The Challenge to Psychoanalysis and Psychotherapy

Light Hypnotic Trance in Psychoanalytic Psychotherapy, Part 1

Transference Aspects

My purpose is essentially clinical and practical. I wish to show—albeit in a summary way, due to the limits imposed by a single chapter—the usefulness of an hypnosis enriched by the contributions of psychoanalysis.

My intention is neither the attempt to deal with the complex relationship between psychoanalysis, transference and hypnosis nor to elucidate the healing factor in psychotherapy, the element of truth or affective bond and suggestion. I am not dealing with the issue of whether there is ‘rupture’ or ‘continuity’ between hypnosis and psychoanalysis, if the transference is the heir of the hypnotic relationship or whether any therapeutic amelioration is no more than the effect of suggestion (though these problems are undoubtedly of interest).

Among the psychoanalytic contributions which have enlarged our understanding and usage of hypnosis we should mention—besides the expanded concept of the transference—the theories of the ‘English School of Object Relation’, the concept of ‘Symbiosis and Individuation’ (Mahler 1968; Mahler, Pine and Bergman 1975; McDevitt, and Settlage 1971), the observation of psychic structure and, finally, Genetic Psychoanalysis.

The realization of limitation in the efficacy of psychoanalytic treatment may have provoked a resurgence of interest in hypnosis.

The result of the ‘widening scope’ of psychoanalysis and its application to more severe psychopathology, so-called narcissistic pathologies, has permitted the recognition of specific forms of transference which do not fit the classical definition (Palaci 1978).

The observation of narcissistic transference phenomena which made possible the analysis of patients until then unanalyzable, raises again the question of what is transference and what is to be considered psychoanalytic. Controversy divides the psychoanalysts between those who want to extend the psychoanalytic method to more severe psychopathology, implying structural ‘deficit’, and those who wish to restrict the method uniquely to neurotic conditions. The latter fear that the broadening of its scope would undermine the concept of the unconscious and of psychic structure formation the very foundation of psychoanalysis.

My concern is with the distinction between hypnotic therapy before analysis, based on catharsis (abreaction) and direct suggestion and psychoanalytic hypnosis. In hypnoanalysis, hypnosis is to be considered as a method of exploration of the unconscious differing from free association, while utilizing the latter under particular conditions.

‘Free association’, beyond its character as a specific mode of communication, implies a partial renunciation of a speech defined by the presence of the ‘other’, a voluntary regression which finds its origin in renouncing the conscious control, which takes place in the hypnotic state—a primitive ancestor offree association. Similar to free association, its purpose is to reactivate primary process mental functioning. This provokes a form of splitting of the subject as well as favoring a primitive object relation, a kind of symbiotic, merging relationship engendering early recollection with a mobilization of primitive affect—all these in the context of various forms of transference.

In what way does hypnosis as a method of exploration offer certain advantages or negatives which permit one to situate it as a particular technique of psychotherapy? From a practical standpoint the question is not, if any, therapeutic improvement. Any change is nothing else than the effect of suggestion. But, rather, does the hypnotic trance permit an earlier remembrance? Does it mobilize more infantile processes and behavior? Does the intense regression of the object relation under hypnosis, with its increased suggestibility, favor change, reorganization and integration?

The clinical observation of the hypnotic state has shown that, under hypnosis, a variety of modifications take place: the conscious awareness of the experiencing of one’s body, of intensified affective manifestations, of motility, of the nature of one’s thoughts from secondary to primary. Under hypnosis the subject has greater access to his unconscious conflicts. The unconscious meaning of the hypnotic experience enables us to identify the influence of various transferential phenomena different from the classic transference. It allows us to recognize the fact that the ego under hypnosis oscillates between an ‘archaic ego’, between primitive forms of psychic functioning and the maintaining of normal ego functions—that is, of perception, of memory, of reality testing, etc.

Hypnosis is an induced structural regression born of a regressive, archaic relationship between two persons. From the point of view of the object relation it is a reactivation of an early phase of its development. Communication can take place on a preverbal, presymbolic level through the body and the affect. We can observe a psychophysiologic transformation and a modification of the state of consciousness where the differentiation between the subject and the object, between the psyche and the soma, tends to disappear.

We can hypothesize a fundamental aptitude of the human individual to various mode of relationships, of rapport to the ‘other’, implying different processes of identification and degrees of regression, reactivation and repetition of aspects of early, primary relationships.

The subject allows himself to be invaded by the ‘other’, by another identity. There is a kind of psychic merging, which might explain the phenomenon of suggestion and the tendency to a primary process of psychic functioning closer to the unconscious pole. Based on experimentation, certain authors have contested the authenticity of early recollection under hypnosis. It seems to me that this earlier form of remembrance is no less valid than the reconstruction of the past history of the patient, both being subject to the influence of the transference and other.

One may wonder where lies the interest, at a time when analysis has the tendency to renounce the exploration of the past, as such, in order to concentrate increasingly on the transferential interaction (Gill 1982), to introduce a parameter constituted by hypnosis, the purpose of which is to produce memories. However, hypnosis, whose functions I have enumerated above, does not limit itself to recollection. It reactivates primary process, infantile behavior and repressed early conflicts.

Freud has pointed to the dream as the ‘royal road to the unconscious’. Hypnosis might be another road to the study of unconscious mechanisms through its manifestation of unconscious wishes, fantasies and anxieties by means of the trance.

Hypnoanalysis and psychoanalysis are two distinct modes of psychological treatment, even if their boundaries often fuse. Hypnoanalysis is a specific form of psychotherapy hardly replaceable in the treatment of certain psychic troubles—such as amnesia, hysteric paralysis, traumatic neurosis—but is also a specific variety of psychotherapy. Hypnosis involves the introduction of hypnotic sessions in a psychoanalytic-oriented psychotherapy at key moments in the treatment. The working through of the material produced will chiefly take place outside the trance. It generally requires light or medium-intense trances which allow the subject to remember the evoked material. In any case, this is fortunate inasmuch as few individuals are sufficiently receptive to deeper somnambulic states. Hypnoanalysis utilizes special techniques—that is, free association, dreams, regression, observation of conflicts, resistances and defenses, suggestions to alleviate symptoms, the intensification of the transference.

Psychoanalysis entails a much stricter neutrality on the part of the practitioner than hypnoanalysis, which demands a more interventionist approach from the therapist—an attitude totally unacceptable from the psychoanalytic viewpoint. The hypnotic relationship has an erotic connotation, often a source of anxiety. Its repercussions on the transference are incontestable and its handling in hypnoanalysis particularly delicate. Hypnoanalysis relies more than psychoanalysis on the senses and on the play of the imagination. One has to distinguish between hypnotherapy in general—a vaster field with varied procedures which make greater demand on the sensitivity, the imagination and the creativity of the hypnotist—and hypnoanalysis—a new emerging field endowed with a more precise theory and technique conforming, to a great extent, to analytic procedures. Yet there exist marked differences and incompatibilities, principally due to the transference—the fundamental element of any therapeutic endeavor.

The first observation of the relation between the hypnotic induction and the transference we owe to Ferenczi (1909), who distinguishes between a ‘motherly’ hypnosis—where the force propelling the subject towards the hypnotic state is ‘love’ and a ‘fatherly’ hypnosis where the activating force is ‘fear’. Ferenczi attributes the efficacy of the hypnotic treatment to the persistence of these unconscious transferences in the patient. Freud had already alluded to this aspect of hypnosis ‘to the purity of libidinal attitudes’, to the existence of ‘a state of love, without sexual tendencies’ (Freud 1921). Today, we would say that this desexualized state is nothing else than an aspect of

Two other authors of the period were already preoccupied with the application of
psychoanalysis to hypnosis: Paul Schilder (1921) in a monograph and, later, in collaboration with Otto Kauders (1926) in a manual on hypnosis in which they examine the biological and physiological basis of the phenomenon. They attempt to combine clinical psychoanalysis and hypnosis while acknowledging the differences. Theirs is a remarkably lucid study for its time, in comparison to which most subsequent studies pale—a notable exception being the writings of Gill and Brenman (1959), which examine the hypnotic relation in the light of ‘Ego Psychology’.

Despite innumerable studies published on the concept, the transference poses multiple questions and presents an ambiguity in its definition:

  • are we dealing with a universal phenomenon of the human mind or one induced by psychotherapy?
  • of a unique unified process or a variety of phenomena? (Thus we speak of a spontaneous transference, of a transference neurosis, of the character ,transference of the borderline, of narcissistic transferences and of the transference psychosis)
  • what distinguishes these different forms of transference?
  • should transference be considered an intrapsychic phenomenon or as it is experienced in the context of a relationship? Does it have an interpersonal meaning? Should experiences outside the intrapsychic domain be included?
  • should the transference be seen as a deformation—a product of wishes and defenses—emerging from the patient and projected on the image of the therapist, requiring rectification; or should it be considered as a perception produced by the personality of the therapist and his interventions, as it affects the psychic experience of the patient (a distortion of the present or a new version of the past)?
  • is the transference resolved by maturity or are we dealing with a continuous process which will influence development through life? Is it essentially an aspect of neurosis of psychic illness, a sign of immaturity or regression, or is it an aspect of any experience of life?
  • is the transference part or the totality of the experience of the patient in the therapeutic situation, or has it to be differentiated from the relation to reality? Does a reality exist which does not include any transference?
  • how do we conceive of the different varieties of transferences other than oedipal-pre oedipal transferences, primary or basic, narcissistic transferences (of the self-object type), where the therapist is experienced as undifferentiated from the self? Have these varieties the same conceptual meaning as the classic transference, where the subject is experienced as distinct from the object?
  • is it pertinent to talk of transference and of countertransference or are we dealing with a dialectic unity, a consistent feedback provoking a continuous movement in the relationship with evolution and danger of rupture, technically referring to the concept of vicarious- empathic-introspection? (Kohut 1959, 1971,1977)

The transference and countertransference hold a different meaning for each therapist and determine his usage of it. His personality being the fundamental instrument in any treatment, the particular remnants of his neurosis and, sometimes, original, psychosis after his personal therapy will affect his objectal and narcissistic vulnerabilities. These basic fragilities will influence his capacity to receive, facilitate, differentiate, interpret and resolve the transference. On this capacity depends the efficacy of any therapeutic process and the utilization of modern hypnosis (Palaci 1978).

The theoretical considerations which I have just outlined are the more valid as observed during hypnosis where different phenomena of transference come into play and where, in the countertransference, early narcissistic configurations of omnipotence, grandiosity, merging and fragmentation are mobilized. In the past, when hypnosis was solely utilized for the purpose of suggestion, the hypnotist would make use of this narcissistic unconscious transference to invest himself with a mystical and sub-natural aura (still used by stage hypnotists). It is important to realize that the status of the hypnotist in itself mobilizes all kinds of early narcissistic elements.

What distinguishes the psychoanalytic method from all others is the interpretation in depth of the transference. In order to combine, for therapeutic purposes, psychoanalysis and hypnosis, one must focus on the way hypnosis affects the transference and on the nature of the transference during a modified state of consciousness.

In addition to the classic transference, hypnosis reactivates specific transferences which are not compatible with its current definition—the significance of the latter has become manifest only in recent years in treating patients suffering from more severe pathology. Such patients were heretofore considered unanalyzable, unable to develop a classic transference. Recently, we have become aware that these patients present forms of transference widely different from those we encounter in the course of the treatment of neurosis. The former are characterized by a vulnerability, a particular fragility of the self, an extreme sensibility to failures and deceptions. The analysis of their psychic conflicts do not improve their condition. In the psychoanalytic situation they manifest more or less openly their narcissistic needs, which impel them to utilize the object in certain ways. They demand that the analyst take over functions which they are not able to assume for themselves—functions destined to secure existence, continuity, self-esteem. In other words, a personal identity. These symptoms demonstrate the lack of psychic
autonomy—evidence of a faulty psychological individuation. Frequent ruptures in the therapeutic process seem to indicate that they originate from empathic failures of the environment or experiences perceived as such. Similar occurrences can take place during hypnosis, where we observe an experimentally-induced massive regression of the object relation.

The fundamental objection that hypnosis alters the transference is, no doubt, justified when we refer to a classic psychoanalytic treatment where the meaning of the transference applies to its libidinal-oedipal-objectal aspect. The so-called narcissistic transference, however, is not a reactivation and a projection of early phases of psychosexual development of the oedipal object relation which applies to a successful separation between self and object. Rather, it is the result of a disturbed psychic preoedipal individuation process. The narcissistic transference represents an attempt by the subject to complete an interrupted development. Those patients in whom it occurs present a structural ‘deficit’ and require the introduction of technical parameters in the treatment situation.

The theory of narcissistic transference has greatly clarified the nature of the hypnotic relationship from which one might infer a reactivation of a preoedipal narcissistic object relation, of a partial destructuralization where the psychic boundaries between the subject and the object are being fused. Manifestly, this early phase of symbiotic merging, where one is to be taken in charge by the ‘other’ represents an attraction by gratifying an unconscious wish, but, at the same time, poses a danger to the subject of losing his identity, his autonomy. As such, it offers a powerful therapeutic potential requiring subtle handling and necessitating great rigor in its working through. The intense regression mobilizes transferential elements of a very archaic nature and the material which emerges during the trance is not always easy to integrate in the conscious layers.

It is important to note that the problem of transference is the more complex in hypnoanalysis, where the phenomena of transference during the induction and during the hypnotic state and in the course of the evolution of the treatment are not identical. We observe a succession and simultaneity of narcissistic and classic transferences: there is the one participating in the induction, the underlying transference sustaining the hypnotic state and the classic transference—that is, the libidinal-oedipal-object transference corresponding to the particular dynamic of the case which emerges and develops during treatment and between hypnotic sessions.

Technically, does the interpretation of the transference apply to the transference phenomenon during the hypnotic state? I have presented some aspects of the contributions of hypnosis to the therapeutic process as an instrument of exploration, permitting the interpretation and analysis of the cathartic material. I should add that hypnosis may act as a transferential envelope, a support to confrontation, clarification and interpretation. Speculatively, relying on psychoanalytic formulations, one might consider that hypnosis assumes the function of the therapist as a ‘container’ (Bion) or as a holding environment (Winnicott 1965, 1958). The hypnotist may be seen as the ‘container’ of the ‘hypnotic state’, which, in turn, contains the emotional experiences of the patient.

The complexity of the transference during hypnoanalytic treatment involves, in addition to the multiplicity of the transference phenomena, an aspect of ‘splitting’ (dissociation)—which becomes the more evident as the therapist makes the distinction between the hypnotic relationship and the total relationship as such. This is the point where the mode of induction and the transference connect. It is the ‘splitting’ which facilitates the experiencing of conflicts and defense mechanisms, of projection, introjection, incorporation, projective identification and of the narcissistic attitudes of omnipotence and idealization as well as devaluation. These manifestations can be most acutely observed during hypnotic transference reactions and it is the splitting which enables one to call them to the attention of the patient. The therapist interprets for him the difference between his subjective experience during hypnosis and that outside the trance as a transferential resistance, making him aware of the usage of the splitting as a defense against anxiety, shame and guilt. He attempts to show the patient that it is fear, fantasies and the defense mechanisms that prevent him from expressing outside hypnosis what he is able to experience so dramatically during the trance.

As the defensive and protective functions of hypnosis are progressively exposed, the thoughts and emotions can find their expression in ‘ordinary conscious living’. These processes occur simultaneously as the mediating function of the ego grows stronger, resulting in a more adequate mastery of primary processes. The patient will then experience a basic change in his interpersonal relationships with a diminishing of primitive (primary) defense mechanisms.

The impermeability of the barrier separating the emotions and thoughts the patient experiences under hypnosis from those outside the trance is the measure of the ‘splitting’. In the earlier stages of the treatment the subjective experience under hypnosis is radically different from the one outside the hypnotic state, often, for example, a love-hate, good-bad opposition. Towards the end of the treatment a greater continuity evolves between the two aspects of the experience and the patient is able, through free association, to explore parts of himself as readily outside the hypnotic state as within it. Love does not change that suddenly into hate. There is a progressive integration of the ‘good’ and the ‘bad’ within the same object (Kernberg 1984, 1976, 1975). A feeling of unity, stability and emotional freedom develops.

The process of interpretation is long and difficult. If, for example, one adopts the Kleinian position, it consists in the working through of the ‘schizoparanoid position’ with its menace of envy, access of rage, projection of hate, hopelessness, feeling of isolation and rejection. This, in turn, implies the relinquishment of sadistic and omnipotent control on which the child relies to overcome his sufferings and handicaps. Time must be given to the process of mourning, which wiII allow the patient to renounce ‘maniac reparation’ and forced control of the object in order to attain true healing rooted in love.

In summary, everything which is experienced during hypnosis but which cannot be observed in the relation outside hypnosis is considered as transference. The exposing of the transference resistance helps to free the patient of his unconscious conflicts ,allowing the expression of sentiments which before could only be felt under the trance. Hypnosis can, therefore, bring the susceptible patient to work through in vivo the fantasies and mechanisms by which he has actively prevented his vital and creative resources from breaking through (Brown and Fromm 1986; Fass and Brown 1990).

A primary characteristic of the hypnotic state is that it originates entirely in the psyche of the subject, who willingly submits himself to the hypnotist only to partake in the magic he endows him with. One can draw a parallel to the period of development where the child recognizes the limits of his own omnipotence and displaces them on his parents with whom he identifies in order to participate in their power. The gratification of the wish for omnipotence is only possible thanks to an unconscious manipulation involving projection and internalization. The hypnotic induction provokes a reactivation of this phase and the hypnotist functions as a trigger to the trance and thereafter refrains from disturbing this state. However, the regression is partial and affects only a part of the personality, the other maintaining a normal relationship with the external world, with reality. We are confronted with a split of the ego.

Without going into detail, let me remind you that the ‘narcissistic object choice’, the narcissistic relationship, consists of a specific transferential configuration of idealization (the grandiose self and the idealized parental imago, omnipotence and power), of merging, of alter-ego and, on the insistence that regulatory systems of the ego that one is not able to assume for oneself, being taken charge of by the other.

In hypnoanalysis we assist at a modification of the use of hypnosis, of its manipulative and suggestive utilization of the past. The therapist maintains so far as possible a neutral listening and vicarious-empathic-introspective stance—a fundamental task in any psychoanalytic psychotherapy. Any form of direct suggestion is essentially avoided (save for certain parameters such as, What are you seeing? Feeling? Where do you find yourself?), hypnosis being reduced to an exploratory instrument through the alteration of the state of consciousness.

The narcissistic transferential reactions (always excepting those which result from a severe narcissistic pathology or of borderline) are due, as we have seen, to the nature of the induction and to the massive regression of the object relation provoked by the hypnotic state. These transferences are evidenced by a process of projection (classic transference) and displacement (narcissistic). If negative, they will make the subject less receptive to the hypnotic state.

Interpretation will focus essentially on the transference developing dynamically (as in analysis) as the treatment proceeds, within, as well as outside, the trance. One does not interpret the transference associated with the induction which maintains the trance state. Towards the end of the hypnoanalytic treatment the hypnotic sessions are being progressively diminished, the focus is on the working through—as in any psychoanalytic psychotherapy.