in terms of the two camps? I fear a return to the situation when the term “two camps” was justified.
1993
Miller, Mary E.; Bowers, K. S. (1993). Hypnotic analgesia: Dissociated experience or dissociated control?. Journal of Abnormal Psychology, 102, 29-38.
High-hypnotizable subjects were found superior to low-hypnotizable subjects in degree of pain reduction produced by hypnotic analgesia and by a stress- inoculation (cognitive-therapy) procedure. But, stress inoculation and not hypnotic analgesia impaired performance on a cognitively demanding task that competed with pain reduction for cognitive resources. This outcome implies that hypnotic analgesia occurs with little or no cognitive effort to reduce pain, challenging the social psychological theory of hypnotic response, at least in high-hypnotizable individuals. The findings are also incompatible with the concept of dissociated experience wherein the pain and cognitive efforts to reduce it are separated from consciousness by an amnesia-like barrier. But the results do support the concept of dissociated control, which proposes that suggestions for hypnotic analgesia directly activate pain reduction and thereby avert the need for cognitive strategies to reduce pain.
Woody, Erik Z. (1993, October). Factors, facets, and fiddle-faddle. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington Heights, IL.
NOTES
The classic suggestion effect implies involuntary behavior. A theory by Norman & Tim Shallice (published in a book on cognitive neuropsychology by Shallice) explains the classic suggestion effect in terms of underlying control processes.
There are 2 complementary systems: 1. contention scheduling (routine acts that don’t require conscious control, activating schemas through environmental events and other schemas) for well learned habitual tasks. 2. supervisory attentional system – nonroutine actions in centralized processes, accessing unique information, operating only indirectly by modulating lower level control system, biasing their selection of schemas by system #1.
These two systems permit the sense of behavior being automatic or willed. The theory can be used to explain hypnotic nonvolition. For highs, hypnosis may partly disable System #2, dissociating lower levels of control and resulting in genuine changes in behavior because System #1 would be more enabled, triggered directly by co-active schemas and environmental stimuli. This increased dependence on a lower level of control would not rule out a wide range of behavior. It’s mainly novel or very complex behaviors that would diminish, plus exercise of will.
The model also illuminates our understanding of behavioral rigidity and the tendency for thought/action to be triggered by [suggestions?]. Spontaneous voluntary behavior would be diminished. (See for example Orne’s studies of the effect of apparent power outage during an experiment, in which high hypnotizable Ss did not move or leave the room but sat passively, whereas low hypnotizable simulating Ss simply got up and left.)
Also a weaker “supervisor” would lead to disinhibition of inappropriate or peculiar associations or behavior. In labs one sees few such triggers, although Hilgard observed drug flashbacks. The phenomena of hypnosis sequelae appear like a disinhibition of experiences.
Hypnotic analgesia follows this model too, an automatic and controlled processing of perceptual input.
Amnesia that follows hypnosis can be explained by this theory. Shallice has a model of how memory is affected: memory is a higher control system, enabling the handling of non-routine situations. Confronted by a nonroutine memory problem, the supervisory system formulates a model of what [the information] should look like, pulls out memories, and compares the model. If hypnosis interferes with the supervisor function it should interfere with memory (the description and verification phases) leading to [hypnotic amnesia?]. [With hypnosis one would predict]: 1. Poor access to memories requiring description (not overlearned material). Recall should demonstrate good cued memory but poor free recall. [It has been observed that] hypnotic amnesia selectively impairs free recall rather than recognition recall. 2. Hypnotized Ss should show poorer verification (the ability to discriminate irrelevant from correct associations). Many studies have shown this, with impoverished verification (e.g. the “discovery” of elaborate previous lives).
A dissociated control theory of hypnosis is thus possible, emphasizing a loss of control of supervisory system processes. It would implicate changes in frontal lobe processing. The essence of hypnosis, according to this approach, is the bypassing of executive control, and the frontal lobe is viewed as a center of executive control.
There are several ways that hypnosis suggests inhibition of frontal lobe functioning: 1. impoverishment of self initiated behavior 2. other-directedness 3. frontal amnesia (unable to distinguish true memories from irrelevant memories; prone to confabulation, especially when probed with false information) 4. poorer in temporal or sequential organization in memory.
How do we proceed to make this theoretical approach useful? We should do more neuropsychological studies, as Helen Crawford does. They emphasize the inhibition of frontal lobe functions.
Testable hypotheses arise: 1. Hypnotizable Ss should show the same kind of problem solving problems as frontal lobe patients. 2. Memory of hypnotized Ss should be like patients with frontal amnesia.
1992
Anonymous (1992, May). Studies: Learning can occur while under anesthesia. Daily Breeze (South Bay, Los Angeles County).
Surgical patients can absorb information while they’re knocked out, and even learn tips that help with recovery, researchers reported Friday at a symposium on memory and anesthesia.
“Researchers at Papworth Hospital in Cambridge, England, studied 51 cardiac patients, one-third of whom heard a tape of positive ‘therapeutic suggestions’ during surgery. Another third heard batches of word associations; the rest heard a blank tape.
“Patients who were played the suggestion tape – which told them they were doing well, or wouldn’t feel much pain – left the hospital 1 1/2 days earlier on average than other patients.
“Another study, from the University of Arizona College of Medicine, found that surgical patients who heard specific pain-relief suggestions recovered more easily than those hearing vague advice such as, ‘Think of being well.’
“‘These are still early days to invest in every operating suite buying a tape recorder to play for the patients,’ said Dr. Sunit Ghosh, a researcher with the Papworth team. ‘But this definitely does hold promise.’
“Scholars at the second annual Symposium on Memory and Awareness in Anesthesia said patients rarely wake up recalling – unprompted – something that happened during anesthesia.
“But several studies showed subconscious learning while the patients were out cold.
“Not everyone accepted the findings.
“‘It shows an enormous sensitivity on the part of the brain, if it can be shown,’ said Eugene Winograd, an Emory University psychologist and organizer of the Emory- sponsored conference. ‘I’m not confident it has been shown yet.’
“Some researchers in other studies found no association between messages heard during anesthesia and learning.
“Dr. Alan Aitkenhead, professor of anesthesia at the University of Nottingham in England, found no significant difference between patients who heard recuperative suggestions and patients who were treated to a deliberately dull history of the hospital where they were.
“Aitkenhead said his study kept all patients quite deeply anesthetized, and that may be why they might not have learned as much as patients in other studies.
“‘By far, most likely, it’s a difference in levels of anesthesia,’ he said.
“The Papworth researchers, in another study, found that some patients showed strong word associations after hearing tapes of groups of words during surgery; but other patients under a different anesthesia didn’t.
“‘There needs to be standardization of our testing,’ Ghosh said. ‘I think it’s partly related to the anesthesia technique and partly related to the way in which material is presented to the patient.’
“Dr. Peter Sebel, an Emory anesthesiologist and conference organizer, said that if patients can retain information about a speedy recovery, they probably retain other information, too – for example, a surgeon’s discouraging operating-room assessment of their prognosis.”
Blankfield, Robert; Scheurman, Kathleen; Bittel, Sue; Alemagno, Sonia; Flocke, Sue; Zyzanski, Stephen (1992, October). Taped therapeutic suggestions and taped music as adjuncts in the care of coronary artery bypass graft patients. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington, VA.
NOTES
18 studies have explored the issue with an experimental design; half used tapes, half didn’t; majority of studies found benefits; 2 were of heart surgery patients.
This study used taped suggestions with coronary bypass patients. Used tape recorder rather than person delivering suggestions because it was more convenient; used tape intra-surgery and post-operatively for more impact.
We hypothesized: shorter length of stay, less narcotic analgesia, less anxiety, faster recovery, more positive mental outlook, resume activities sooner, have less symptoms postoperatively, etc.
Used a prospective, randomized, single-blind trial in 2 community hospitals in Cleveland with coronary artery bypass graft surgery patients. Study was done between Dec 1989 – Feb 1992.
3 groups were involved: (1) Suggestion, (2) music, and (3) tape. Control subjects had a blank tape. Tapes were played continuously and repeatedly with headphones. Postoperatively, a different tape was played.
Excluded: Patients with emergent surgery, hearing impairment, poor comprehension of English, patients who died in hospital, patients whose hospital stay lasted longer than 14 days (3 of them). 5% of sample were eliminated for last 2 reasons.
Music: Herb Ernst, Dreamflight II. Suggestions: Music background, permissive, based on Evans & Richardson’s study.
Outcome Measures: Nurse assessment of anxiety and progress post operatively, Symptom scale, Depression scale.
Mean age 62, 3/4 men, 92% white, 75% married. The groups were same on a variety of preoperative variables (status of heart and arteries). Length of stay was 6.5 in all 3 groups. No difference in narcotics use, in nurse assessment of anxiety or of progress; of depression scale, or activities of daily living.
Recategorized data into patients who said the tapes were helpful (both music and suggestion) N = 33 vs the other patients N = 62. No difference in the variables evaluated.
Bruner, Jerome (1992). Another look at New Look 1. American Psychologist, 47, 780-783.
New Look 1 was not initially about the unconscious. It was the new mentalism on its way to becoming the Cognitive Revolution. Its subsequent concern with “unconscious defense mechanisms,” although useful, was not its main theoretical thrust. Its principal questions have always been how and where selective processes operate in perception. Obviously, many such processes are unconscious, for consciously guided attention and search become automatized easily in use. And they are fairly flexible as well. So how smart is “the unconscious”? Not very, but a big help anyway.
Erdelyi, Matthew, Hugh (1992). Psychodynamics and the unconscious. American Psychologist, 47, 784-787.
The original New Look integrated the constructivist-psychodynamic traditions of Bartlett and Freud. The unconscious (Greenwald’s “New Look 3”) is a logically different idea, although in practice it is often intertwined with constructivist – psychodynamic approaches. The unconscious is a pretheoretic term with a variety of problems: It has multiple and unsettled meanings; null reports need not signify null awareness; the conscious-unconscious dichotomy implied by the limen may not exist; even “absolute subliminality” (chance-level accessibility) is relative to the time interval of testing, as accessibility can increase to above-chance levels over time (hypermnesia). Yet, the phenomena that the unconscious sloppily subsumes are not simple or dumb. The capacity of subliminal perception should not be confused with the capacity of subliminal (unconscious) memory and cognition.
Gravitz, Melvin A. (1992, October). Historical and legal issues. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington, VA.
NOTES
The 1976 Chowchilla kidnaping case in California stimulated interest in using hypnosis for forensic investigation; in the same year, it was used in a case of airline hijacking in the Mediterranean to Uganda. Hypnosis is used for obtaining “leads” and doesn’t claim to develop “the truth.”
Other uses include: lifting amnesia of witnesses and victims of trauma–including but not limited to crime; obtaining additional information in nonamnesic Ss; evaluation of a subject’s mental condition (e.g. multiple personality disorder vs malingering, as in the Bianchi case). In each use, hypnosis is not infallible, is not complete. But no procedure is. Motivation, resistance, transference are all critical.
Historic questions: 1. whether coercion is entailed 2. impact of hypnosis on memory 3. possible harm to subject, physically and mentally
The coercion issue dates to Mesmer, whose procedures led to accusations of immoral suggestions. In the 1880s Charcot said no one could be forced to do anything while the Nancy school (Liebeault) said they could. Since then we have seen laboratory studies using student volunteers, fake “poison,” rubber daggers, etc., as well as recent “real life” studies where Ss were induced to violate their morals (see Watkins). Review articles include those by Jacob Conn of Baltimore and the 1985 JAMA article written by a panel headed by Martin Orne.
For impact of hypnosis on memory, see the Orne report which did not fully support using hypnosis for memory enhancement.
Regarding possible harm to a hypnotic subject in the 19th century, a young man’s death was attributed to nervousness and exhaustion and diabetes due to repeated hypnosis. Other studies of death (of chickens, of a frog) due to repeated hypnotization were published. Now the consensus is that hypnosis is not dangerous (but incompetence using hypnosis may be dangerous).
LEGAL PRECEDENTS.
In 1897 a California court refused to accept testimony of a Subject who had been hypnotized. People vs Eubanks.
The 1950’s Cornell case established that a person can be hypnotized for their own defense.
In 1963 the California supreme court ruled that a lower court made a mistake in not admitting testimony from someone who had been hypnotized.
In Harding (a Maryland case), the trauma victim, amnestic, was hypnotized one month later. The testimony was accepted. A 1983 Maryland appeals court overturned it, influenced by the California Shirley case.
In 1983 Hurd case, a victim, hypnotized, identified her husband as attacker. Lower court didn’t permit the testimony; then a higher court reversed it. The court issued what are known as the Hurd rules, governing testimony that is acceptable: 1. hypnotist is licensed psychologist or psychiatrist with training in hypnosis 2. hypnotist must be independent of both the prosecution and defense 3. all information given to the hypnotist about the case must be written 4. hypnotist must obtain a nonhypnotic account of the memory before hypnosis is used. 5. must have taped record of the hypnosis sessions (preferably videotaped) 6. only hypnotist and subject should be present in the room
Soon after, California had the Shirley case. The California court ruled hypnosis per se is unreliable because it produces confabulation. This decision had a chilling effect throughout the country for several years.
In 1987 we had Rock vs Arkansas, the first and only case involving hypnosis to come before the U. S. Supreme Court. Vicky Rock shot her husband. Under hypnosis, she remembered she did not have her finger on the trigger, and her husband grabbed her and shook her. Lower court wouldn’t admit the testimony of the gun expert, who testified the trigger was sensitive to jarring. Supreme Court ruled defendants (not necessarily others) could use hypnosis in their own defense.
Greenwald, Anthony G. (1992). New Look 3: Unconscious cognition reclaimed. American Psychologist, 47, 766-779.
Recent research has established several empirical results that are widely agreed to merit description in terms of unconscious cognition. These findings come from experiments that use indirect tests for immediate or long- term residues of barely perceptible, perceptible-but-unattended, or attended-but-forgotten events. Importantly, these well-established phenomena–insofar as they occur without initially involving focal attention–are limited to relatively minor cognitive feats. Unconscious cognition is now solidly established in empirical research, but it appears to be intellectually much simpler than the sophisticated agency portrayed in psychoanalytic theory. The strengthened position of unconscious cognitive phenomena can be related to their fit with the developing neural network (connectionist) theoretical framework in psychology.
Jacoby, Larry L.; Lindsay, D. Stephen; Toth, Jeffrey P. (1992). Unconscious influences revealed: Attention, awareness, and control. American Psychologist, 47, 802-809.
Recent findings of dissociations between direct and indirect tests of memory and perception have renewed enthusiasm for the study of unconscious processing. The authors argue that such findings are heir to the same problems of interpretation as are earlier evidence of unconscious influences–namely, one cannot eliminate the possibility that conscious processes contaminated the measure of unconscious processes. To solve this problem, the authors define unconscious influences in terms of lack of conscious control and then describe a process dissociation procedure that yields separate quantitative estimates of the concurrent contributions of unconscious and consciously controlled processing to task performance. This technique allows one to go beyond demonstrating the existence of unconscious processes to examine factors that determine their magnitude.
Kihlstrom, John F.; Barnhardt, Terrence M.; Tataryn, Douglas J. (1992). The psychological unconscious. American Psychologist, 47, 788-791.
In response to Greenwald’s article on contemporary research on unconscious mental processes, the authors address three issues: (a) the independence of much recent research and theory from psychodynamic formulations; (b) the broad sweep of the psychological unconscious, including implicit perception, memory, thought, learning, and emotion; and (c) the possibility that the analytic power of unconscious processing may depend both on the manner in which mental contents are rendered unconscious and the manner in which they are to be processed.
Lewicki, Pawel; Hill, Thomas; Czyzewska, Maria (1992). Nonconscious acquisition of information. American Psychologist, 47, 796-801.
The authors review and summarize evidence for the process of acquisition of information outside of conscious awareness (covariations, nonconscious indirect and interactive inferences, self-perpetuation of procedural knowledge). Data indicate that as compared with consciously controlled cognition, the nonconscious information – acquisition processes are not only much faster but are also structurally more sophisticated, in that they are capable of efficient processing of multidimensional and interactive relations between variables. Those mechanisms of non- conscious acquisition of information provide a major channel for the development of procedural knowledge that is indispensable for such important aspects of cognitive functioning as encoding and interpretation of stimuli and the triggering of emotional reactions.
Loftus, Elizabeth F.; Klinger, Mark R. (1992). Is the unconscious smart or dumb?. American Psychologist, 47, 761-765.
How sophisticated is unconscious cognition? This is one of the most fundamental questions about the unconscious that has been posed by research psychologists over the past century. Anthony Greenwald takes a contemporary look at this classical problem and concludes that unconscious cognition is severely limited in its analytic capability. In response, other leading scholars agree that the reality of unconscious processes is no longer questionable. Although there is some disagreement about just how sophisticated these processes are, the consensus is that exciting times are ahead for both research and theory concerning the mental processes involved in unconscious cognition.
Merikle, Philip M. (1992). Perception without awareness: Critical issues. American Psychologist, 47, 792-795.
NOTES
This is the introduction to a group of articles. “To a large extent, this entire controversy over perception without awareness has centered on the issue, What constitutes an adequate behavioral measure of conscious perceptual experience? Depending upon one’s answer to this question, the evidence for perception without awareness is either overwhelming or nonexistent.
The distinction is much more significant and interesting if conscious and unconscious processes lead to qualitatively different consequences than if unconscious processes are simply quantitatively weaker versions of unconscious processes. Three different qualitative differences have been established: 1. Groeger (1984, 1988) has demonstrated that words are coded differently depending on whether they are perceived with or without awareness. 2. Stroop effect research showed that prediction based on stimulus redundancy only occurs when subjects consciously perceive the predictive stimuli (Cheesman & Merikle, 1986). The fact that the color word predicted the name of the color patch on 75% of the trials was only used by the subjects to facilitate naming of the color patches when the words were clearly visible. 3. Marcel (1980) showed that conscious awareness is necessary for the selection of a context-relevant interpretation of a stimulus.
The important findings are that performance differs qualitatively across the aware and non aware conditions.
Rondi, Glenys (1992, October). Postoperative impact of information presented during general anesthesia. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington, VA.
We tried to improve on the methodology in the literature. Thus we included a limited range of surgery procedures; standardized anesthesia; monitoring of anesthesia; suggestions that were only positive (the suggestions did not mention pain or nausea); patient-controlled analgesia in order to have a more accurate measure; and hypnotizability was measured. They do not equate the hypnotic state with the anesthesia state, but there may be an overlap in the ability to perceive and respond to suggestions in these two states.
All hysterectomy and bilateral [missed word …ectomy] patients were approached, excluding those without English language, etc.
Bowers and she phrased simple, positive suggestions to maximize benefits; Suggestions lasted 3 minutes, and were repeated 3 times on a 60 minute tape. Brief melodies alternated with suggestions or with silence. Conditions included: 1. Suggestions 2. Melody 3. Suggestions + melody 4. Blank tape
Half of the tapes contained suggestions; half not. It was a counterbalanced design. Double blind ratings were made by students.
State-trait Anxiety and Profile of Mood States were measured before surgery. Patients were reminded to listen to suggestions for recovery just before they fell asleep. MDs ordered premedication for the surgery “only if very necessary.”
Patients rated their own recovery as -3 worse than expected to +3 better than expected; and completed a visual analogue scale. Then 24 hours later the researchers asked them if they remembered the tape, and if they had been given suggestions or not.
On Day 5 post operation they administered the Stanford C hypnotizability scale.
RESULTS.
None of the patients recalled or dreamed anything that could be attributed to the period of anesthesia. There was a response bias to say “Yes” to “Did you have suggestions?” (34 of Suggestion patients and 28 of non-suggestion patients said “Yes” and there were 48 in each group. Taking response bias into consideration, patients with suggestions were above chance in saying “Yes” to “Did you have suggestions?”
Only 73 of the 96 completed the hypnotizability scale. Duration of the tape (therefore of surgery) was longer for the suggestion group (90 vs 72 minutes). So authors also did a univariate measure.
They divided morphine use by patient weight for each post operative day. The difference in dose for suggestion and no suggestion groups did not reach significance on Day 1 but on Day 2 patients who had suggestions used significantly less morphine.
The correlation matrix showed that patient age was negatively correlated with morphine use; subjected to 1-way ANOVA of covariance; the effect of suggestions remains significant.
Surgery time was covaried out, as it was associated with more negative post operative symptoms; patient age was a second covariate. None of the main effects or 2- way interactions were significant.
Hypnotizability, suggestion group, and their interaction were analyzed. Neither hypnotizability nor its interaction with suggestion contributed to any outcome variable.
Using only highs (13) and lows (12) for another analysis and 2×2 ANOVAS to examine suggestion by hypnotizability. Highs used significantly less morphine in the first hours, whether or not they received suggestions.
Even when weight is taken into account, hypnotizability accounted for significant amount of variance in first 24 hours. Highly hypnotizables’ guesses about whether they were played a tape with suggestions was 100% accurate; guesses of lows were 42% accurate.
CONCLUSIONS.
Some patients show evidence of hearing, and of responding to suggestions. Hypnotic ability did not mediate the response; but patients with high ability showed 100% accuracy in guessing whether they were played suggestions, in the absence of confidence in their response. They may be particularly sensitive to their environment during general anesthesia.
1991
Block, Robert I.; Ghoneim, M. M.; Sum Ping, S. T.; Ali, M. A. (1991). Efficacy of therapeutic suggestions for improved postoperative recovery during general anesthesia. Anesthesiology, 75, 746-755.
There have been claims that the postoperative course of patients may be improved by presentation during general anesthesia of therapeutic suggestions which predict a rapid and comfortable postoperative recovery. This study evaluated the effectiveness of such therapeutic suggestions under double-blind and randomized conditions. A tape recording predicting a smooth recovery during a short postoperative stay without pain, nausea, or vomiting was played during anesthesia to about half the patients (N = 109), while the remaining, control patients were played a blank tape instead (N = 100). The patients were primarily undergoing operations on the fallopian tubes, total abdominal hysterectomy, vertical banding gastroplasty, cholecystectomy, and ovarian cystectomy or myomectomy. The anesthesia methods consisted of either isoflurane with 70% nitrous oxide in oxygen to produce end-tidal concentrations of 1.0, 1.3, or 1.5 MAC; or 70% nitrous oxide in oxygen combined with high or low doses of opioids. Assessments of the efficacy of the therapeutic suggestions in the recovery room and throughout the postoperative hospital stay included: the frequency of administration of analgesic and antiemetic drugs; opioid doses; the incidence of fever; nausea, retching, and vomiting; other gastrointestinal and urinary symptoms; ratings of pain; ratings of anxiety; global ratings of the patients’ physical and psychological recoveries by the patients and their nurses; and length of postoperative hospital stay. There were no meaningful, significant differences in postoperative recovery of patients receiving therapeutic suggestions and controls. These negative results were not likely to be due to insensitivity of the assessments of recovery, as they showed meaningful interrelations among themselves and numerous differences in recovery following different types of surgery. Widespread utilization of therapeutic suggestions as a routine operating room procedure seems premature in the absence of adequate replication of previously published positive studies. (Key words: Anesthesia, depth: Awareness, Memory, Recall, Learning.)
NOTES
Patients ages 19-55 were accepted into the study and they were paid for participation. (Older patients were excluded to guard against memory or hearing problems.) Other criteria for exclusion were: ASA physical status 4 or 5 indicating significant systemic disease, visual or hearing problems, middle ear disease (because it increases probability of nausea and vomiting), if their condition might require heavy sedation, if they were currently taking medication that interferes with memory (e.g. benzodiazepines, if there were intolerance to opioids, or if there were a likelihood of using postoperative pain treatment other than opioids.
The Spielberger State-Trait Anxiety Inventory was administered before surgery. Either suggestions (lasting 6 minutes) or a blank tape were played through headphones, starting 5 minutes after the surgical incision. The tape was played once for the first 59 patients, continuously for the remaining 150 patients. The first 139 patients received additional verbal materials on the tape, for memory tests to test possibility of learning under anesthesia. Operating room sounds were recorded by a tape recorder near the patient’s head, throughout period of unconsciousness (except when tape was being played).
After the first 25% of cases, the team decided that lack of effect on therapeutic suggestions attributable to type of anesthesia did not warrant restriction to a single anesthetic method; also, multiple presentations of the suggestions on tape did not show an effect different from a single presentation.
After the patient regained consciousness and was reoriented, pain, nausea, retching, and vomiting were assessed every 30 minutes. Pain was rated orally on a scale from 1 to 10 in the recovery room, then on visual analogue scales every 2 hours on the day of surgery and the second day, and every 4 hours on subsequent hospital days during waking hours. Variables that were rated by staff every 24 hours included: opioids, other analgesics, antiemetics, nausea, vomiting, retching, presence or absence of nasogastric tube, passage of flatus, bowel movement, fluid intake, solids intake, urination. Temperature was recorded every 4 hours for the first 2 days after surgery, and after that less often. The anxiety measures were repeated on Day 3 postsurgery, as well as self ratings and nurse ratings on physical and psychological recovery. Staff recorded length of postoperative hospital stay and reasons for any delay of discharge. Separate analyses were performed for patients receiving opioids via patient-controlled analgesia (52%) vs traditional administration (48%), but no differences were found for effects of therapeutic suggestions except on postoperative Day 8.
“The inability to detect beneficial effects of therapeutic suggestions probably was not due to insensitivity of the measures of recovery. These measures were sensitive enough to show numerous significant differences in recovery after different types of surgery” (p. 751). The authors supported their contention that the measures were sufficiently sensitive by demonstrating meaningful correlations among the measures themselves; and by demonstrating adequate statistical power for detecting the effects of theoretical interest–at least 1 day in postoperative hospital stay or one half day in fever.
Discussion: The authors note that a recent investigation that found positive results in a double-blind, randomized design with 39 hysterectomy patients (Evans & Richardson, 1988. Improved recovery and reduced postoperative stay after therapeutic suggestions during general anaesthesia. Lancet, 2:491-493) may not have controlled for variables such as presence of malignancy, physical status of patients before surgery, or ethnicity. Authors note that Evans and Richardson observed shorter periods of pyrexia despite there being no relevant suggestions, but no differences in pain intensity, nausea, vomiting, or urinary difficulties despite there being suggestions relating to those symptoms. There also were no differences in mood and anxiety test scores postoperatively for the experimental and control groups.
The authors note that McLintock, Aitken, Downie, & Kenny (Postoperative analgesic requirements in patients exposed to positive intraoperative suggestions. Br M J 301:788-790. 1990) reported a 23% reduction in opioids by patients receiving suggestions, but no reduction in pain, nausea, or vomiting. They contrast the present study with these earlier studies that had obtained positive results.
“We studied patients who had more than one type of surgery to obtain a large sample size and to assess the possibility that beneficial effects of therapeutic suggestions would be restricted to certain types of operations. Had this been the case, interactions of therapeutic suggestions with type of surgery would have been significant in the overall analyses, and follow-up analyses would have indicated that they were attributable to beneficial effects of therapeutic suggestions for certain surgeries. This did not occur. The two types of surgeries involving the largest numbers of patients seemed particularly promising for demonstrating beneficial effects. It has been reported that therapeutic suggestions presented during anesthesia are likely to be less successful with major and extensive surgery. Certainly, surgery on the fallopian tubes and gastric stapling did not involve a great deal of tissue trauma and blood loss. Patients were motivated to have the surgery and to recover quickly; particularly motivated were those having operations on the fallopian tubes, who were very eager to become pregnant, and those having vertical banding gastroplasties, who wanted desperately to lose weight” (pp. 753-754).
“In practice, we observed no beneficial effects of therapeutic suggestions, and there was no hint that anesthesia methods influenced the efficacy of the therapeutic suggestions. Interestingly, anesthetic methods also did not influence learning under anesthesia in the implicit memory tests we have used previously. Patients anesthetized with nitrous oxide and opioids did not differ from those anesthetized only with inhalational agents. In general, implicit or unconscious memory occurs in patients regardless of anesthesia methods or dosages of drugs” (p. 754).
“The few significant effects of therapeutic suggestions in our study did not point toward a beneficial influence of these suggestions. We found, in fact, an increased frequency of retching (but not nausea or vomiting) in the experimental group. The multiple variables examined in this study increased the likelihood of significant differences arising by chance, such that the null hypothesis was rejected when it should have been accepted. This is the way we interpret the effect on retching—i.e., as a type I error. We used in our therapeutic suggestions one negative or exclusionary sentence, ‘You won’t feel nauseous or have to vomit’, among several positive or affirmative statements, e.g., ‘You will enjoy eating, drinking…You will swallow to clear your throat and everything will go one way, straight down. . . The food will taste good….Your stomach will feel fine.’ We do not think that the negative sentence led to paradoxical results. Evans and Richardson (personal communication) used in their therapeutic suggestions a negative sentence (‘You will not feel sick’), which they repeated, yet the reported incidence of nausea and vomiting did not differ between the experimental and control groups” (p. 754).
Brown, Jason W. (1991). Self and process: Brain states and the conscious present. New York: Springer-Verlag.
Author, from the Department of Neurology at New York University Medical School, presents a theory about the genetic unfolding of mental content (mind) through stages, from mental state into consciousness or into behavior. He relates the genesis of mind to brain development but avoids assuming that there is a straightforward correlation between brain development (e.g. myelination) and cognitive development or perception. To some degree, the theory is based on subjective report data and psychological symptoms. The author discusses issues that bear on the phenomena of nonvoluntary responding and dissociation that are reported or described by hypnotized persons.
“The nature of the mental state will determine the relation between self and world, and thus the interpretation given to agency and choice. … The crossing of the boundary from self to world is a shift from one level in mind to another” (pp. 10-11).
“… if we begin with mind as primary and seek to explain objects from inner states and private experience, the discontinuity between inner and outer evaporates: mind is everywhere, a universe. … Whereas before we thought to perceive objects, now we understand that we think them” (p. 19).
“The concept of a stratified cognition is central to the notion of a mental state …. This entails an unfolding from depth to surface, not from one surface to the next, a direction crucial to agency and the causal or decisional properties of consciousness” (p. 52). By unfolding from depth to surface, he means from Core, through Subconscious, then Conscious Private Events, and finally Extra-Personal Space.
He goes on to provide a definition of mental states. “A mental state is the minimal state of a mind, an absolute unit from the standpoint of its spatial and temporal structure. … The state also has to include the prehistory of the organism. … The concept of a mental state implies a fundamental unit that has gestalt-like properties, in that specific contents– words, thoughts, percepts–appear in the context of mind as a whole (p. 53).
“The entire multitiered system arborizes like a tree, with levels in each component linked to corresponding levels in other components. For example, an early (e.g., limbic) state in language (e.g., word meaning) is linked to an early stage in action (e.g., drive, proximal motility) and perception (e.g., hallucination, personal memory) …. In sum, a description of the spatial and temporal features of a _single_ unfolding series amounts to a description of the minimal unit of mind, the _absolute_ mental state” (p. 54).
The author’s discussion of an individual’s physical movement relates to the concept of nonvoluntary movement (or movement without awareness of volition) in hypnosis. “More precisely, levels in the brain state constitute the action structure. As it unfolds, this structure generates the conviction that a self-initiated act has occurred. This structure–the action representation–does not elaborate content in consciousness. … As with the sensory-perceptual interface, the transition to movement occurs across an abrupt boundary. In some manner, perhaps through a translation of cognitive rhythms in the action to kinetic patterns in the movement, levels in the emerging act discharge into motor (physical) events” (p. 57).
“The self has the nature of a global image or early representation within which objects-to-be are embedded. … The self is the accumulation of all the momentary cognitions developing in a brain configured by heredity and experience in a particular way (p. 70).
“The deposition of a holistic representation … creates the deception of a self that stands behind and propagates events. The feeling of the self as an agent is reinforced by the forward thrust of the process and the deeper locus of the self in relation to surface objects. The self appears to be an instigator of acts and images when in fact it is given up in their formation. The self does not cause or initiate, it only anticipates (p. 70).
The foregoing notes cover only the first five chapters, less than half the book. Other chapters relevant to hypnosis would be those titled ‘The Nature of Voluntary Action,’ ‘Psychology of Time Awareness,’ ‘From Will to Compassion,’ and ‘Mind and Brain.’
Dennett, Daniel C. (1991). Consciousness explained. Boston: Little, Brown & Co..
Material in this book is relevant to discussions about ‘nonvoluntary’ behavior and (un)conscious experiencing. It combines information from cognitive neuroscience with the philosophy of mind. The author presents a view that consciousness (the ‘mind’) is the consequence of the brain’s activities which give rise to illusions about their own properties. He presents the Multiple Drafts model of consciousness, which reformulates the concept of a ‘stream of consciousness.’ This provides a basis for consideration of concepts central to cognitive neuroscience and phenomena associated with hypnosis, e.g. experiential states and the nature of the self.
The author gives various examples of phenomenology and notes that although these examples are familiar to us, they are totally inaccessible to materialistic science; e.g. the way the sunset looks to someone. He treats people’s descriptions of what they experience as a record of speech acts. Thus, observing and interpreting speech acts, inferring from them the speaker’s inner states, is like a reader who is interpreting a work of fiction. He gives as examples of how one can scientifically study what does not ‘exist’ (a) literary theorists who describe fictional entities, (b) anthropologists who study cultural artifacts like gods and witches, and (c) physicists who study a center of gravity.
In Dennett’s theory, multitrack processes of interpretation of sensory inputs and elaboration of those inputs amounts to a kind of ‘editorial revision’ by the brain. For example in the phi phenomenon a red dot is displayed, followed by a green dot in a different location; the first spot seems to begin moving and then change color in the middle of its illusory passage toward the second location. He points out that awareness of the change in color must occur after seeing the green spot, but one consciously experiences a single spot first red, then red-turning-to-green, finally green. In an example that relates directly to the words used for his theory, he cites contemporary publishing practices, in which several different drafts of an article are in circulation even while the author is revising it. Deciding on some specific moment of brain processing as the moment of consciousness is arbitrary, according to his Multiple Drafts model.
“Visual stimuli evoke trains of events in the cortex that gradually yield discriminations of greater and greater specificity. At different times and different places, various ‘decisions’ or ‘judgments’ are made; more literally, parts of the brain are caused to go into states that discriminate different features, e.g., first mere onset of stimulus, then location, then shape, later color (in a different pathway), later still (apparent) motion, and eventually object recognition. These localized discriminative states transmit effects to other places, contributing to further discriminations, and so forth. The natural but naive question to ask is: ‘Where does it all come together’? The answer is: Nowhere. Some of these distributed contentful states soon die out, leaving no further traces. Others do leave traces, on subsequent verbal reports of experience and memory, on ‘semantic readiness’ and other varieties of perceptual set, on emotional state, behavioral proclivities, and so forth. Some of these effects–for instance, influences on subsequent verbal reports–are at least symptomatic of consciousness. But there is no one place in the brain through which all these causal trains must pass in order to deposit their content ‘in consciousness'” (pp. 134-135).
The author describes the evolution of the brain, along Darwinian lines, and introduces the idea of culture as a repository and transmission medium for innovations (including innovations of consciousness) as a medium of evolution. Through learning, we humans evolve an American or a Japanese brain. Once we have evolved the ‘entrance and exit pathways’ for language, they become ‘parasitized’ by _memes_ (entities that have evolved to thrive in such a niche).
Richard Dawkins coined the term _memes_ to describe the smallest idea elements that replicate themselves reliably (e.g. wheel, alphabet, wearing clothes, right triangle). “The transformation of a human brain by infestations of memes is a major alteration in the competence of that organ” (p. 209).
Dennett discusses the similarities and dissimilarities of brains and computers. He suggests that human minds are like serial virtual machines implemented on parallel processing hardware. The stream of consciousness results from our rehearsal of brief experiences, to commit them to memory; language then permits us to describe to ourselves the process of thinking which leads to judgement and action.
The author’s discussion of how a verbal expression evolves and becomes manifest is related to how so-called intentional action occurs. [This relates to discussions of nonvoluntary actions in hypnosis.] We assume that because our actions make sense, they are the product of serial reasoning. However, there are multiple channels “in which specialist circuits try, in parallel pandemoniums, to do their various things … (pp. 253- 254). Bernard Baars has suggested “that consciousness is accomplished by a ‘distributed society of specialists that is equipped with a working memory, called a _global workspace_, whose contents can be broadcast to the system as a whole (p. 42)'” (p. 257). Dennett states that there is no line dividing the events that are definitely in consciousness from those that are outside consciousness. He urges scientists to forgo the concept of the ‘inner observer’ implied by Cartesian materialism.
Examples of perception that is unaccompanied by consciousness include blindsight (in which the subject does better than chance on visual tests but denies consciousness, and the denials are given credence by neurological evidence of brain damage) and hysterical blindness, which is given less credence because subjects often use the visually provided information in ways blindsight Ss do not. Other behaviors not controlled by conscious thought include blinking when things approach the eye, walking without falling over, regulating our body temperature, adjusting our metabolism, etc. “If I am trying to see a bird that I hear, and stare at the spot but do not distinguish the bird from its background, can I say that it is present in the background of my (visual) consciousness or not?” (p. 336).
The author maintains that if an event doesn’t linger and the person is unable to identify and reidentify the effect, it cannot be reported. But such reportability can be improved, as with training the palate of wine tasters. Often, however, we continue disregarding stimuli that impinge on us. There are minor oversights, such as our ‘blind spots’ or proof reading errors, and major oversights such as a brain-damaged patient’s hemi-neglect. In the Multiple Drafts theory, the Observer is replaced by ‘coalitions of specialists’ that are distributed around in the brain, distributed in both time and space.
Though discrimination or discernment happens, there is no one Discerner doing the work. However, Dennett takes the middle ground on the question of whether a self exists: it is simply a creation like the nest of the Bower bird, or the organized colony of termite ants. “So wonderful is the organization of a termite colony that it seemed to some observers that each termite colony had to have a soul (Marais, 1937). We now understand that its organization is simply the result of a million semi-independent little agents, each itself an automaton, doing its thing. So wonderful is the organization of a human self that to many observers it has seemed that each human being had a soul, too: a benevolent Dictator ruling from Headquarters” (p. 416). The sense of self is a creation, like a physicist’s center of gravity.
Thus, multiple personality disorder is viewed as a self that has gaps; and our sense of self might include different aspects from one year to the other. Hence, “selves are not independently existing soul-pearls, but artifacts of the social processes that create us, and, like other such artifacts, subject to sudden shifts in status. The only ‘momentum’ that accrues to the trajectory of a self, or a club, is the stability imparted to it by the web of beliefs that constitute it, and when those beliefs lapse, it lapses, either permanently or temporarily” (p. 423).
Finally, the author has an extensive discussion of the concepts of ‘qualia’ and of ‘epiphenomena’ and seems to have little use for either term in trying to understand Mind.
Dixon, Norman F.; Henley, Susan H. (1991). Unconscious perception: Possible implications of data from academic research for clinical practice. Journal of Nervous and Mental Disease, 179 (5), 243-252.
Evidence for the reality of unconscious perception and perceptual defense suggests that the experimental paradigms used to investigate these phenomena might play a role in the understanding and treatment of mental disorders. The literature on applying subliminal stimulation to problems of diagnosis and therapy indicates that data support the view that the meaning of external stimuli of which the recipient is unaware may be responded to and determine emotional responses, lexical decisions, overt behavior, and subjective experience. Data confirm the reality of psychopathology as a substrate of emotionally colored, stored information with a potential for producing somatic symptoms and disorders of thinking, affect, and behavior. To the extent that psychopathology is screened from conscious scrutiny and thus impervious to supraliminal information, it may be accessed and ameliorated by drive-related stimuli of which the S is not aware.
Jansen, C. K.; Bonke, B.; Klein, J.; van Dasselaar, N.; Hop, W. C. J. (1991). Failure to demonstrate unconscious perception during balanced anaesthesia by postoperative motor response. Acta Anaesthesiologica Scandinavica, 35, 407-410.
Eighty patients undergoing a standardized balanced anaesthesia were randomly assigned to either a suggestion group (N = 38) or a control group (N = 42), in a double-blind design. Anaesthesia was maintained with nitrous oxide, enflurane and fentanyl. Patients in the suggestion group were played seaside sounds, interrupted by statements of the importance of touching the ear during a postoperative visit, by means of a prerecorded audiotape and headphones. Tapes containing these suggestions were played from 30 min after the first incision, for a duration of 15 min. Patients in the control group were only played seaside sounds. There were no significant differences between the groups in either the number of patients touching their ears postoperatively or the number and duration of ear touches.
NOTES
This research follows upon other studies in which patients carried out postoperative motor responses while still being amnesia for the source of the suggestions for the action (e.g. Bennett, Davis, & Giannini, 1985; Goldmann, Shah, & Hebden, 1987). The earlier studies used widely varied anesthesia techniques, small sample sizes, and did not measure baselines for those responses or clearly delimit the amount of time for recording the responses postoperatively. This investigation was an attempt to improve on the research design of earlier investigations that had obtained positive results.
Patient assignment to groups was stratified over three levels of estimated intensity of pain stimulation during surgery (based on the type of surgery).
The outcome measure, number of ear touches and their duration, was made by the anesthetist and an observer during the first 10 minutes of the pre- and postoperative interviews. (The observer was blind for the patient group assignment.) 75 of the patients were interviewed on the first postoperative day, and the remainder on the second postoperative day. The interview included questions regarding recall of the intravenous administration of drugs and of events during surgery. The outcome data may be seen in the Table below.
Distribution of ear touches during the first 10 min of the preoperative interview and, after the intraoperative suggestion, during the first 10 min of the postoperative interview. ——————————————————————————————————-
No. of patients with Total no. of ear touches for Duration of ear touches
ear touches for all responders
——————————————————————————————- Grp N Pre Post Pre Post Pre Post —————————————————————————————————— S 38 2 3 2 9 62 155 C 42 5 3 8 4 38 23 ——————————————————————————————————
S = suggestion group C = control group
In discussing their results, the authors offer several reasons why they might not have obtained the same results as those of previous investigators. “First, our anaesthetic techniques were different from those used in the studies of Bennett et al., 1985, and Goldmann et al., 1987” (p. 408).
“A second reason for the discrepancy between our results and those of the other two studies could be that our suggestion was perhaps less meaningful to the patients undergoing surgery than the one used by our fellow researchers. It has been argued that recollection of perioperative events is influenced by the salience of the stimuli [Dubovsky & Trustman, 1976, Anesth Analg; Goldmann & Levey, 1986 (letter) Anaesthesia]. This salience depends largely on the content of the message. It may be that the requested response, i.e., to touch the ear, is one that in our culture, or environment, has insufficient emotional impact and is thus ignored. It is interesting to note in this context that the percentage of patients touching the ear postoperatively was significantly lower (Fisher’s exact test: P<0.01) in our study than in the study by Bennett et al., both for the suggestion group and the control group. On the other hand, recent findings showed robust effects with emotionally neutral stimuli [Jelicic, Bonke, & Appelboom, 1990, Lancet; Roorda- Hrdlickova, Wolters, Bonke, & Phaf, 1990, in Bonke, Fitch, Millar, Eds. Memory and awareness in anesthesia. Amsterdam: Swets & Zeitlinger]. Salience also depends on the timbre and strength of the requesting person's voice, the manner in which the response is requested and, possibly, many other subtle factors. We tried to increase the emotional impact of the message by adding reassuring phrases, as had been done in the previous studies. Furthermore, we had the message recorded by the anaesthetist who also conducted the pre- and post-operative interviews, assuming this would make the voice more familiar to the patient. During all interviews, as well as on the tape, the anaesthetist clearly introduced himself to the patient, mentioning his name a number of times. This was done to increase the possibility that the voice was 'recognized'" (p. 409).