Hypnoanalytic insight

Hypnoanalytic Insight Therapy Rigorously controlled studies show hypnosis is not only an eff ective adjunctive intervention but also superior to a number of widely employed treatment procedures when applied directly to infl uence symptoms as reviewed in Barabasz and Watkins (2005) (also revealed by Lynn, Kirsch, A. Barabasz, Cardeña, & Patterson, 2000). Perhaps it is because of this demonstrated effi cacy, combined with cost-effi ciency in the face of soaring medical costs (Lang & Rosen, 2002), that its potential for even greater contributions to the sophisticated reconstructive therapies involving insight has not been fully appreciated. Despite there being many variations of psychoanalysis, all are based on the assumption that neurotic symptoms are the external manifestations of underlying confl icts and lift ing the repression of unconscious factors and achieving “insight,” will resolve the symptoms. Indeed, the classical psychoanalyst would likely hold that this is true of all neurotic symptoms and that unless insight has been achieved into the underlying dynamic structure of a specifi c neurosis, no permanent cure can be expected. In the face of now hundreds of studies to the contrary (reviewed by J. G. Watkins, 1992a), this extreme position is no longer tenable. As discussed in Barabasz and Watkins (2005), many symptomatic conditions respond favorably and permanently to direct hypnotic interventions. Hypnosis has enormous facilitative eff ects when used in conjunction with standard therapies. For example, two meta-analyses (Kirsch, Montgomery, & Sapirstein, 1995; Kirsch, 1996) showed that the addition of hypnosis substantially enhanced treatment outcomes, so that the average client receiving cognitive-behavioral hypnotherapy showed greater improvement than at least 70% of the clients receiving nonhypnotic treatment. However, there are oft en neurotic symptoms that do not seem to be permanently relinquished unless unconscious confl icts, at their root, are brought into conscious awareness and reintegrated through that kind of understanding called insight. Th erapies that aim at such insight, whether they are person-centered, cognitive, cognitive-behavioral, psychoanalytic, or any of numerous brief psychoanalytic approaches, can oft en produce lasting results with the addition of hypnotherapeutic interventions. Intellectual and Experiential Insight What is intended by the term insight? Much that appears to pass for insight in therapeutic interventions turns out to be nothing more than intellectualizations 6 • Advanced Hypnotherapy: Hypnodynamic Techniques or intellectual understandings limited to only the cognitive (surface-deep) sphere of personality. Th us, reconstructive alteration of the personality is not possible with such superfi cial approaches. Even a number of analytic therapies go on month aft er month without showing signifi cant change, despite the fact that the patient has learned to verbalize the dynamic constellation that underpins his or her neurosis. Th e point is that the patient has achieved nothing more than superfi cial insight, which has failed to adequately pervade the entire personality. Such examples fuel the arguments against the use of psychoanalytic therapy by those who are insuffi ciently educated or experienced to appreciate the issue at hand. Th ese situations are responsible for the time-honored joke that “aft er 7 years of analysis the patient still bangs his head on the fl oor, but now he knows why.” Our goal here is pervasive reconstructive change rather than mere superfi cial self-understanding. Many years ago, J.G.W. interpreted to a depressed patient that he unconsciously hated his father. Th e evidence from his associations and dreams was quite clear on this point, so unmistakable that he immediately agreed: “You’re absolutely right, Dr. Watkins. I am depressed because I hate my father. It’s really clear now.” However, no change in his symptoms occurred until several weeks later, when the patient burst into the offi ce. He stood, wild-eyed and with a horror-struck expression, shouting, “I really do hate my father.” Th at was genuine insight, not his fi rst agreement with the interpretation. His initial understanding had only been at the cognitive intellectual level. Nonetheless, it had managed during the ensuing weeks to work its way through to an emotional level, which at long last mobilized feelings as well. A signifi cant reorganization of his entire perceptual network was the result. Finally, the patient really understood. His depression began to clear. He had achieved true insight, and the symptoms never returned. Reorganization of the patient’s understanding is more than verbal or cognitive. Insight as we use it here means a thorough-going understanding including an essential alteration at the emotional level, the perceptual level, the motor level, and even the tissue level. It is a “gut” comprehension that, to be successful, must pervade the patient’s entire being in all of these areas: physiological, psychological, and social. It is an alteration in meaning that changes the entire Gestalt of his or her personality. As such, it resolves inner confl icts and thus achieves a permanent impact on the dynamic factors that have maintained the symptoms. Using this defi nition, insight is a signifi cant and profound experience that genuinely infl uences the entire lifestyle of the patient. Th ere oft en remains a presumption that insight is ineff ective. Th is is based on the erroneous, yet pervasive, defi nition of it as simply an intellectual understanding. Th e techniques described in this treatise for achieving insight are intended to teach you how to achieve this greater and more comprehensive objective even though a superfi cial cognitive understanding is at fi rst attained. Th e Hypnoanalytic Insight Th erapy • 7 point should always be borne in mind that therapy has not achieved much if you stop at that level. It can, but it is best viewed as a precursor to more permanent changes of feelings and behavior. Criticisms of Hypnosis by Psychoanalysts Psychoanalysts have frequently criticized hypnosis because they misconstrue it or assign it to the role of nothing more than symptom suppression through direct suggestion. Anna Freud asserted that, even if some insight may have been achieved, this understanding is “bypassed by the ego” and hence cannot be reintegrative (1946). Th is criticism has been repeated and believed by numerous analysts ever since. Somehow, it is assumed that when one is hypnotized, the ego is laid aside, that it is not involved in the uncovering process, and that, accordingly, such material as does emerge cannot be absorbed or utilized by the patient for genuine change. Th e notion is that loss or reduction of symptoms must, thereby, be temporary because no change, or at best only a superfi cial one, has been made in the basic personality. Th erefore, the neurotic confl icts are assumed to reassert themselves, and the symptoms will then return as soon as the infl uence of the hypnotherapist is no longer present. Th is position, though unsupported by clinical or empirical fi ndings, has been positively and repeatedly stated in G. Blanck and R. Blanck’s (1974) frequently cited volume on ego psychology. Hypnotic Depth It would seem obvious to all but the most casual observer that adequate hypnotic depth should be produced before expecting a hypnotizable participant to complete a task diffi cult enough to elicit pain control for major surgeries (see A. Barabasz & M. Barabasz, 1992). Nonetheless, achieving great depth does not necessarily require a lengthy procedure. Very brief inductions as well as spontaneous trances can oft en produce deep hypnosis. One of many interesting examples appeared in a study involving stringent selection of high and low hypnotizable subjects in an experimentally controlled investigation of the eff ects of alert hypnosis versus the identical suggestion only on EEG event-related potentials (ERPs) (A. Barabasz, 2000). Consistent with numerous studies of hypnosis and ERPs, the data showed that only the hypnotic induction with eff orts to insure adequate depth made it possible for high (but not low) hypnotizable individuals to signifi cantly alter their brain activity in response to a hypnotic induction plus a suggestion, in contrast to the identical suggestion without the induction of hypnosis. Th is fi nding added further disproof to the sociocognitive notion that suggestion alone can account for all that can be wrought with hypnosis. Interestingly, and perhaps of the greatest clinical signifi cance to the fi ndings, was that one highly hypnotizable participant produced almost identical responses in both conditions. He altered his event-related potential brain 8 • Advanced Hypnotherapy: Hypnodynamic Techniques activity, in both the suggestion-only and the hypnotic-induction-plus-suggestion conditions. Simplistically, this would appear to be a statistically nonsignifi cant exception to the overwhelming fi ndings of the study, but nonetheless it was an exception supporting the sociocognitive position. However, the postexperiment independent inquiry conducted by researchers not otherwise engaged in the investigation revealed the participant’s strategy. Th is subject stated, “When I got the instruction to make like there were earplugs in my ears, I just did what I learned to do when I was a kid.” “Tell me more,” replied the inquirer. “Well, when I got spanked by my dad, I could turn off the pain just like going to another place, so that’s what I did with the suggestion, same as the hypnosis part.” As discussed in Barabasz and Watkins (2005, p. 85) this could be a classic example of spontaneous hypnosis with apparent dissociation. Alternatively, the suggestion alone constituted the hypnotic induction (Nash, 2005), and the highly hypnotizable subject merely responded with a level of depth suffi cient to alter his ERPs. We recommend that hypnotherapists should always be on the lookout for such behaviors. It is also of importance to understand that a nonhypnotizable participant may provide a greater number of simplistic or easy motor responses to a hypnotic induction aft er exposure to a hypnotic induction calling for increased depth. In such cases, because the subject is incapable of true hypnotic responding, the evocations for greater depth by the hypnotist provide nothing more than social infl uence demands for performance on the requested items. Clearly, social infl uences can produce alterations in a participant’s behaviors and production of simple voluntary responses when the subject has little or no hypnotic capacity. Let us consider the issue of hypnotic depth or trance depth from a diff erent light. Consider hypnotic depth to be a continuum extending from total alert awareness, through hypnoidal relaxation (such as occurs on the analyst’s couch), into intermediate states, then to deep (somnambulistic) regions of consciousness (where hypnoanalytic therapy has generally been practiced). Th e deeply hypnotized individual may achieve what Erickson (1968) termed a “plenary” trance, perhaps something similar to coma. Hypnosis can then be viewed as a dimension of personality, and the question becomes: “Does the most eff ective therapy occur when the patient is sitting up, wide awake, relaxed, slightly hypnoidal, and reclining on the couch, in an intermediate hypnotic depth or trance state, or only within a profound level of hypnosis?” Furthermore, is the therapy best conducted in one area on this continuum or should there be movement from one dimension to another, fi rst uncovering repressed material on the deep end of the spectrum, and then bringing it back to the more conscious position for ego integration? From this point of view, hypnoanalytic therapy and psychoanalytic therapy can be perceived as similar uncovering and integrating approaches that owe Hypnoanalytic Insight Th erapy • 9 their diff erence primarily to the position on the hypnotic depth dimension in which they are commonly practiced. Hypnoanalysis is capable of using the traditional analytic techniques of free association, dream interpretation, and especially analysis of transference, but does so at diff erent points on this depth-of-conscious dimension. Hypnoanalysts have developed a number of new methods and sophisticated procedures for revealing preconscious and unconscious material, isolating and activating defenses, eliciting dynamic patterns of impulse, bypassing or working through resistances, dealing with transferences, and achieving integrative insight. Th erefore, it would seem that practitioners of hypnotherapeutic insight therapy, as well as hypnoanalysis, can employ the same therapeutic techniques as do the more traditional analysts. However, they have in addition another dimension of impact and a number of unique therapy streamlining procedures that can be used to achieve the same result in less time than traditional approaches. Let us compare this to the military commander who follows the same basic war strategies that have been eff ective over the years, but who now has available a number of newer weapons, recently developed technologies, and advanced tactics for the achievement of battle objectives. Th e commander need no longer fi ght engagements with troops armed only with rifl es. Similarly, it is our position that, although much of basic analytic theory (including the developments of the last century in ego psychology and object relations) continues to be valid, psychoanalytic treatment tactics that were developed nearly a hundred years ago can be much improved with the advanced techniques available through hypnoanalysis. It is time that classic psychoanalysts adopt more fl exible procedures, including the hypnotic modality. Th e relationship between depth of hypnosis and ego participation is shown in Barabasz and Watkins (2005, p. 188, fi gure 7.1). In psychoanalysis, the patient is induced to relax on the couch and become preoccupied with inner associations. His or her fi eld of external participation is restricted and attention is focused on inner thoughts. Th is process is time-consuming. But it is precisely what happens when we induce a hypnotic state. Th e patient can achieve rapid relaxation, the patient’s external awareness becomes focused and restricted within his or her own control, and the patient is induced to experience a world consisting only of the therapist and him- or herself. It is when the narrowing of the fi eld of attention (H. Spiegel & D. Spiegel, 2004) is focused on inner processes that we can begin to make progress toward restructuring of the personality. Th e majority of a psychoanalyst’s patients, upon achieving relaxation on the couch, may well develop a hypnoidal or light hypnotic state. Th erefore, psychoanalysis in most cases probably involves, at least, light hypnosis, but it is uncontrolled. Th e patient is merely left to develop spontaneously whatever state of consciousness he or she may wish to develop, or a level precipitated by 10 • Advanced Hypnotherapy: Hypnodynamic Techniques the currently salient defense mechanisms, which further delay or complicate the development of true insight regardless of their accuracy. Had the instruction to lie on the couch, relax, and occupy concentration with inner associations been continued further, we would have termed it a hypnotic induction technique, and many patients would have drift ed into a medium or even a deep trance. As noted at the beginning of this subsection, some patients develop a deep level of hypnosis upon initiation of the initial suggestion. Th e diff erence in hypnoanalysis is that the therapist is keenly aware of the process taking place and uses it to the patient’s advantage. Th e psychoanalyst stops far short of this and simply leaves the patient with a signifi cant degree of ego alertness, but with some ego “relaxation,” which Freud (1953b) felt necessary to precipitate preconscious material and unconscious derivatives, making it possible for them to seep through to conscious awareness. In fi gure 2.1, the line on the left (e–g) shows the position of the patient in psychoanalysis where most of his or her ego (f–g) is alert and that only a small amount of behavior and experiential potentials stem from unconscious process (e–f). As one proceeds along the continuum of hypnotic depth from left to right, the participation of the ego becomes progressively less, and the emerging of unconscious material increases. In the deep hypnoanalytic position (h–j), there is minimal ego involvement (i–j) as more underlying unconscious and repressed material (h–i) is activated. However, the situation is not at all as it has been traditionally represented in the psychoanalytic literature, Figure 2.1 In the psychoanalytic position (e–g), a small amount of raw material (e–f) is activated and submitted to a fi nal processing (f–g). In the deep hypnoanalytic position (h–j), a small ego factory (i–j) must confront a huge amount of unconscious raw material (h–i). Hypnoanalytic Insight Th erapy • 11 in which the ego is presumed to have been bypassed by the use of hypnosis. Lessened, yes; eliminated? No. If we can agree that the fi rst part of the analytic process is to activate unconscious material and bring it into awareness, then it should be obvious that a much greater amount is accessed and secured in the hypnoanalytic position than in the psychoanalytic one. Th ese data might be compared to the raw material provided for fabrication into an article. Th e fi nished product is to be genuine insight, which is the basis upon which one can achieve signifi cant personality restructuring or change, but it must be fashioned into its fi nal form from the original raw material. Only aft er it is worked through in such a manner can it elicit a signifi cant adaptive personality change. True reintegration cannot take place without this. To answer the question as to which position on the hypnotic depth continuum shown in Figure 2.1 would be most eff ective to combine uncovering with reintegration, let us return to our analogy of the factory and the raw material. In the psychoanalytic position (e–g) in Figure 2.1, a small amount of raw material (e–f) is activated and submitted to a fi nal processing (f–g). In the deep hypnoanalytic position (h–j), a small ego factory (i–j) must confront a huge amount of unconscious raw material (h–i). On this theoretical basis, it would seem perfectly reasonable to infer that neither the psychoanalytic position nor the deep hypnoanalytic one could be the most productive area for therapeutic work, but rather somewhere in between may represent an optimal balance of these factors. Th e greatest likelihood of therapeutic progress would appear to lie in a psychoanalytic approach conducted within a medium or mid-level of hypnotic depth rather than a deep one. Almost 50 years ago, Conn (1959) emphasized the advantages of working in the mid-level to light states of hypnosis. An equally tenable position would be that we could elicit material during a deep hypnotic state and then bring it back for submission to a more vigorous ego, as represented by the left -hand area of the hypnotic-depth dimension. We opine that hypnoanalytic therapy then may best proceed when it consists of moving back and forth on this continuum. When employing the briefest of the powerful hypnoanalytic procedures, ego-state therapy, A.F.B. suggests that it is essential to ensure full egotization (ego integration) of memory material elicited during deep hypnosis. Abreaction must be brought to full conscious awareness in the context of a supportive soothing re-emergence from deep through light hypnosis. In both psychoanalytic therapy as well as hypnoanalysis, it would seem valuable to control the level of hypnotic depth and not merely leave it to chance. As discussed earlier, the defense mechanisms (or even momentary whims) of a patient may impel him or her to carry through the analysis at a comfortable and convenient intensity level, rather than one that he or she is capable of achieving. Such patients have histories of fl ight from therapeutic intervention 12 • Advanced Hypnotherapy: Hypnodynamic Techniques when the going becomes demanding rather than working to their potential and achieving self-actualizing results. By permitting the ego factory to work at a comfortable level when we submit only small amounts of raw material (such as may be elicited slowly by free association, if at all) to conscious awareness, integrating patients work far below their capabilities. Th e uncovering and integration of new material proceeds at a lazy and unsystematic pace. Th us, the analysis takes far longer than necessary. Now, if we uncover unconscious matter at an accelerated tempo, we supply our integrating ego with substantial quantities of raw material. Conscious or light hypnotic state patients will oft en be strongly resistant to this and will quickly muster the usual defensive postures, such as rationalization or fl ight from therapeutic interaction. Alternatively, hypnotized patients have the resources at hand to move in an accelerated manner, achieving remarkable therapeutic results. By controlling the variable of trance depth, we have the opportunity to provide suffi cient participation of our ego factory so as to maximize desired productivity, thus making possible the most rapid achievement of genuine reintegrating insight. Th e “working through” process, repeated by contact between the ego and previously unconscious material, is a key element in psychoanalysis. It is not dispensed with in hypnoanalytic treatment, but it may be speeded up. Repetition of material elicited while in hypnosis is still essential. Such repetition, especially of emotions, as well as cognitions, is particularly eff ective in the conduct of hypnotic abreactions (see Chapter 5 in the present volume). Hypnotic Depth at the Intermediate Level Material elicited and submitted for egotization in the intermediate level of hypnotic depth (Figure 2.1) can and frequently does stimulate considerable anxiety. Th e confrontation at this point is much more severe for the patient than using either the slow psychoanalytic free-association technique or the deep hypnoanalytic end of the continuum. For example, if the patient cursed his or her father (unconscious raw material) but he (ego) is not present, no actual confrontation takes place, and no therapeutic movement is possible. Th is would be represented by the extreme right-hand position in the fi gure discussed earlier. Th ere is no meeting of the incompatible elements. It is like trying to teach a completely unconscious person. Alternatively, if the father is present, but the patient does not express any negative thoughts about him (that is, they are thoroughly repressed), then again there is no confrontation and no therapeutic movement. Th is is like the position at the extreme left - hand side of the fi gure. Th e ego is completely present; hence, defense mechanisms are at the maximum, and the ego is, thereby, not in contact with any of the preconscious or unconscious impulses that drive their behaviors. Alternatively, if the patient utters an oath against his or her father while he is present in the room (as represented by the intermediate zone level of Hypnoanalytic Insight Th erapy • 13 hypnotic depth dimension), then the sparks will fl y. Th e confrontation takes place. If the contact continues, the unpleasant heat of the anxiety that is developed can be dissipated only by a change in the attitudes and acceptances of either or both of them. A new Gestalt of understanding and relationship must be forged. Th ey can no longer be in confl ict with each other or dissociated from one another. Genuine therapeutic change has thus been achieved. Th e process then is no diff erent in hypnoanalysis than in psychoanalysis, but a greater fl exibility of technique and ego participation has been available to facilitate this objective. Th e intermediate zones of hypnotic depth involve working through at a high intensity and, thereby, have some potential hazards. If more material is liberated from repression than the ego can assimilate, and if its defenses are incapable of warding off painful contact with such material, then they may be overwhelmed. Th is confl ict can precipitate a fl ight into a psychotic reaction. It is very rare and quite acute, but it can happen. However, in most cases the patient’s defenses arise and thus do not permit it to occur. In some way, the patient’s ego will break off contact with the undigestible material, which is now emerging in too great a strength. Sometimes, the patient may spontaneously emerge from hypnosis and seek the extreme left end of the hypnotic depth spectrum (light hypnosis or complete conscious awareness) or, in a very few cases, decathect his or her ego temporarily and enter a profound trance state. Th e state may be so profound that the patient may become deaf to your words. Such hypnotic deafness is not absolute. Th e laboratory-controlled and fully replicated experiential evidence (A. Barabasz, M. Barabasz, Jensen, Calvin, Trevisan, & Warner, 1999; A. Barabasz, 2000; Ray & De Pascalis, 2003) clearly reveals that EEG event-related potentials, as in the earlier studies (A. Barabasz & Lonsdale, 1983; D. Spiegel, Cutcomb, Ren, & Pribram, 1985) of reactions to verbal stimuli, are attenuated, not obliterated. Your voice is dissociated, but contact can be reestablished. Patients are taught in less deep levels of hypnosis that they will hear every word that the therapist is saying when the therapist touches their shoulder. It is, therefore, possible to re establish contact quickly. Rest assured that this reaction happens very infrequently, and you, as the analyst, can minimize any potentially catastrophic reactions by your normal caring attention to the therapeutic relationship. Perhaps the most important point is that the ego strength of the patient is never a constant. It is greater sometimes than others, whereas the demands of signifi cant daily relationships can lower it. If the patient maintains alliances with constructive others, particularly you as the therapist, ego strength can be reinforced. It is times like these when even somewhat pathological signifi cant others in the patient’s life can be especially destructive to the overall growth. Such destructiveness fuels the patient’s needs to maintain control over them. 14 • Advanced Hypnotherapy: Hypnodynamic Techniques Hypnotic Depth at the Optimal Level If you are practicing insight therapy at the intermediate level of hypnotic depth, it is essential that you off er an intensive therapeutic relationship, an alliance involving much “resonance” (J. G. Watkins & H. H. Watkins, 1978). Th is process involves a partial merging of the ego of the therapist with that of the patient, a temporary identifi cation balanced with appropriate objectivity. Th is is a partial merging of your ego with that of the patient, a temporary identifi cation with you. Patients are then reassured and can approach the analytic confrontations with a fuller mobilization of their resources because they perceive that they (in a “with-ness”) can succeed, where alone they could not. Th e analyst who guides his or her patient through the dark labyrinths of unconscious representations is like the good parent who takes the child by the hand and goes with him or her into the dark closet to confront the “Boogie Man.” Th e therapeutic “with-ness” is a temporary and partial merging of the patient’s and therapist’s egos. Th e intensity of the hypnotic relationship enhances such togetherness, as the therapist and the patient make a common commitment to the analytic task. Th is “with-ness” is not counter- transference, which is the projection of the therapist’s immature needs onto the patient (Frederick, 2005). Given various levels of hypnotic depth, we can reveal diff erent facets of impulse and defense during the analytic interview. Because hypnosis is also a form of regression, it can sometimes indicate the contents that may have to be merged during a more classical psychoanalysis session. As one proceeds into deeper and deeper levels of hypnotic involvement, the nature of defenses may be revealed that would only be uncovered at much later stages in classical psychoanalysis. Even if the therapeutic plan were to proceed in more traditional analytic ways, the prescouting value of an overview of the patient’s neurosis might aid the psychoanalyst in planning his or her strategy, and facilitate his or her timing of interpretations. Some analysts (Stekel, 1943c) asserted that the fi rst dream in analysis was like an overview of the entire structure of the patient’s neurosis, one whose full meaning would only become clear by the end of the analysis. Similarly, a hypno-diagnostic prestudy can frequently reveal the order in which the various transference reactions would have emerged had the patient freeassociated on the psychoanalytic couch. Some analysts may prefer not to use so much control. Th ere has been, even among the older analysts, substantial controversy as to how much the analyst should permit the material to emerge without directivity or to evolve according to a plan based on his or her conceptualization of personality structure (Reich, 1949). Working through and Hypermedia Hypermedia can facilitate the reconstruction of memory material, which is experiential and not always veridical. Th e fact that such reconstructed Hypnoanalytic Insight Th erapy • 15 material may or may not represent true happenings but rather remembrances or screen memories should be explained to your patient at the onset of therapy. Claire Frederick and Maggie Phillips (2004) recommended that a release form be signed by the patient and be kept on fi le. We think this is controversial, because signing a release form protects the therapist but it impairs the therapeutic relationship, because it implies that the therapist does not fully trust the patient. In hypnotic abreaction, strongly repressed aff ects can be mobilized so that a re-experiencing, not merely a remembering, takes place. Th e re- experiencing is critical, in our view, to therapeutic movement and reconstruction of the personality. Hypnotically facilitated release of such bound aff ects provides a fuller participation by the patient in genuine insight reactions. It thus becomes possible that newer and constructive meanings can initiate real and lasting therapeutic change. Abreaction and other specifi c hypnoanalytic techniques will be described in later chapters that explain how to initiate the lift ing of repressions, the activation of transferences, the release of bound aff ects, and the revivifi cation of early experiences. One tactic might be noted in comparison with classical psychoanalytic technique. During psychoanalysis, the state of consciousness equivalent to the light trance depth is held constant or at least is not directly manipulated by the analyst. Th e repressions are gradually lift ed, and the preconscious and unconscious material is submitted to the patient in gradually increasing doses. In hypnoanalysis, we lift a repression; release a great quantity of unconscious, unegotized material; and then manipulate the trance depth to submit this larger amount of now unrepressed material to increasing impact with the ego. Th ese are simply two diff erent ways of working through the end result of complete egotization, and reintegration may be the same, only the procedures for its accomplishment have varied. In conclusion, our goals and basic strategies in hypnoanalysis do not diff er greatly from those in traditional psychoanalysis. Th e underlying theoretical concepts are quite similar. However, their employment in conjunction with hypnosis off ers the possibility of greatly increased fl exibility through the alteration of hypnotic depth and the availability of a much wider variety of techniques. Summary Basic hypnotherapy, as discussed in Barabasz and Watkins (2005), involves primarily, although not exclusively, the amelioration of symptoms by direct hypnotic intervention via the establishment of the hypnotic state and the use of appropriate suggestions coupled in some cases with self-hypnotic techniques. Hypnotherapy at this level is a kind of “putting in.” Alternatively, and with much greater elegance, hypnoanalysis is a “pulling out.” Hypnoanalysis in practice involves the addition of the induction of hypnosis, plus the use of special 16 • Advanced Hypnotherapy: Hypnodynamic Techniques techniques that hypnosis makes possible. As in psychoanalysis, hypnoanalysis attempts to eliminate symptoms indirectly by the lift ing of repressions and the achieving of true insight. To be eff ective, insight must be more than intellectual; it must also be experiential, involving aff ective and motor responses as well as cognitive ones. Following Freud’s renunciation of hypnosis, psychoanalysts for years criticized the process as being “superfi cial,” “bypassing the ego,” and not resulting in permanent character/personality change. At one time, these criticisms may have been valid when the hypnotic state was induced solely to potentiate suggestions. Such arguments are no longer tenable. Trance depth is related to the amount of ego participation. In the deeper stages, much preconscious and unconscious material may be uncovered, but there is far less ability to “egotize” this. In the lighter stages of hypnosis, less material can be elicited but with greater ego participation. It appears that the most eff ective areas for treatment are in the medium zones of trance depth or the weaving back and forth between deeper and lighter states. A.F.B. maintains that the greatest and most rapid changes can oft en take place when material is reexperienced in a deep abreactive state, but that it is essential that this be brought through to the lighter and fully conscious states in the context of a Rogersian-like, supportive, postabreactive intervention. Just as in psychoanalysis, material lift ed from repressions with hypnoanalysis must be worked through to achieve lifelong therapeutic benefi ts. 17 3