MECHANISMS OF HYPNOSIS: Toward the Development of a ...nvvh.com/wp-content/uploads/2015/08/IJCEH-63-1-03.pdf · in self-hypnosis should be considered a “ﬁrst-line” treatment

Intl. Journal of Clinical and Experimental Hypnosis, 63(1): 34–75, 2015Copyright © International Journal of Clinical and Experimental HypnosisISSN: 0020-7144 print / 1744-5183 onlineDOI: 10.1080/00207144.2014.961875

MECHANISMS OF HYPNOSIS:Toward the Development

of a Biopsychosocial Model

Mark P. Jensen

University of Washington, Seattle, USA

Tomonori Adachi

Osaka University, Japan

Catarina Tomé-Pires

Rovira and Virgili University, Tarragona, Catalonia, Spain

Jikwan Lee and Zubaidah Jamil Osman

University Putra Malaysia, Selangor, Malaysia

Jordi Miró

Rovira and Virgili University, Tarragona, Catalonia, Spain

Abstract: Evidence supports the efficacy of hypnotic treatments, butthere remain many unresolved questions regarding how hypnosis pro-duces its beneficial effects. Most theoretical models focus more or lesson biological, psychological, and social factors. This scoping reviewsummarizes the empirical findings regarding the associations betweenspecific factors in each of these domains and response to hypnosis. Thefindings indicate that (a) no single factor appears primary, (b) differentfactors may contribute more or less to outcomes in different subsets ofindividuals or for different conditions, and (c) comprehensive modelsof hypnosis that incorporate factors from all 3 domains may ultimatelyprove to be more useful than more restrictive models that focus on just1 or a very few factors.

Manuscript submitted November 8, 2013; final revision accepted January 9, 2014.Address correspondence to Mark P. Jensen, Department of Rehabilitation Medicine,

University of Washington, Harborview Medical Center, 325 Ninth Avenue, Box 359612,Seattle, WA 98104, USA. E-mail: [email protected]

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mailto:[email protected]

BIOPSYCHOSOCIAL MODEL OF HYPNOSIS 35

A growing body of research supports the efficacy of hypnosis and hyp-notic treatments for benefiting individuals with a variety of conditionsincluding acute pain (Landolt & Milling, 2011; Madden, Middleton,Cyna, Matthewson, & Jones, 2012; G. H. Montgomery, DuHamel,& Redd, 2000; Patterson & Jensen, 2003; Tomé-Pires & Miró, 2012),chronic pain (Elkins, Jensen, & Patterson, 2007; Jensen, 2009; Jensen &Patterson, 2006; G. H. Montgomery et al., 2000; Patterson & Jensen, 2003;Tomé-Pires & Miró, 2012), irritable bowel syndrome (Rutten, Reitsma,Vlieger, & Benninga, 2013; Tan, Hammond, & Joseph, 2005), depression(Alladin, 2012), and anxiety (Golden, 2012; Hammond, 2010). Hypnosishas also been shown to enhance the efficacy and benefits of othertherapeutic approaches, such as cognitive-behavioral therapy (Kirsch,Montgomery, & Sapirstein, 1995). Moreover, unlike many biologicalinterventions such as analgesic medications for pain that can have sig-nificant financial costs (due to the need for ongoing use), negative sideeffects, and social costs (associated with problems with diversion), hyp-notic interventions are relatively easy and inexpensive to provide, havea plethora of beneficial “side effects” (such as increased sense of con-trol over pain and its impact, increased sense of well-being) and havevery few negative side effects (Jensen et al., 2006). Given their efficacy,low cost, and positive side effect profile, the data suggest that trainingin self-hypnosis should be considered a “first-line” treatment for manychronic health conditions.

However, many questions remain regarding the mechanisms thatexplain the effects of hypnosis. Although a number of models havebeen proposed to explain these effects (Bányai, 1991; Barnier, Dienes, &Mitchell, 2008; Gruzelier, 1998; Kirsch, 1991; Lynn, Kirsch, & Hallquist,2008; Nash, 2008; Rainville & Price, 2004; D. Spiegel, 2008; H. Spiegel,2007; Wagstaff, David, Kirsch, & Lynn, 2010; Woody & Sadler, 2008),no single theory or model has been endorsed by the majority of hyp-nosis researchers and clinicians. Moreover, each existing model focuseson only some aspects of hypnosis at the exclusion of others (Hammond,2005). For example, dissociation models, which date back to Pierre Janet(1901), focus on the degree of association and dissociation betweendifferent mental processes (cognitive monitoring, cognitive control,consciousness, sensory experience; see Woody & Sadler, 2008). Socialcognitive theories focus on the hypnotic context and the subject’sabilities, attitudes, beliefs, expectancies, attributions, and motivations(Lynn et al., 2008). An ability-aptitude model hypothesizes a causalrole for two key factors in influencing hypnotic responding (and eachother): (a) a latent cognitive ability/talent for hypnotic responding and(b) the subject’s beliefs about their own future hypnotic responding(Benham, Woody, Wilson, & Nash, 2006). The social-psychobiologicalmodel stresses the importance of the relationship between the hypnotistand the subject, emphasizing how these interact with the physiological

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36 MARK P. JENSEN ET AL.

mechanisms as well as the personal characteristics of the hypnotistand the subject and physiological mechanisms (Bányai, 1991). However,even this relatively comprehensive model does not take into account anumber of factors hypothesized to influence hypnotic responding byother theories.

Importantly, the available evidence can be interpreted to be consis-tent with each one of the existing theories and models of hypnosis; thatis, each remains viable. This suggests that each model retains potentialutility for understanding the components of hypnosis that they focuson and supports continued work with and development of these mod-els. On the other hand, the fact that none of the existing models takesinto account all of the factors that have been shown to be associatedwith hypnotic responding suggests that each existing model also hasimportant limitations. The field lacks an overarching model or frame-work for organizing the many factors that may contribute to hypnoticresponding.

We propose in this review that a model hypothesizing roles for bio-logical, psychological, and social factors, and their interactions—thatis, a biopsychosocial model of hypnosis—might serve this organizingrole. Biopsychosocial models have proven to be useful in understand-ing other complex issues, such as chronic pain (Novy, Nelson, Francis, &Turk, 1995), depression (Schotte, Van Den Bossche, De Doncker, Claes, &Cosyns, 2006), and substance abuse (Buckner, Heimberg, Ecker, & Vinci,2013). Importantly, biopsychosocial models allow for the possibility thatmany factors can play a role and contribute to hypnotic responding.Such models therefore have the potential for having more explanatorypower than more restrictive models (Novy et al., 1995).

The purpose of this scoping review is to explore the potential utilityof a biopsychosocial framework for understanding hypnosis and hyp-notic responding by performing a scoping review of what is now knownregarding the associations between biological, psychological, and socialfactors that have been hypothesized to explain hypnosis and hypnoticanalgesia by the primary more restrictive perspectives (Barnier et al.,2008; Gruzelier, 1998; Lynn et al., 2008; Nash, 2008; Rainville & Price,2004; H. Spiegel, 2007; Woody & Sadler, 2008). Although the idea ofusing a biopsychosocial approach to understand hypnotic respond-ing is not new (Bányai, 1991; Hammond, 2005), no review to date hassought to evaluate and summarize the empirical evidence with respectto the relative importance of factors within each of the biological,psychological, and social domains in the same article.

A scoping review is a technique to “map” an area of relevant lit-erature that provides comprehensive coverage but extracts a limitedamount of information from published studies (Arksey & O’Malley,2005). A scoping review can be contrasted to a systematic review, whichseeks to answer a very specific question (e.g., “What is the average effectsize of hypnotic analgesia?”; see G. H. Montgomery et al., 2000) based

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on a small set of the highest quality studies available. A scoping review,on the other hand, seeks to answer more broad questions using selectedstudies from a large body of research. A scoping review is particu-larly useful when the body of research to be reviewed is so large thata systematic review is not practical; it can therefore identify the mostimportant focused questions that can then be addressed with systematicreviews.

The primary goals of this review were (a) to identify the key bio-logical, psychological, and social factors that have been hypothesizedas having a potential role in explaining response to hypnotic sugges-tions and then (b) to evaluate the relative importance of each factor forpredicting response to hypnotic suggestions based on the available evi-dence. In particular, we were interested in determining if a single factoror a small subset of factors consistently emerged as strongly relatedto hypnotic responding, thereby supporting the development of morerestrictive models that focus on just this factor or these factors, or if mul-tiple factors emerged that tend to evidence weaker or more moderateassociations to hypnotic responding, thereby supporting the develop-ment of more complex models (e.g., a “biopsychological” model if onlybiological and psychological factors were identified as important, oran even more comprehensive “biopsychosocial” model if factors in allthree domains emerged as important).

Method

A number of articles and chapters have been published thathave comprehensively reviewed the associations between biological(mostly, neurophysiological) factors and responses to hypnosis andhypnotic suggestions (Barabasz & Barabasz, 2008; Crawford, 1990,1994; Crawford & Gruzelier, 1992; De Pascalis, 1999; Gruzelier, 1998;Kihlstrom, 2013; Oakley, 2008; Oakley & Halligan, 2010; Ray, 1997).These reviews served as the primary sources for conclusions regardingthe current state of the science knowledge regarding the importance ofbiological factors, as well as sources to identify published articles sup-porting these conclusions. However, findings from a selected numberof empirical studies as well as studies that have been published sincethese reviews were also included in our review if they illustrated keyconclusions or provided additional important information not includedin the existing reviews. To help identify these additional articles, weperformed a search of the PubMed, Cumulative Index of Nursing andAllied Health Literature (CINAHL), and PsycINFO databases, usingthe search terms hypnosis combined with each of the following: EEG(for electroencephalogram), fMRI (for functional magnetic resonanceimagery), and PET (for positron emission tomography).

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As a starting point to identify articles reporting findings regardingthe relative importance of psychological and social factors that couldcontribute to our understanding of the mechanisms of hypnosis, weread and extracted information from extant reviews and theoreticalpapers by prominent theoreticians in this area and that tended to focuson these factors (Bányai, 1991, 1998; Barnier et al., 2008; Coe & Sarbin,1977, 1993; Diamond, 1987; Evans, 2000; Hammond, 2005; Killeen &Nash, 2003; Kirsch, 1991; Kirsch & Lynn, 1995, 1997, 1999; Lynn et al.,2008; Lynn & Rhue, 1991; Spanos, 1991; Spanos & Chaves, 1989; Spanos& Coe, 1992; Wagstaff et al., 2010; Welch, 1947). Based on these reviewsand the articles they cited, we identified five psychological domains andtwo social domains that were most commonly considered or studied.

The psychological factors identified included hypnotizability,expectations, motivation, absorption/imaginative involvement/fantasyproneness, and attitudes toward hypnosis, and the social factorsidentified were rapport (also referred to as “resonance” and “har-mony”) and social context. Although historically some theorists mayhave associated the concept of “hypnotizability” with the concept of“hypnotic state” (i.e., with biological models of hypnosis), the con-cept of hypnotizability has also been explained from the perspectiveof psychosocial models (Wagstaff et al., 2010). Moreover, becausehypnotizability is generally viewed as a stable trait and is assessedusing behavioral scales (i.e., a person’s score is based on their behav-ioral response in a social context) and given that the biological sectionwill focus on the correlates of hypnosis with objective physiologicalresponses (e.g., brain activity as measured by fMRI, PET, and EEG), theconcept of hypnotizability seemed to us to fit better into the psycholog-ical domain than in the biological domain. However, we acknowledgethat hypnotizability could reasonably be classified as either a psycho-logical or biological factor. To ensure that we identified the key articlesthat might describe the associations between psychological and socialfactors and the response to hypnosis, we performed searches of thePubMed, CINAHL, and PsycINFO databases that reported findingsregarding these factors, using the search term hypnosis combined witheach of the following: expectancies, attributions, motivation, absorption,imaginative involvement, fantasy proneness, attitudes, rapport, resonance,and social. We limited the search to studies published in English.

All of the relevant articles identified were read by pairs of authorsfor each of the three domains. MPJ and TA read all of the biological fac-tors review articles and articles resulting from the search on the topicof biological factors; JM and CTP read all of the psychosocial theoret-ical and review articles and chapters and articles from the search onthe topic of psychological factors; JL and ZJO read all of the psychoso-cial theoretical and review articles and chapters and articles that wereidentified from the search on the topic of social factors. These pairs of

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authors identified those articles and chapters that provided answers tothe primary review question and extracted the key findings from thesearticles for the current review.

Results

Biological Factors Associated With Hypnotic RespondingIn this section, we first introduce the reader to the primary brain-

imaging techniques used to study the neurophysiolgical correlates ofhypnosis and hypnotic responding. This is followed by a discussion ofthe findings of the review, organized by the key conclusions that can bedrawn from the existing body of research.

Measures of neurophysiolgical structure and responding. The primarystrategies used to assess neurophysiological structure and respondingin hypnosis research assess (a) activity in specific areas of the brain(initially using mostly positron emission tomography [PET] and thenmore recently using mostly functional magnetic resonance imaging[fMRI], but occasionally using magnetoencephalography [MEG]), (b)brain structure (usually using structural magnetic resonance imaging),and (c) brain states (usually using electroencephalography [EEG]).

PET, fMRI, and MEG can all produce three-dimensional images ofbrain function. Both PET and fMRI measure blood flow in specific areas,which is thought to reflect activity in the central nervous system. WithPET, a radioactive tracer is injected into (or inhaled by) the subject, andby measuring the locations associated with more versus less radioac-tive decay, the PET scanner can identify areas of more or less blood flow.An fMRI assesses local magnetic fields. Because hemoglobin (which car-ries oxygen in the blood) has different magnetic properties when it isoxygen rich than when it is oxygen poor, the fMRI scanner is able toidentify specific brain areas that are using more or less oxygen at anyone time. MEG records the magnetic fields produced by the electricalactivity of neurons in the brain and, therefore, is more closely associ-ated with actual neuronal activity (as opposed to the proxy measure ofbrain activity—blood flow and blood oxygen use—assessed by PET andfMRI) than PET or fMRI. However, MEG has less spatial resolution thaneither PET or fMRI. Structural and diffusion magnetic resonance imag-ing (MRI) are used to assess the density of regional grey matter (neuralcell bodies) and white matter (neural axons), as well as the anatomicalconnectivity between brain areas, respectively.

EEG uses electrodes placed directly on the scalp to record electri-cal activity in cortical neurons. Activity can be measured from just onescalp site using one electrode or up to 256 different scalp sites using a“net” of electrodes. The more sites used, the more able an investigator

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is to localize the source of electrical activity. However, because EEGassesses activity only from the very top layers of the cortex (i.e., notdeeper structures) and assesses that activity through the skull, skin,and dura matter, the spatial resolution of the EEG is very low, espe-cially when compared to PET or fMRI. On the other hand, temporalresolution with EEG is very high, which makes EEG a powerful tool formeasuring brain activity changes over time. Importantly, the EEG signalcan be filtered into specific frequency ranges, each of which has behav-ioral correlates reflecting brain states. A preponderance of very slowdelta waves (up to four cycles per second or 4 Hz) is associated withsleep. Theta waves (between 4–8 Hz) are associated with drowsinessas well as both focused attention and memory functions. Alpha waves(between 8–12 Hz) tend to occur in posterior regions and are associ-ated with feelings of relaxation, as well as a lack of sensory input (e.g.,eye closure). Beta waves (13–35 Hz) tend to occur more frontally andare associated with feeling alert and active, or even anxious. Gammawaves (38 + Hz) occur during memory tracing and recall and are alsoassociated with cross-modal sensory processing (binding different sen-sory experiences processed in different parts of the brain into a coherentwhole; for example, the sights, smells, and touch senses of an object orexperience).

However, a great deal has yet to be learned about the mechanismsof different brain oscillations. Moreover, the standard boundaries usedto differentiate between the different oscillation bandwidths are basedmostly on convention and can therefore be considered as somewhatarbitrary. There is also between-person variability in peak levels of eachbandwidth. Thus, it is possible that “low alpha” (9 Hz activity) in oneindividual might operate like and contribute to the same processes astheta oscillations (4–8 Hz) do in another individual. Similarly, “highbeta” (33 Hz) might serve the same function as gamma usually doesin a specific sample or individual. The distinctions between theta andalpha, or between beta and gamma, may not therefore be strong or clearand can contribute to inconsistencies in the research findings. Finally,it is also important to note that the traditional bandwidths are quitebroad, and evidence suggests that each one contains more than one nar-rower bandwidth that may have different functions (Michels et al., 2010;Vogel, Broverman, & Klaiber, 1968; Williams & Gruzelier, 2001); tradi-tionally operationalized theta, alpha, beta, and gamma oscillations can allserve different purposes.

Given this background information regarding the most common bio-logical variables studied in hypnosis research, we now discuss andsummarize the key conclusions that can be drawn from the availableresearch on biological correlates of hypnotic responding, citing thereviews and specific articles that support each one.

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People who score high on hypnotizability scales demonstrate different pat-terns of neurophysiological responses to hypnotic inductions and suggestionsthan people who score low on hypnotizability scales. Perhaps the mostcommon experimental design used to study the neurophysiological cor-relates of hypnosis and hypnotic responding involves selecting studyparticipants who score either very high (highs) or very low (lows) onstandardized tests of hypnotizability. Some investigators screen forhypnotizability two or even three times, to ensure that they have true(or extreme) highs and true lows. Less often, individuals who scorein the midrange (mediums) are included in research studies and arecompared to both highs and lows. The procedures then often involvecomparing the groups on measures of brain activity and assume thatany between-group differences found reflect responses and processesimportant to hypnotic responding.

One of the most consistent findings from this body of research isthat the brains of highs consistently react differently to hypnosis andhypnotic suggestions than the brains of lows on a number of keyneurophysiology measures, including (a) specific areas of the brain thatrespond to hypnosis in general and specific hypnotic suggestions in par-ticular and (b) shifts in brain states following hypnosis as measured byEEG activity (Barabasz & Barabasz, 2008; Crawford, 1994; De Pascalis,1999; Gruzelier, 1998). Details regarding some of the most consistentfindings with respect to brain areas and processes that evidence dif-ferences between highs and lows are summarized in the sections thatfollow. But the general conclusion from this body of research is clear:People who are more likely to respond to hypnosis and hypnotic sug-gestions consistently show different patterns of brain responses thanthose who do not respond to hypnotic analgesia suggestions.

Virtually all of the brain areas involved in the processing of pain have beenshown to be impacted by hypnosis and hypnotic analgesia. Our understand-ing of how the body and brain work together to create the experienceof pain has expanded significantly in the last 50 years, and especiallyin the last 2 decades as brain-imaging technology has advanced toallow for real-time assessment of brain activity (e.g., PET and fMRIscans) and brain states (e.g., EEG assessments) while people experi-ence more or less pain. Instead of a simple Cartesian notion of thebrain as a passive recipient of information from sensory nerves in theperiphery regarding physical damage, we now understand pain as theend product of a dynamic series of multiple neurophysiological mecha-nisms that modulate information about physical damage at many sitesand levels, including the periphery, the spinal cord, and supraspinalsites such as the thalamus (where the majority of sensory informationfrom the periphery first enters the brain), the sensory cortices (where

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information about the location, magnitude, and sensory qualities ofpain is processed), the insula (where information regarding the need to“do something” about pain is processed), the anterior cingulate cortex(where information regarding the affective/emotional aspects of painare processed), and the prefrontal cortex (where information about themeaning of pain to the individual is processed; see Apkarian, 2013;Apkarian, Bushnell, Treede, & Zubieta, 2005; Craig, 2003; Jensen, 2008).There is no such thing as a “pain center” in the brain.

With respect to the effects of hypnosis and hypnotic analgesia onthe brain areas and processes that underlie the experience of pain, ithas become increasingly clear that hypnosis and hypnotic analgesia caninfluence all of these sites and processes (De Benedittis, 2003; Jensen,2008). Hypnotic analgesia suggestions have been shown to reducethe inflammatory processes associated with heat injury and increasedsensitivity to pain in the periphery (Chapman, Goodell, & Wolff,1959). Effective hypnotic analgesia also influences spinal reflexes—areflex that cannot be influenced by conscious efforts (Danziger et al.,1998; Kiernan, Dane, Phillips, & Price, 1995). When effective, hyp-notic analgesia suggestions have been shown to reduce activity in thethalamus, sensory cortices, insula, anterior cingulate cortex, and pre-frontal cortex (Hofbauer, Rainville, Duncan, & Bushnell, 2001; Rainville,Duncan, Price, Carrier, & Bushnell, 1997; Wik, Fischer, Bragee, Finer,& Fredrikson, 1999). Thus, just as our initial models of pain as a sim-ple sensory response to stimulation or damage in the periphery haveevolved into a much more complex understanding of the many pro-cesses involved in the creation of pain, our neurophysiological modelsof hypnotic analgesia mechanisms have evolved to encompass themany ways that hypnosis can influence pain (and comfort; see Jensen,2008). Just like there is no such thing as a single “pain center” in thebrain, there is no such thing as a single “physiological mechanism” ofhypnotic analgesia. Rather, because hypnosis can influence pain in alarge variety of ways, it makes more sense to speak of physiologicalmechanisms of hypnotic analgesia.

Findings regarding hypnosis and EEG-assessed measures of brain statesshow (a) a fairly consistent pattern of more theta activity among highs, rela-tive to lows; (b) both increases and decreases in most bandwidths with hypnosisexcept for theta, which tends to show increases with hypnosis in both highs andlows; (c) stronger effects of hypnosis and hypnotic suggestions on brain activityamong highs than lows. Researchers have been examining the associa-tions between hypnotizability and EEG bandwidth activity, as well asthe effects of hypnotic inductions on EEG, for close to half a century.In the initial studies in the 1970s in this area, researchers hypothesizedthat hypnosis would be associated with more alpha activity, given the

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interest in this bandwidth as being associated with relaxation and avariety different meditative states (Kihlstrom, 2013; Oakley & Halligan,2010). However, although hypnotic inductions sometimes result inincreases in alpha activity (De Pascalis & Palumbo, 1986; Graffin, Ray, &Lundy, 1995; Macleod-Morgan, 1979; Morgan, Macdonald, & Hilgard,1974), effects on alpha activity are not consistent (Crawford, 1990;Kihlstrom, 2013; Ray, 1997; Sabourin, Cutcomb, Crawford, & Pribram,1990).

The most consistent finding with respect to differences betweenhighs and lows in baseline EEG activity, noted by a number of review-ers (Barabasz & Barabasz, 2008; Crawford, 1994; Crawford & Gruzelier,1992; Kihlstrom, 2013; Ray, 1997), is that individuals who score higheron hypnotizability tests evidence higher baseline levels of theta activ-ity than individuals who score lower on hypnotizability tests (Freeman,Barabasz, Barabasz, & Warner, 2000; Galbraith, London, Leibovitz,Cooper, & Hart, 1970; Kirenskaya, Novototsky-Vlasov, & Zvonikov,2011; D. D. Montgomery, Dwyer, & Kelly, 2000; Sabourin et al., 1990;Tebecis, Provins, Farnbach, & Pentony, 1975). In addition, there is a ten-dency for individuals—especially highs—to respond to hypnotic induc-tions with increases in theta activity (Sabourin et al., 1990; D. White,Ciorciari, Carbis, & Liley, 2009; Williams & Gruzelier, 2001). However,this effect has not been observed in either highs or lows in response tohypnotic analgesia suggestions (De Pascalis & Perrone, 1996). In fact, inone hypnotic analgesia study, reductions in low theta (4–5.75 Hz) wereobserved in the left hemisphere of highs (De Pascalis & Perrone, 1996).

De Pascalis (2007) recently reviewed the literature with respect togamma activity and hypnosis. He described an overall inconsistency inthe research findings on these effects. Some research has found higherbaseline gamma activity in highs relative to lows (Akpinar, Ulett, & Itil,1971; Schnyer & Allen, 1995) and also more gamma activity in responseto hypnosis (De Pascalis, 1993). However, other studies have foundlower levels of gamma power in highs, relative to lows (De Pascalis,Marucci, Penna, & Pessa, 1987) and decreases in gamma with hypnoticanalgesia suggestions among highs (De Pascalis, Cacace, & Massicolle,2004). In a follow-up study using a “obstructive imagery treatment”(instructions to relax and focus attention on the right hand and imaginga glove that attenuates all sensations; that is, not formal hypnosis butsomething much like hypnosis), a decrease in gamma was specific tohigher gamma frequencies (38–42 Hz and 42–46 Hz) and to central areas(Cz in the International 10/20 system, De Pascalis & Cacace, 2005; seealso, Croft, Williams, Haenschel, & Gruzelier, 2002). Yet, other studiesreport that highs evidence both (a) a greater increase in gamma den-sity during recollection of positive emotional events than lows and (b)a greater reduction in left hemisphere gamma activity and an increase

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in right hemisphere activity in gamma, relative to lows, during hyp-nosis (De Pascalis, Marucci, & Penna, 1989; De Pascalis et al., 1987).More recent research has found levels of gamma to be associated withhypnotic depth (Cardeña, Jonsson, Terhune, & Marcusson-Clavertz,2013). Another study found an association between gamma activity andpain intensity (in response to painful stimulation) evident in both highsand lows that disappeared with hypnosis in highs only (Croft et al.,2002).

Two tentative conclusions can be made from this body of researchregarding gamma activity. First, it appears that gamma activity oftenchanges following hypnotic inductions and hypnotic suggestions.Second, there is a tendency for higher levels of gamma to be associ-ated with more hypnotizability and response to hypnotic suggestions.But this tendency is not entirely consistent across samples or hypnoticsuggestions. It appears that whether gamma increases or decreaseswith hypnosis may depend more on the content of the suggestionsthan whether more or less gamma is linked to hypnotic responding(De Pascalis, 2007).

The findings with respect to beta bandwidths also do not yet providea clear picture regarding their involvement, one way or the other, inhypnotic responding. For example, a number of studies find no impactof hypnosis on beta activity (De Pascalis & Cacace, 2005). When an effecthas been found, highs evidence decreases in low beta (13–15.75 Hz)with hypnotic analgesia suggestions (De Pascalis & Perrone, 1996)and increases in beta (13–16 Hz, 16–20 Hz, and 20–36 Hz) in the lefthemisphere during age-regression suggestions (De Pascalis, 1993).

In sum, when changes in EEG-measured brain activity followinghypnosis (including hypnotic analgesia) are compared between highsand lows, differences are almost always found (Graffin et al., 1995; Ray,1997; Williams & Gruzelier, 2001). These differences tend to be observedmore often in the theta and gamma bandwidths, with higher levelsof theta tending to be associated with more hypnotizability and hyp-notic responding, and greater differences and changes (both directions)in gamma associated with more hypnotizability and hypnotic respond-ing. But changes in activity in other bandwidths are also sometimesobserved, with a tendency for there to be (a) differences in the direc-tion of changes between highs and lows (i.e., sometimes when highsshow increases, lows show decreases) and/or (b) greater changes inhighs, relative to lows (i.e., if both show increases in a bandwidth, highstend to show greater increases than lows). These general conclusions arealso consistent with findings showing differences between highs andlows in both the patterns of associations between EEG-assessed band-width activity and subjects’ phenomenological experience of hypnosis(Cardeña et al., 2013) and in the brain areas (source locations) associatedwith theta and beta activity (Isotani et al., 2001).

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Although a number of specific brain areas can be impacted by hypnosis,frontal (in particular dorsolateral prefrontal cortex) and cingulate cortical areasappear to be impacted most often. One of the clear conclusions from anumber of reviews of research studies examining neurophysiologicalresponses to hypnosis is that a number of different brain areas, manyof which subsume the cognitive process of attention and conscious-ness, are impacted by hypnosis (Crawford, 1994; De Benedittis, 2003;Jensen, 2011; Rainville & Price, 2004). However, two brain areas appearto be most consistently linked to hypnotic responding in general andhypnotic analgesia in particular: the frontal and cingulate cortices.

Frontal cortices. The frontal cortices are an integral part of the exec-utive function network and are involved in planning, goal setting,selective attention, and modulation (mostly via inhibition) of otherbrain functions, including sensory functions and those that underliemotor behavior. Moreover, a number of neurophysiological modelsof hypnosis argue for a central role for frontal functions in hypnoticresponding. For example, Gruzelier (1998, 2006) describes a three-phasemodel of hypnosis in which specific brain areas are hypothesized tobecome involved and become either more or less active, dependingon the phase of the hypnotic procedure. In the first phase, when thesubject is invited to focus their attention on an object during the induc-tion, frontolimbic structures are hypothesized to become engaged andactive. In the second phase, and in response to suggestions for tiredness(from fixation during the first phase) and relaxation, an inhibition inand/or dissociation within the frontolimbic structures is hypothesized,during which time the subject is more open to respond to suggestions.In the third phase, to the extent that the hypnotic procedures theninvolve suggestions for imagery, right-sided temporoposterior regionsare hypothesized to be activated. Note that this model does not hypoth-esize that activity in these structures changes in this stepwise pattern inresponse to all hypnotic procedures, but only those that involve a fixa-tion induction followed by suggestions for relaxation (“letting go”) andthen for imagery. Research findings support this model. In particular,findings indicate a reduction in frontal cortical activity and dissociationof frontal structures from other brain areas in response to hypnosis,as summarized by Gruzelier (Gruzelier, 1998, 2006). Additional evi-dence supporting a role for a reduction in frontal activity in hypnoticresponding comes from two recent studies showing an increase inresponse to hypnotic suggestions following (a) a disruption of activityin the dorsolateral prefrontal cortex with repetitive transcranial mag-netic stimulation (Dienes & Hutton, 2013) and (b) alcohol intake, whichis known to impair frontal executive functioning (Semmens-Wheeler,Dienes, & Duka, 2013).

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However, although inhibition of the executive functioning system(i.e., frontal areas) might be expected to be associated with response tomany (if not most) hypnotic suggestions, an increase in frontal activitywith hypnosis might be expected when or if such activity is necessaryor useful when responding to a suggestion—for example, to inhibit sen-sory experiences. Consistent with this idea, evidence also indicates anincrease in frontal activity (in highs, but not necessarily lows) with hyp-notic suggestions for both motor imagery (Muller, Bacht, Schramm, &Seitz, 2012) and analgesia (Crawford, Gur, Skolnick, Gur, & Benson,1993). As a group, these findings support the conclusion than frontalcortical areas are involved in hypnosis and the response to hypnoticsuggestions. However, the extent to which a reduction or interruptionof versus an increase in frontal activity (or, perhaps, in the specific neu-ronal assemblies within frontal areas) facilitates response to hypnoticsuggestions appears to depend on the specific hypnotic proceduresused or suggestions made.

Midcingulate and anterior cingulate cortices. The midcingulateand anterior cingulate cortices (MCC and ACC, respectively) are areasof the (frontal) limbic system involved in many different functions,including reward anticipation, error detection, attention, motivation,and emotion. In fact, the cingulate cortices are involved in so manyaspects of human experience and behavior that it would be diffi-cult to imagine these areas not being involved in many if not mostresponses to hypnotic suggestions, which by definition involve changesin experience, behavior, or both.

However, whether response to hypnotic suggestions is linked toincreases or decreases in cingulate activity depends on the suggestionsbeing made. Increases in ACC activity as measured by PET scales havebeen shown to be associated with ratings of more hypnotic absorp-tion in highs (Rainville, Hofbauer, Bushnell, Duncan, & Price, 2002).Increases in ACC have also been shown to be associated with hyp-notic suggestions to vividly imagine a pleasurable autobiographicalmemory; a suggestion that also results in decreases in pain intensityand unpleasantness (Faymonville et al., 2000). In a separate study,such suggestions were found to be associated with increases in activ-ity in the MCC (Faymonville, Boly, & Laureys, 2006). On the otherhand, hypnotic suggestions to decrease pain unpleasantness (Rainville,Carrier, Hofbauer, Bushnell, & Duncan, 1999) and pain intensity directly(Derbyshire, Whalley, & Oakley, 2009; Derbyshire, Whalley, Stenger, &Oakley, 2004) have both been shown to be associated with decreases inACC activity. Thus, it appears that the MCC and ACC are involved inhypnotic responding, but they are engaged to the extent that changes inactivity—either more or less activity—are required in the response.

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Hypnosis is associated with hemispheric asymmetry. Some researchershave suggested that hypnotic responding may be associated morewith right hemisphere than left hemisphere processing, because hyp-notic responding appears to be associated more with right than lefthemisphere cognitive activities and processes, such as creativity, intu-ition, and nonverbal/nonanalytic thinking (e.g., metaphors, stories, andimagery). Indeed, some preliminary support for this idea came fromstudies demonstrating greater dominance in the right hemisphere withhypnosis in general (Edmonston & Moscovitz, 1990; MacLeod-Morgan& Lack, 1982) and hypnotic analgesia in particular (Chen, Dworkin,& Bloomquist, 1981). However, research indicates no difference inhypnotizability between individuals with left versus right hemispherelesions (Kihlstrom, Glisky, McGovern, Rapcsak, & Mennemeier, 2013).In addition, even though as cited above, greater right hemisphere activ-ity has sometimes been shown to be associated with hypnotizability,greater left hemisphere activity has also been found to be associatedwith more hypnotizability in some studies (Sabourin et al., 1990), andfindings from other studies show no differences in right versus lefthemisphere activity (Graffin et al., 1995; Morgan et al., 1974).

Thus, hypnosis and hypnotic responding is not consistently associ-ated with greater right hemisphere activity. On the other hand, highshave been shown to evidence greater differences in hemisphere activitythan lows, regardless of the direction of those differences (i.e., some-times right > left, sometimes left > right) (Crawford, 1990; De Pascalis& Perrone, 1996). Thus, the findings are more consistent with a model ofhypnosis hypothesizing greater overall physiological flexibility amonghighs (i.e., shifting from left to right, anterior to posterior, as needed torespond to the suggestion), rather than a general tendency to simplyshift from left to right hemisphere processing with hypnosis (Crawford,1989).

Hypnosis and hypnotic responding is associated with both increasesand decreases in functional connectivity between brain areas. Hypnosisalso influences measures of connectivity between brain regions(Faymonville et al., 2006; Gruzelier, 1998; Oakley, 2008). However, thedirection of effects can be variable and, like many of the other physi-ological activity measures discussed so far, differ as a function of bothgeneral hypnotizability and the contents of the hypnotic suggestions.One study, for example, reported a decrease in general connectivitybetween brain areas during a hypnotic induction (Cardeña et al., 2013),and another reported a decrease in connectivity between frontal midlineareas and left lateral scalp sites in highs (but not lows) after hypnosis(Egner, Jamieson, & Gruzelier, 2005). Similarly, Gruzelier and colleaguesfound that a hypnotic induction resulted in decreases in connectivitybetween prefrontal regions and other areas in highs but an increase in

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connectivity between these sites in lows (Gruzelier, 1998). One casestudy found mostly decreases in connectivity (and mostly betweenfrontal and other areas) with hypnosis in a single highly hypnotiz-able subject with hypnosis, although there was also one consistent andstrong increase in connectivity (between the left temporal and rightoccipital areas) with hypnosis (Fingelkurts, Kallio, & Revonsuo, 2007).Other research has shown increases in connectivity between precuneusand other regions with hypnotic paralysis (Cojan et al., 2009; Pyka et al.,2011). In sum, the findings in studies of hypnosis not involving analge-sia suggest mostly decreases in connectivity (and mostly with highs)with hypnosis, but some increases in connectivity, depending on thesites examined as well as the level of hypnotizability.

With respect to hypnotic analgesia specifically, increases in con-nectivity have been found in response to hypnotic suggestions to re-experience a pleasurable autobiographical memory, which also resultedin analgesia (Faymonville et al., 2000, 2003; Vanhaudenhuyse et al.,2009). However, the extent to which these increases are or are notassociated with other hypnotic suggestions that can result in analge-sia (e.g., direct suggestions to experience a decrease in pain intensity orsuggestions to experience dissociation from parts of the body that aresometimes painful) is not known.

Hypnotizability is associated with higher levels of structural connectivity.In contrast to the findings that hypnotic inductions and suggestionscan both decrease and increase functional connectivity between areasof the brain, depending on both hypnotizability and the specific sug-gestions made, two studies suggest the possibility of greater structuralconnectivity between brain areas as a functioning of hypnotizability. Forexample, using diffusion MRI, Hoeft and colleagues showed strongerconnectivity between the prefrontal cortex and ACC in highs, relative tolows during resting state (Hoeft et al., 2012). Similarly, Horton and col-leagues found that highs (who were also able to eliminate pain percep-tion with hypnotic suggestions) had significant and substantially larger(32%) rostrum (the anterior portion of the corpus callosum, involved intransfer of information between the frontal cortices) than lows (Horton,Crawford, Harrington, & Downs, 2004). Thus, while there is relativelylittle research regarding structural differences between highs and lows,these two findings suggest the intriguing possibility that not only dothe brains of highs and lows differ in how they respond to hypnosis,but they may actually show differences in how they are hardwired, withhighs evidencing greater overall structural connectivity than lows.

Summary of the findings regarding biological correlates of hypnosis.Although the research findings regarding the associations betweenhypnotizability, hypnotic responding, and brain activity measures arecomplicated, a picture is emerging and some general conclusions

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appear possible. First, there is not (yet) a clear brain “signature” of hyp-nosis. Brain-activity measures change in response to hypnotic induc-tions and suggestions, but, for the most part, the areas and type (moreversus less) of activity seems to be more closely related to and consistentwith the suggestions made, rather than hypnosis per se. Suggestionsfor “letting go” may be associated with decreased frontal activity, whilesuggestions for analgesia appear to be associated with increases infrontal activity (as executive systems are engaged to suppress the expe-rience of pain). Moreover, the neurophysiological responses to hypnosisand hypnotic suggestions are consistently shown to differ between indi-viduals with high versus low hypnotizability. The biological measuresthat seem to be most closely associated with hypnosis and hypnoticresponding include (a) higher levels of theta activity in highs and inresponse to hypnotic inductions and (b) perhaps higher levels of struc-tural connectivity between left and right hemisphere frontal areas andbetween frontal areas and the ACC. It is possible that differences inthese biological domains in particular—that is, theta activity and struc-tural connectivity—may facilitate hypnotic responding. This possibilityshould be examined further.

Psychological Factors Associated With Hypnotic RespondingAs described previously, based on our reading of the articles and

chapters presenting theories of hypnosis that focus on or include psy-chological factors, we identified five psychological factors as beingthe ones most consistently mentioned as important: hypnotizability,expectancies, motivation, absorptive capacity/fantasy proneness, andattitudes towards hypnosis. In the sections that follow, each of thesefactors is discussed under a heading that provides a summary of thekey results from our review of the evidence regarding that factor.

The strength of the associations found between measures of generalhypnotizability and response to specific hypnotic suggestions is variable.Most of the research studying the associations between generalhypnotizability1 and response to specific suggestions has focused onpain. As described by a number of scientists who have reviewed theliterature in this area, research shows that an individual’s ability to

1Throughout the literature terms such as hypnotizability, suggestibility, hypnoticresponsivity, hypnotic susceptibility, hypnotic preparedness, hypnotic responding, andhypnotic depth have been used interchangeably at various times and by various inves-tigators. The terms “hypnotic susceptibility” and “hypnotic suggestibility” imply stabletraits of individuals, whereas “hypnotic responsivity” and “hypnotic responding” refermore to an individual`s behavior in response to a specific suggestion or set of sugges-tions. Here, we use the term “hypnotizability” to refer to an individual`s response to testsuggestions after a hypnotic induction procedure (Heap, Brown, & Oakley, 2004; Kirsch& Council, 1992).

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experience and respond to hypnosis, in general, is usually—but notalways—associated positively with response to specific hypnotic anal-gesia suggestions (Accardi & Milling, 2009; Jensen & Patterson, 2006;G. H. Montgomery et al., 2000; Patterson & Jensen, 2003; Tomé-Pires& Miró, 2012). However, there is a great deal of variability in thestrength of the associations found. The strongest associations havebeen reported for the treatment of acute and procedure-related painin children ranging from .50 to .81 (Liossi & Hatira, 1999, 2003; Liossi,White, & Hatira, 2006). Weaker, and in some studies nonsignificant,associations are found in chronic pain studies in adults (Jensen, Barber,Romano, Hanley, et al., 2009; Jensen, Barber, Romano, Molton, et al.,2009; Jensen et al., 2005). When reported, the strength of the associa-tions in studies of laboratory pain in healthy subjects tends to rangefrom moderately weak (e.g., r = .25) to large (e.g., r = .55 or Cohen’sd = > 1.00 between highs and lows; see Appel & Bleiberg, 2005; DePascalis, 1999; Hilgard & Hilgard, 1994; Milling, Kirsch, Meunier, &Levine, 2002).

The high degree of variability in the associations found, as wellas the differences in the strength of the associations as a function ofstudy population (laboratory pain, acute procedural pain, chronic pain)strongly suggest the existence of moderating factors that influence theextent to which hypnotizability is associated with outcome. A numberof moderating factors have been hypothesized by investigators in thisarea. For example, Hilgard and Hilgard (1994) and Hammond (2005)have both noted that response to relatively “easy” suggestions (e.g.,for ideomotor phenomenon and at least some analgesic response) doesnot require a great deal of hypnotic ability. For such suggestions andresponses, general hypnotizability may play a relatively minor rolein outcome. Other hypnotic suggestions and responses (e.g., for hal-lucinations, profound amnesia, or the complete elimination of painduring noxious stimulation) may require much more dissociative capac-ity, and therefore greater hypnotic ability may be required. Thus, thespecific type and wording of suggestions may influence the role thathypnotizability plays on outcome. Other moderating factors in addi-tion to type of suggestions surely exist. However, to date very fewresearchers have examined hypnotizability as a potential moderator ofhypnotic responding (see Milling & Breen, 2003, and Milling, Reardon,& Carosella, 2006, for two rare exceptions). Additional research focus-ing on this question would have important theoretical and clinicalimplications.

The strength of the associations found between measures of expectancies andresponse to specific hypnotic suggestions is variable. Outcome expectanciesrepresent the extent to which the subject believes that he or she willexperience a specific response following a hypnotic intervention (e.g.,

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that hypnosis will lead to analgesia, or that the dominant hand will raiseseemingly of its own accord following an induction). Expectancies arethought to reflect automatic processes influenced by past experience,the current context, and the interaction. Expectancies are important, ifnot central to, a number of hypnosis theories (Kirsch, 1991; Kirsch &Lynn, 1995, 1997, 1999; Lynn et al., 2008; Lynn & Rhue, 1991; Spanos &Chaves, 1989; Wagstaff et al., 2010).

Evidence from a number of studies is consistent with the hypoth-esis that expectancies play a role in hypnotic responding, especiallyin laboratory settings (Benham et al., 2006; Braffman & Kirsch, 1999;Kirsch, Silva, Comey, & Reed, 1999). However, research also suggeststhe importance of expectancies may be less in response to hypnotictreatment for chronic pain (Jensen, Barber, Romano, Hanley, et al., 2009;Jensen, Barber, Romano, Molton, et al., 2009; Jensen et al., 2005). Onestudy examining the relative importance of outcome expectancies aspredictors of the benefits of hypnosis for a variety of symptoms foundthat the strength of the associations varied as a function of the symptombeing considered, with outcome expectancies playing a smaller role forpredicting improvements in nausea (r = .20) and “discomfort” (r = .23)than for predicting improvements in pain intensity (r = .52) and fatigue(r = .62) (G. H. Montgomery & Bovbjerg, 2004). Another study foundlarger effects of expectancy on response to some more difficult hyp-notic suggestions (e.g., audio hallucination, amnesia) than some easiersuggestions (e.g., ideomotor suggestions) and to be larger among highsthan lows (Kirsch et al., 1999).

One methodologically strong approach for evaluating the impor-tance of any potential mechanism factor in hypnotic responding is touse mediational analyses (Baron & Kenny, 1986; Sobel, 2008). In suchanalyses, if a factor is primary (i.e., explains most if not all of an out-come), when the factor is controlled, then the significant benefits of atreatment become nonsignificant. If a factor plays a limited but not pri-mary role (i.e., explains a portion of an outcome), the significant effectsof a treatment are reduced when that variable is controlled, but someportion of the treatment effects remain. In this instance, the factor issaid to be a “partial” mediating variable.

A number of studies have examined the extent to which outcomeexpectancies are full mediators versus partial mediators versus nonmedi-ators of the effects of hypnosis. One study found evidence for fullmediation for expectancies in response to hypnotic analgesia for lab-oratory pain (Baker & Kirsch, 1993). Most other studies have foundevidence for partial mediation in laboratory pain (Milling & Breen, 2003;Milling et al., 2002; Milling, Levine, & Meunier, 2003), medical proce-dure (breast biopsy) pain (G. H. Montgomery, Weltz, Seltz, & Bovbjerg,2002), and postsurgical pain and fatigue (G. H. Montgomery et al.,

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2010). One study found no mediation effects of expectancy on the effectsof hypnosis for reducing postsurgical nausea (G. H. Montgomery et al.,2010). In short, the findings regarding mediation are consistent with theresearch examining expectancies as a predictor of outcome; that is, themediation effects of expectancies are supported more often than not, butthe strength of those effects vary to some degree across populations andsymptoms studied. As is the case with hypnotizability, this variabilitysuggests the likely presence of moderating factors that influence the rolethat expectancies play in response to hypnotic treatments.

Trait absorptive and imaginative ability are consistently associated (mod-erately) with response to hypnosis. As noted by Kirsch and Council(1992), since the 1960s research on personality correlates of hypnoticresponsiveness has been focused primarily on absorption, imaginativeinvolvement, and fantasy proneness, which are constructs so closelyrelated to one another that it is unclear that they represent differentdomains. A fair number of studies have examined the associationsbetween measures of these domains and response to hypnosis and hyp-notic suggestions, and the findings are fairly consistent. Specially, thatindividuals scoring higher on these measures tend to evidence morehypnotic response (Glisky, Tataryn, Tobias, Kihlstrom, & McConkey,1991; Poulsen & Mathews, 2003; Silva & Kirsch, 1992). When coefficientsbetween measures of imaginative ability or absorption and response tohypnosis or hypnotic suggestions are reported, they tend to be weakto moderate (e.g., rs range = .17 to .44; Glisky et al., 1991; Poulsen& Mathews, 2003; Silva & Kirsch, 1992). The strength and range ofthese associations indicates both (a) a role for absorptive ability and(b) the possibility that other factors may moderate the strength of theassociations found.

Motivation has rarely been tested as a predictor of response to hypnosis,but, when examined, motivation shows positive associations with hypnoticresponding. A number of theorists have hypothesized that successfuloutcome and response to hypnotic treatments depend at least in parton heightened subject motivation (Barber, 1969; Hammond, 2005; Lynnet al., 2008; Patterson, Adcock, & Bombardier, 1997; Spanos, 1986; R. W.White, 1941). However, this factor has been rarely tested as a predictorof response to hypnosis. In fact, our search only yielded one study thatexamined this factor directly. In this study, Braffman and Kirsch (1999)assessed motivation using a 5-point Likert scale assessing “the degreeto which [the participant] wanted to experience” hypnotic suggestionsand found weak-to-moderate positive correlation coefficients betweenthese ratings and response to both behavioral and phenomenologicalresponses to hypnotic suggestions ranging from .13 (ns) to .41 (p < .001)(Braffman & Kirsch, 1999).

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Attitudes towards hypnosis have rarely been tested as predictors of responseto hypnosis. Attitudes about hypnosis have been proposed as impor-tant predictors of hypnotic responding by a number of theorists forat least 40 years (Barber, 1969; Lynn & Kirsch, 2006; Spanos & Chaves,1989). However, despite the fact that two adequately reliable measuresof attitudes towards hypnosis exist—the Attitudes Towards Hypnosisscale or ATH (Milling, 2012; Spanos, Brett, Menary, & Cross, 1987) andthe Valencia Scale of Attitudes and Beliefs Toward Hypnosis scale, orVSABTH (Capafons, Cabanas, Espejo, & Cardeñåa, 2004; Capafons,Espejo, & Mendoza, 2008)—very little research has been performedthat has examined its importance to hypnotic responding (Milling,2012). We were only able to find two studies that reported associa-tions between these scales and measures of hypnotic responding. In thefirst of these, the total ATH score, assessing (a) positive beliefs abouthypnosis, (b) an absence of fear concerning hypnosis, and (c) beliefsabout the mental stability of hypnotizable people evidenced weak-to-moderate (rs = .19 to .31) associations with subscales of the CarltonUniversity Responsiveness to Suggestion Scale (Spanos et al., 1987). Theinvestigators also noted that the associations were curvilinear; that is,individuals with negative attitudes tended to have low hypnotizability,while those with positive attitudes tended to show a greater range inhypnotizability. The associations between the subjects’ scores of theVSABTH scales and hypnotizability were even more variable, rang-ing from r = –.10 to .29 (Green, 2012). The strongest associations (bothrs = .29) were between the VSABTH Help and Interest scales (assess-ing beliefs about hypnosis’s potential helpfulness and the respondent’sinterest in being hypnotized, respectively) and hypnotizability. In short,while not all attitudes about hypnosis appear important, some may beas important as other factors (e.g., expectancies, motivation) found tobe associated with hypnotic responding.

Summary of the findings regarding psychological correlates of hypnosis.The psychological factors most often hypothesized as playing a role inresponse to hypnosis and hypnotic suggestions include hypnotizability,expectancies, absorptive/imaginative ability, motivation, and attitudestowards hypnosis. While the associations between measures of thesefactors and response to hypnosis and various hypnotic suggestionshave not been extensively studied, the findings that are available pro-vide a fairly consistent picture. First, when tested, the findings showweak-to-moderate associations between each of these factors and hyp-notic responding. Second, although very few studies have examined themediating role of these factors, using more sophisticated mediationalanalyses—and of those that have been performed, only expectancieshave been tested as possible mediators—evidence supports a partialmediational role for expectancies. Third, the variability in associations

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between these factors and response to hypnosis suggests the existenceof factors that likely influence (moderate) their role. Preliminary find-ings support the following as moderators for expectancy effects: (a)the specific symptom being examined (e.g., expectancies may be moreimportant for hypnotic analgesia than hypnotic relief from nausea); (b)type of suggestion (e.g., expectancies may play a larger role for respond-ing to more difficult suggestions than easier suggestions); and, (c) withrespect to hypnotic analgesia, type of pain (e.g., expectancies may playa larger role for laboratory and acute pain than for chronic pain). Thepossible role of moderating factors that might influence the importanceof other psychological factors and response to hypnosis has not yet beenadequately examined.

Social Factors Associated With Hypnotic RespondingWhile sociocognitive models of hypnosis argue that hypnotic

responding has both cognitive and social components, Radtke and Stam(2008) have argued that these models tend to focus more on cogni-tive factors (e.g., the factors discussed in the previous section) than thesocial aspects of hypnosis. This may be one of the reasons that onlytwo social factors have been examined with respect to their associa-tion to responses to hypnosis: rapport (also referred to as “therapeuticalliance,” “resonance,” and “harmony,” among other labels) and socialcontext.

Rapport and therapeutic alliance. The collaborative and affective bondbetween a clinician and client/patient is often considered to be an essen-tial component in any therapeutic relationships including hypnosis.In support of this idea, a meta-analysis based on 68 (nonhypnosis)clinical studies that examined the contribution of therapeutic alliancesuggested that positive alliance was weakly but consistently associatedwith better therapeutic outcomes (weighted estimate r = .22; Martin,Garske, & Davis, 2000). Research in hypnosis also supports a role forthis variable in outcomes. For example, Sheehan (1980) manipulatedthe interaction approach of the hypnotist (which presumably wouldinfluence rapport) to determine if rapport might influence the subjects’receptiveness towards the hypnotist’s suggestions, even when the sug-gestions contradicted the subject’s previous conception of how theyshould respond (also known as countering). The results indicate thatsubjects who are exposed to negative rapport conditions (where thetherapist depersonalized himself or herself from the session or criticallyevaluated the subjects) exhibited less countering response, although thefacilitation of positive rapport (through interaction that is characterizedas spontaneous, positive, warm, and involved) did not result in a signif-icantly higher rate of countering response. In other words, poor rapport(or at least, clinician behaviors that could contribute to poor rapport)

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may inhibit subjects’ hypnotic responsiveness. In another study, a groupof low and medium hypnotizability subjects were given hypnotizabilitymodification training with varying levels of hypnotist interpersonalinvolvement and were asked to complete measures of rapport (Gfeller,Lynn, & Pribble, 1987). With respect to rapport, the results revealed that(a) rapport was moderately correlated with posttraining hypnotizability(r = .49, p < .001) and (b) rapport was significantly associated withhypnotic responding (r = .42, p < .001).

Research also suggests that hypnotizability may moderate theeffects of rapport on hypnotic responding. Lynn and colleagues foundincreases in hypnotizability in a high-interpersonal condition in lowsbut not in highs (Lynn et al., 1991). Finally, Varga and colleagues(Varga, Józsa, Bányai, & Gösi-Greguss, 2001) administered the DyadicInteractional Harmony questionnaire (DIH) to two samples of healthyvolunteers, along with standardized measures of hypnotizability. TheDIH assesses four domains of perceived hypnotist-subject interac-tion: intimacy, communion, playfulness, and tension. They found thatthe three scales representing positive interactions demonstrated con-sistently positive weak-to-moderate associations (rs range = .18 to.33) with hypnotizability, and the negative interaction scale assess-ing perceived tension was negatively associated (rs range = –.07 to–.22) with hypnotizability.

Social context and influence. Sociocognitive theorists have argued thatexpectations are often context dependent, and that putting subjects ina hypnotic context may facilitate expectations and other psychologi-cal processes that then facilitate increases in hypnotic responding (Coe& Sarbin, 1977, 1993; Spanos, 1991; Spanos & Coe, 1992). Consistentwith this idea, Hylands-White and Derbyshire (2007) found that a relax-ation procedure that was labeled as “hypnosis” produced more painreduction than the same procedure labeled as “relaxation.”

Spanos, Kennedy, and Gwynn (1984) demonstrated that the hyp-notic context can moderate the association between hypnotizabilityand response to hypnotic analgesia suggestions. In their study, subjectswith different levels of hypnotizability (high, medium, and low) weregiven either (a) brief instructions to try to reduce pain, (b) a hypnoticinduction followed by the same instructions, and (c) neither a hyp-notic induction nor instructions. Results indicated that subjects in boththe instruction-alone and hypnosis conditions reported pain reductionsmore than the control subjects. In a subsequent study, Spanos, Gabora,Jarrett, and Gwynn (1989) found that defining an imagination task as“imagination” instead of “hypnosis” reduced the strength of the asso-ciation between hypnotizability and task performance (from r = .65to r = .34).

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Summary of the findings regarding social factor correlates of hypnosis.Although virtually all theorists recognize that hypnosis has a social con-text, and a number of theories specifically include “social” in the labelthey give to their theory, there has been a paucity of research examiningthe associations between measures of social factors (such as rapport andcontext) and response to hypnosis and hypnotic suggestions (Radtke &Stam, 2008). The little research that has been performed supports bothdirect and moderating roles for social variables—at least the ones thathave been studied to date—and hypnotic responding. Although therange of the strength of the associations found tends to vary from weakto moderate, the direction of the associations is consistent, supportinga reliable finding. Higher levels of rapport are associated with moreresponse to hypnotic suggestions, and defining an interaction as “hyp-nosis” also tends to increase hypnotic responding. The effects of socialfactors may also be moderated by trait hypnotizability (with “nega-tive” rapport perhaps decreasing the likelihood of response in highs,and “positive” rapport increasing the likelihood of response in lows).

Discussion

The key findings from this scoping review are summarized inFigure 1 and indicate that: (a) Measures of a number of biologi-cal, psychological, and social factors are all associated with hypnoticresponding; (b) there is variability between studies in the strengths ofthe associations found for many factors; and (c) there are differencesbetween studies in the directions of the associations found for somebut not all factors. The findings have important theoretical and clini-cal implications for understanding the mechanisms and enhancing theefficacy of hypnosis and hypnotic responding.

Theoretical Implications of the FindingsSupport for biopsychosocial models of hypnosis. The significant associa-

tions found between a number of biological, psychological factors, andsocial factors and measures of hypnotic responding are more consis-tent with comprehensive models that take into account factors from allthree domains (i.e., biopsychosocial models of hypnosis; Bányai, 1991;Hammond, 2005) than with more restrictive models that focus on onlyone or a some small subset of domains and factors. This conclusion par-allels the conclusions made by scientists studying other complex humanresponses and experiences, such as chronic pain (Novy et al., 1995).Although we believe that the development and testing of theoreticalmodels that explain how specific factors may operate and interact withother factors to influence hypnotic responding have contributed a great

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Biological factors

- Activity in frontal cortices +/–

- Activity in ACC +/–

- Functional connectivity +/–

- Structural connectivity +

- Hemisphere asymmetry +

- Brain states (theta) +

Social factors

- Rapport +

- Hypnotic context +

Psychological Factors

- Expectancies +

- Hypnotizability +

- Motivation +

- Absorption +

Hypnotic

Responding

Figure 1. Summary of state of the science findings regarding biological, psychological, andsocial factors that contribute to response to hypnosis and hypnotic suggestions.Note: “+/–” indicates that the factor has demonstrated both positive and neg-ative associations with hypnotic responding; “+” indicates that the factor hasdemonstrated mostly positive and consistent associations.

deal to our understanding of hypnosis, the findings from this reviewindicate that restrictive models will not likely provide an adequateexplanation of hypnotic phenomenon.

As mentioned previously, we are not the first authors to suggestthe potential utility of a biopsychosocial model of hypnosis (Bányai,1991; Hammond, 2005). However, to our knowledge, no one has yetperformed a state of the science review that summarizes the empiricalevidence regarding the biological, psychological, and social factorsmost often proposed as contributing to hypnotic responding by contem-porary hypnosis theorists. To the extent that a biopsychosocial model isappropriate for understanding hypnosis, the findings from this reviewprovide an empirical basis for determining the specific biological, psy-chological, and social factors that should be included in such a model(see Figure 1). In our view, there is no longer a need for research todetermine if the 12 factors identified in this review are associated withhypnotic responding; the evidence indicates that they all are. Instead,we view the most important next steps as being to (a) determine whichof these factors play a causal role (i.e., influence) and which ones merelyreflect hypnotic responding; (b) identify factors that moderate the influ-ence of these 12 factors on hypnotic responding; and (c) identify andexplore additional possible biological, psychological, and social factors

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that should be included in the model. The rest of this section addresseseach of these points.

Neurophysiological models and correlates of hypnosis. The findings pro-vide strong support for a number of consistent associations betweenmeasures of central nervous system functioning and structure andresponse to hypnosis and hypnotic suggestions. The findings areconsistent with theoretical models of hypnosis that focus on itsneurophysiological substrates (Dienes & Hutton, 2013; Gruzelier,1998, 2006; Jensen, 2008; Rainville et al., 2002; Rainville & Price,2004). This conclusion is perhaps neither surprising nor controver-sial, given that all experience and behaviors—including those involvedin response to hypnotic inductions and suggestions—are related toneurophysiological processes.

Questions remain, however, regarding the meaning of the specificassociations found. Do the neurophysiological structures and functionslinked to hypnosis simply reflect hypnotic responding (as a spinningpinwheel held outside of the window of a moving automobile “reflects”the speed of the automobile), or do (some of) these structures and pro-cesses themselves contribute to (influence) hypnotic responding, likethe horsepower of an engine influences the 0 to 60 mph time or topspeed at which an automobile can travel?

Although the findings from this review cannot be used to answercausal questions definitively because so much of the existing research isbased on correlational data, the results can provide evidence that maybe used to identify some of the biological factors that are more or lesslikely to reflect hypnosis versus those that may play a causal role inproducing or facilitating hypnotic responses. Specifically, we proposethat if a measure of a neurophysiological variable evidences both pos-itive and negative associations with hypnotic responding (i.e., activityin frontal cortices, activity in the ACC, and functional connectivity, seeFigure 1), the factor assessed by that measure is more likely to reflecta factor associated with hypnotic responding to a specific suggestion(i.e., a factor that reflects a hypnotic response) rather than one thatinfluences hypnotic responding in general. On the other hand, if a mea-sure tends to evidence consistent associations with hypnotic responding(e.g., always positive), then the factor assessed by the measure remainsviable as one that might influence or otherwise be important to hyp-notic responding. Continuing with the automobile analogy to illustratethis logic, the fact that a pinwheel would spin in one direction when anautomobile moves forward and another direction when the automobilemoves backward is consistent with the idea that pinwheel spinning mayreflect automobile speed (and direction) but has no causal influence onautomobile speed. On the other hand, engine horsepower would tend toshow a consistently positive association with automobile speed; when

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tested and when significant associations are found, more horsepowerwould tend to be positively associated with shorter 0 to 60 mph timesand faster top speeds; negative associations are very unlikely. This find-ing would be consistent with engine horsepower as being a factor thatcould facilitate automobile speed.

With this metaphor in mind, and based on the findings from ourreview, given the inconsistent (i.e., both positive and negative associ-ations) results with respect to activity in the frontal cortices and ACC,as well as functional connectivity, the findings suggest that these mayunderlie processes that reflect but do not facilitate hypnotic respond-ing. For example, when a hypnotic suggestion calls for the subject todo or experience something that requires more activity in the frontalcortices, such as the suppression of pain via frontal inhibitory systems,an increase in frontal cortical activity can be expected (Crawford et al.,1993). When a suggestion calls for a reduction in executive controlor “letting go,” such as is the case for a number of hypnotic induc-tions and suggestions, a decrease in frontal activity can be anticipated(Gruzelier, 1998, 2006). If the suggestions call for changes in perceptionsof color, then changes in activity in the brain areas that process colorinformation can be expected (Kosslyn, Thompson, Costantini-Ferrando,Alpert, & Spiegel, 2000). Similarly, procedures that effectively reducefrontal activity could be expected to increase response to some hyp-notic suggestions but not others, rather than increase general hypnoticresponsivity (Dienes & Hutton, 2013).

On the other hand, the more consistent findings (with respect to thedirection of associations) between hypnotic responding and measuresof structural connectivity, hemisphere asymmetry, and theta bandwidthactivity (see Figure 1) are consistent with the possibility that these mayreflect factors that facilitate response to hypnotic suggestions in general.Thus, given that individuals with high hypnotizability have greaterstructural connectivity between left and right hemisphere frontal cor-tices and between left dorsolateral prefrontal cortex and the ACC (thatis, those areas specifically involved in many hypnotic responses) thanindividuals with low hypnotizability (Hoeft et al., 2012; Horton et al.,2004), it is possible that more structural connections that facilitate com-munication between and control over different brain structures maymake hypnotic responding easier. Similarly, higher levels of hemisphereasymmetry may measure processes that facilitate response to hypno-sis, such as greater overall neurophysiological flexibility (Crawford,1989). Slow wave brain oscillations, in particular theta bandwidth activ-ity but also some alpha, have been linked to better memory tracingand recall functions (Basar & Guntekin, 2012; Buzsáki, 2006; Buzsaki &Moser, 2013; Klimesch, 2012). Given the central importance of memoryin most if not all human responses (e.g., we must recall words to speakand recall images and sensations in order to re-experience them), it is

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possible that activity in these bandwidths, in particular, may help facil-itate response to a variety of hypnotic suggestions. Note that we are notproposing here that more structural connectivity between frontal sitesand other brain structures, greater hemisphere asymmetry, and moretheta activity are necessarily biological “signatures” of a hypnotic state;it is too early to draw such a conclusion. Instead, the findings indicatethat if a biological signature or biological signatures of hypnosis exist,these three factors remain as possible contenders for playing such a role.

Psychological and social models and correlates of hypnosis. One of thefindings from this review was the relative lack of research examin-ing the importance of psychological and in particular social factors inhypnotic responding, despite the fact that theorists have been hypoth-esizing roles for both as factors that contribute to hypnotic respondingfor decades (Bányai, 1991, 1998; Barnier et al., 2008; Coe & Sarbin, 1977,1993; Diamond, 1987; Evans, 2000; Hammond, 2005; Killeen & Nash,2003; Kirsch, 1991; Kirsch & Lynn, 1995, 1997, 1999; Lynn et al., 2008;Lynn & Rhue, 1991; Spanos, 1991; Spanos & Chaves, 1989; Spanos &Coe, 1992; Wagstaff et al., 2010; Welch, 1947).

The role that social factors, in particular, may play has not yet beenadequately examined (Radtke & Stam, 2008). A rare exception to a lackof attention to social factors in the field is the work of Éva Bányai,Katlin Varga, and their colleagues at the Eötvös Loránd University inBudapest, who have developed an impressive program studying hyp-nosis in the context of its social and interactional elements (Bányai, 1985,1998; Varga, 2013; Varga, Bányai, & Gösi-Greguss, 1994; Varga, Bányai,Gösi-Greguss, & Tauszik, 2013; Varga, Józsa, Bányai, & Gösi-Greguss,2009; Varga, Józsa, Bányai, Gösi-Greguss, & Kumar, 2001). Much of thework completed by this group to date focuses on the assessment of thephenomenological experiences of the hypnotist and subject and theirinteraction. It will be interesting to see in future studies how thesephenomenological experiences are associated with response to differenthypnotic suggestions.

There is also a need to move beyond correlational designs in thefield. Although the findings from correlational research can be used toreject a factor as unimportant when it shows weak and nonsignificantassociations with hypnotic responding, when significant associationsare found (as they often are), causal conclusions cannot be drawn.Mediational analyses, while also a type of correlational study, providea more sophisticated strategy for testing hypothesized mechanisms ofhypnosis (Baron & Kenny, 1986; Sobel, 2008).

We were only able to identify five studies that used this approachto test for the potential mediation effects of a biopsychosocial vari-able (Baker & Kirsch, 1993; Milling & Breen, 2003; Milling et al., 2002;Milling et al., 2003; G. H. Montgomery et al., 2010). In each of these

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studies, the factor examined was expectancies. Four of these exam-ined the mediation effects of expectancy on analogue (laboratory) pain,and only one (G. H. Montgomery et al., 2010) examined mediationaleffects in a clinical population. More mediational studies such as thesewould be extremely useful to advance our knowledge regarding the rolethat other psychological and social factors play in influencing hypnoticresponding.

Whereas mediational analyses can provide information regardingwhy hypnosis may be effective, moderation analyses can provide infor-mation regarding for whom hypnosis is most effective, or for whoma specific factor may play a greater or lesser role (Baron & Kenny,1986). In a moderation analyses, two factors are examined togetherwith respect to their interaction effects in predicting outcome. Whena significant interaction effect emerges, it indicates that the strength orimportance of one of the factors depends on the level of the other one.

The results of this review indicate that moderation analyses may beparticularly relevant for better understanding the roles of expectanciesand hypnotizability in understanding hypnotic responding. For both ofthese psychological variables, although they tended to show positiveassociations with hypnotic responding, the strength of the associa-tions found demonstrated a great deal of variability from study tostudy, ranging from very weak and nonsignificant to (mostly) mod-erate. This level of variability provides support for the presence ofmoderator variables that could influence how important each factorwould be in any particular situation. Unfortunately, interaction effectsare rarely examined in hypnosis research. In support of the potentialutility of such analyses, in the rare instance where moderation effectshave been considered, and as cited in the Results section of this review,moderation effects have been found. For example, Milling and col-leagues (2006) found that hypnotizability moderated the outcome foran analogue hypnotic analgesia treatment, but not for a distraction orcognitive-behavioral treatment. G. H. Montgomery and Bovbjerg (2004)found that outcome expectancies were more important for predictingresponse to hypnotic analgesia suggestions than for suggestions forreductions in nausea or “discomfort,” and Kirsch and colleagues foundthat expectancies played a larger role in response to more difficulthypnotic suggestions than easier hypnotic suggestions (Kirsch et al.,1999).

Research is needed to determine the extent to which these mod-eration findings replicate across different populations, as well as toidentify additional moderating variables. For example, we can envisionthe possibility that individuals with high trait hypnotizability may bemore responsive (vulnerable) to their own self-suggestions (i.e., bothpositive and negative). Such a model would predict an Expectancy ×Hypnotizability interaction predicting response to hypnotic cognitive

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therapy. Findings supporting such an interaction effect across popu-lations would support the importance of teaching individuals withmore hypnotizability how to protect themselves from the impact ofnegative self-suggestions (Jensen et al., 2011) as well as how to takeadvantage of their “talent” by benefiting from systematic positiveself-suggestions. Research testing for other possible interaction effectsbetween the factors within domains (e.g., Motivation × Expectancy)or even across domains (e.g., Theta Bandwidth Power × Expectancy,Rapport × Absorption) could help us identify additional variablesthat influence the role of psychological and social factors in hypnoticresponding.

Clinical ImplicationsPerhaps the most important conclusion for clinicians from this

review is the confirmation that an individual’s response to hypnosisis highly complex, and not easily or strongly predicted by any onebiological, psychological, or social factor. Many if not all clinicianswho use hypnosis regularly see evidence for this conclusion in theirdaily practice, when a client or patient is seen to respond favorablyto hypnotic treatment despite (a) a noisy environment not thought tobe conducive to hypnotic responding, (b) low scores on measures oftrait hypnotizability, (c) adamant proclamations of the belief that hyp-nosis will not be helpful or effective, and (d) the presence of evidencefor significant secondary gain for having a symptom (i.e., low appar-ent motivation to respond). None of these factors impact response ineveryone and in every situation.

Does evidence for “only” weak-to-moderate associations betweenbiological, psychological, and social factors and response to hypnosismean that these factors should therefore be ignored? We do not believeso. Each of these factors has evidence supporting its importance in someindividuals. The experienced clinician, who wishes his or her clientsand patients to obtain the most benefit possible, will do everything rea-sonable to enhance outcomes. This can, and should we believe, include(a) facilitating a reasonable level of hope and outcome expectancies,(b) enhancing motivation for treatment outcome, (c) enhancing posi-tive rapport, and (d) creating a “hypnotic” environment for treatment.As more is learned about the role that biological factors play in hyp-notic responding, it might even be possible to prepare clients andpatients to respond more strongly to hypnosis treatment using strate-gies that enhance certain brain states (Batty, Bonnington, Tang, Hawken,& Gruzelier, 2006).

LimitationsPerhaps the most important limitation of this review is that it is

scoping and not a systematic review. As such, we based our search for

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articles to review mostly on the reference lists of primary review articlesas well as some key articles identified via a literature search using veryspecific—but limited—search terms. Thus, it is likely that some articlespresenting findings relevant to this review were missed. However, wedid not believe that a systematic review of the topics covered in thisarticle was feasible, both in terms of the resources that such a reviewwould require, as well as the number of pages that would be availablein an article to present the findings (of all published studies regardingthe associations between all biological, psychological, and social factorsever examined). Moreover, the results that did emerge from the reviewstill provide clear findings that have important theoretical and clinicalimplications. We would encourage future researchers to perform sys-tematic reviews on more focused domains or factors described here(e.g., a systematic review of the importance of outcome expectancies inhypnotic responding) to help confirm the general conclusions we madefrom the articles we identified and cited.

Relatedly, because we only reviewed studies involving those factorsthat have been studied most often in the research literature, we did notreport on or discuss findings regarding a number of factors for whichthere are positive preliminary findings and for which may ultimatelyprove to be as or even more important than the factors identified here.For example, researchers are beginning to examine additional biologicalfactors associated with hypnosis such as changes in peripheral hor-mone levels (Bryant, Hung, Guastella, & Mitchell, 2012; Varga & Kekecs,2014), heart rate and heart rate variability (Santarcangelo et al., 2012;Santarcangelo, Varanini, et al., 2013; Sebastiani, Simoni, Gemignani,Ghelarducci, & Santarcangelo, 2003; Yuksel, Ozcan, & Dane, 2013), res-piratory rate (Sebastiani et al., 2003), and blood pressure (Santarcangelo,Paoletti, et al., 2013). Doubtless, some of these factors as well as otherbiological, psychological, and social factors not examined here will beidentified as being associated with, and may ultimately be shown toinfluence, hypnotic responding.

Summary

Despite the limitations associated with this review, the findings sup-port a number of important conclusions that have both theoreticaland clinical relevance. First, the findings indicate that hypnosis andhypnotic responding are probably best explained by more compre-hensive models that take into account factors from biological, psycho-logical, and social domains. More restrictive models that focus onlyor primarily on a single factor or subset of factors, while useful forincreasing our understanding the role of these factors may play, areunlikely to be adequate for providing a thorough understanding of thedomain of hypnosis. Second, the findings provide preliminary evidence

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regarding the variables that remain viable as factors that might facil-itate hypnotic responding; that is, structural connectivity, hemisphereasymmetry, higher levels of theta bandwidth activity, expectancies, traithypnotizability, motivation, absorptive capacity, rapport, and context.A greater focus on examining the causal (versus only correlational)role that these factors may play in hypnotic responding is warranted.Third, the findings point to the need for additional research to betterunderstand how the factors discussed both mediate (explain) and worktogether (interact) to predict hypnotic responding. Finally, clinicians canuse the findings from this review to help identify targets for potentiallyenhancing response to hypnotic treatment. Our hope is that the find-ings reported in this review encourage theoreticians and clinicians to“think outside of” our preferred theoretical boxes and to consider howwe might expand our views and models, so as to better understandhypnosis and ultimately improve its beneficial effects.

Acknowledgments

Mark P. Jensen is the author of two books related to the topic ofthis article (Hypnosis for Chronic Pain Management: Therapist Guide andHypnosis for Chronic Pain Management: Workbook). He receives royaltiesfor the sale of these books.

Funding

This research was supported by National Institutes of Health,National Institute of Child Health and Human Development, NationalCenter for Medical Rehabilitation Research grant R01 HDD070973. Theviews presented here are not necessarily those of the National Institutesof Health.

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Mechanismen der Hypnose : Zur Entwicklung einesbiopsychologischen Modells

Mark P. Jensen, Tomonori Adachi, Catarina Tomé-Pires, Jikwan Lee,Zubaidah Jamil Osman und Jordi Miró

Abstrakt: Beweise unterstützen die Effizienz von Behandlungen mitHypnose, doch bleiben viele unbeantwortete Fragen hinsichtlich dessen,wie Hypnose die positiven Effekte hervorruft. Die meisten theoretischenModelle fokussieren mehr oder weniger die biologischen, psychologischenund sozialen Faktoren. Dieses Scoping-Verfahren fasst die empirischenErgebnisse bezüglich der Zusammenhänge zwischen spezifischen Faktorenin jeder dieser Gebiete und die Antwort auf Hypnose zusammen. DieErgebnisse zeigen, daß (1) kein Einzelfaktor zuerst auftaucht, (2) unter-schiedliche Faktoren mehr oder weniger an Resultaten bei verschiedenenTeilmengen von Individuen oder verschiedenen Bedingungen beitragen und(3) umfassende Modelle von Hypnose, die Faktoren aller drei Gebiete zusam-men zeigen, brauchbarer sind als restriktivere Modelle, die nur einen odereinige wenige Faktoren betrachten.

Stephanie Reigel, MD

Mécanismes de l’hypnose : Vers l’élaboration d’un modèle biopsychosocial

Mark P. Jensen, Tomonori Adachi, Catarina Tomé-Pires, Jikwan Lee,Zubaidah Jamil Osman et Jordi Miró

Résumé: Des faits probants appuient l’efficacité des traitements hypno-tiques, mais on ignore toujours comment l’hypnose produit ses effets béné-fiques. La plupart des modèles théoriques sont plus ou moins axés sur desfacteurs biologiques, psychologiques et sociaux. Cette étude de l’influencede ceux-ci résume les constatations empiriques relatives aux liens entre desfacteurs particuliers dans chacun de ces domaines et la réaction à l’hypnose.

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http://dx.doi.org/10.1080/00207140802463690

http://dx.doi.org/10.1053/eujp.1998.0093

http://dx.doi.org/10.1080/00207144.2013.753826


Ces constatations sont les suivantes : 1) aucun facteur isolé ne semble pri-mordial; 2) différents facteurs peuvent contribuer plus ou moins aux résultatsobtenus chez différents sous-groupes de personnes ou dans des circonstancesdifférentes; et 3) des modèles exhaustifs d’hypnose incorporant des facteursassociés à ces trois domaines peuvent s’avérer plus utiles que des modèlesplus restrictifs axés sur un seul facteur ou sur quelques-uns d’entre euxseulement.

Johanne ReynaultC. Tr. (STIBC)

Mecanismos de la hipnosis: Hacia el desarrollo de un modelo biopsicosocial

Mark P. Jensen, Tomonori Adachi, Catarina Tomé-Pires, Jikwan Lee,Zubaidah Jamil Osman, y Jordi Miró

Resumen: La evidencia sustenta la eficacia de los tratamientos hipnóticos,pero siguen existiendo muchas preguntas sin resolver sobre la forma en quela hipnosis produce sus efectos benéficos. La mayoría de los modelos teóricosse enfocan en mayor o menor medida en factores biológicos, psicológicos ysociales. Esta revisión de la literatura resume los hallazgos empíricos sobrelas asociaciones entre los factores específicos de cada uno de estos dominiosy la respuesta a la hipnosis. Los resultados indican que: (1) no hay un solofactor que aparezca como primario; (2) distintos factores podrían contribuiren mayor o menor medida a los resultados en distintos grupos de individuoso en distintas condiciones; y (3) modelos comprehensivos de hipnosis queincorporen factores de los 3 dominios podrían probar ser más útiles que losmodelos más restrictivos que se enfocan en 1 o en muy pocos factores.

Omar Sánchez-Armáss Cappello, PhDAutonomous University of San Luis Potosi,Mexico

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MECHANISMS OF HYPNOSIS: Toward the Development of a ...nvvh.com/wp-content/uploads/2015/08/IJCEH-63-1-03.pdf · in self-hypnosis should be considered a “ﬁrst-line” treatment