The Ethics of Hypnosis

I've been meaning to write about the ethics of hypnosis since reading Jane Brody's article in the New York Times several weeks ago.

In the early 1970s Dr. Erika Fromm offered a CME course on hypnosis in Boston. I'd heard good things about her as a teacher and I decided to take the course. But like most of my psychiatrist contemporaries I was deeply sceptical about hypnosis. The "you are in my power" stage hypnosis that most of us got our image of hypnosis from seemed like the opposite of thoughtful psychoanalytic psychotherapy, which was at its heyday then.

Dr. Fromm taught "permissive hypnosis," in which the therapist (a) develops the plan for using hypnosis with the patient, (b) defines hypnosis as an opportunity for the patient to access dormant capacities, (c) emphasizes that achieving a hypnotic state is something the patient can choose to do (or not to do), and (d) typically coaches the patient on how to apply self-guided techniques on her or his own.

I was enthralled by the ethics of Dr. Fromm's approach - respectful, pragmatic and collaborative - and impressed by the experience of being hypnotized.

A few years after the course a patient was referred to me for treatment of trichotillomania (compulsive hair pulling). I'd had no experience with the condition and went to the literature. There weren't many good ideas. Medications were the most recommended treatment at the time, but they weren't seen as very effective. The articles I saw said hypnosis didn't work.

My patient was an intelligent, "non-neurotic" person. Compulsive hair-pulling was an isolated symptom. We didn't identify any significant psychological conflicts or sources of tension. I reported what I'd read in the literature. My patient definitely did not want medication, and asked about hypnosis. (Forgive my repeated use of the phrase "my patient." As part of maintaining confidentiality I'm avoiding gendered terms.) I said that the literature didn't suggest hypnosis was effective for trichotillomania.

Despite my report on what the literature said, my patient liked the idea of hypnosis. We agreed that although the literature was dubious about its efficacy we didn't see any significant risks in trying hypnosis other than it might waste my patient's time and the HMO's money. We created an image drawn from my patient's experience (a field of lushly growing vegetation - focusing directly on hair and hair pulling was less promising than a suggestive metaphor) and combined it with relaxation exercises. I made a tape for the patient to use.

It worked.

Twenty years later my patient returned. In a context of increased stress the symptoms had returned. We reviewed the situation and essentially gave a booster shot to the self hypnosis program. Technology having advanced, this time I made a CD for the patient to use.

It worked again. At a follow up meeting before I ended my practice a year ago the symptoms remained in remission.

For me the "permissive" approach to hypnosis, combined with coaching in how to apply the technique on one's own, represents psychiatry and psychological medicine at their ethical best. Clinicians like Erika Fromm took a technique that in its origins was authoritarian and potentially degrading to the patient, and transformed it into a collaborative, educative, empowering approach to self management. Except for treatments conducted when the patient is under anesthesia or otherwise unconscious this is how health care ideally proceeds - with patients understanding the condition, the treatment, and their power to exert an influence.