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American Journal of Clinical Hypnosis Copyright 2006 by the American Society of Clinical Hypnosis
48:4, April 2006
Alert Hypnosis: A Review and Case Report
David M. Wark
University of Minnesota
Abstract
This review summarizes the use of hypnotic inductions while the subject is
physically active, open-eyed and focused on the external environment. Research
cited from several sources documents that traditional and alert inductions produce
similar hypnotic susceptibility scores, but after an alert induction, subjects may
report feeling more alert and in control. A case is reported of a client who was
able to use such an induction to stay in alert hypnosis for an extended time, and
reduce the long-standing anxiety effects of past failure. Finally, a systematic way
is discussed to generate inductions that may expand the use of hypnosis to new
applications.
Key words: Alert hypnosis, active hypnosis, hypnotic inductions, test
anxiety
Address correspondences and reprint requests to:
David M. Wark, Ph.D.
1313 5
th
St. SE.
Minneapolis MN, 55414
Email: wark@umn.edu
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Alert Hypnosis: A Review and Case Report
This paper reviews a development in the understanding of hypnosis. A method of
hypnotic induction is showing up in the literature, referred to by several different titles,
usually including the term “alert” as in “hyperalert hypnosis” (Ludwig & Lyle, 1964), “active-
alert hypnosis” (Bányai & Hilgard, 1976; Robazza & Bortoli, 1995; Cardeña, E., Alarcon,
A., Capafons, A., & Bayot, A., 1998), “alert hypnosis” (Wark, 1998), “awake-alert” (Iglesias
& Iglesias, 2005) or “waking hypnosis” (Capafons, 2004). Regardless of the designation,
the technique is distinct in two significant respects. First, a subject does it with open eyes.
The operator does not use phrases like “You are getting more and more sleepy and drowsy.
Your eyelids are becoming heavier, more and more tired and heavy.” as found in classic
inductions such as the Stanford Hypnotic Susceptibility Scales (Weitzenhoffer & Hilgard,
1959). Second, the subject can be moderately to vigorously active. There is no need for
catalepsy or even relaxation. (Ludwig & Lyle, 1964; Bányai, É., Meszaros, I., & Greguss,
A.C., 1983). In spite of these differences, the response to suggestions is practically the same
as for more traditional techniques (Wark, 1998).
This review makes a distinction between the suggestions used for induction and
those used for treatment. Of course, the distinction is purely heuristic. Inductions are
suggestions formalized into an arbitrary procedure or ritual. But it is helpful to make a
distinction between the suggestions used early for the induction of hypnosis and the
suggestions used later for treatment or change.
Applications of Alert or “Waking” Hypnosis
The earliest contemporary report of “waking” hypnosis was an educational
application. In the early 20th century, hypnosis was popularly considered to be a type of
sleep, in part a carry over from the historical writings of Braid (1843) and in part agreement
with the more contemporary work of Pavlov, who considered hypnosis a type of cerebral
inhibition (Windholz, 1996). Wells (1924) was interested in demonstrating hypnosis to his
classes in psychology, and countering the false idea that it was a form of sleep.
Wells used a technique he called “waking hypnosis”. He wrote that waking hypnosis
was less mysterious, took less time, was easier to use and succeeded with more students.
Instead of sleep or drowsiness, his preinduction talk covered the concept of normal
dissociation of mind and body, while awake. His examples included lapses of memory, and
absent minded acts. Following the lecture he gave a direct suggestion for eye closure or
finger lock. After that, he gave more suggestions, depending on how the subject responded,
and what he wanted to demonstrate. He reported effective awake suggestions for hypnotic
phenomena such as amnesia, automatic writing, recalling forgotten information, complex
mental computation and anesthesia. In every case, Wells said, the subject was awake and
alert. Wells’ evidence for the application was anecdotal, but his enthusiasm for waking
hypnosis was very strong.
A major demonstration of highly active hypnosis developed from an observation in
social science. Ludwig and Lyle (1964) introduced the concept of “hyperalert” hypnosis to
describe people who seemed to be following suggestions in a hypnotized way, while physically
very active. As examples of this “natural hypnosis” they cited tribal dances, religious revivals
and political rallies. To demonstrate the process experimentally, they used 9 prison inmates
who were told they were participating in a new treatment program. The investigators use a
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variety of suggestions to increase tension, alertness and stimulation
while diminishing comfort and concentration. For one example, subjects were told to spin
around while sweeping the room with their eyes. They were told that they would become so
dizzy they would be forced to sit down and enter a very tense hyperalert state. After 5 to 25
minutes of this and other active tension inductions, subjects appeared to be awake, but their
faces had a flat “trance-like” quality. The subjects’ responses to 11 standard hypnotic challenge
items (arm rigidity, hand anesthesia, negative hallucination, posttrance amnesia, etc) were
tested after both the active and traditional eye closure and relaxation inductions. The
investigators found no significant differences between response to suggestions following
hyperalert or traditional inductions (Ludwig & Lyle, 1964).
If alert hypnosis was ever to be useful, Vingoe (1968) realized that there should be
a measure of hypnotic response using the eyes open induction. He developed a Group Alert
Trance (GAT) hypnosis scale. For induction, the subject gazes fixedly at the left hand, while
receiving suggestions for physical relaxation and mental alertness and readiness to carry out
any suggestion. The patter is similar to the Stanford Hypnotic Susceptibility Scale: Form B
(SHSS:B) (Weitzenhoffer & Hilgard, 1959), but with the suggestions for sleep or drowsiness
removed, and instructions for mental alertness inserted. Following the induction, the subject
receives suggestions for five tasks [head fall, alert state, communications inhibition, post
hypnotic suggestion and posthypnotic amnesia]. The results for these test items on which
they can be compared are no different from the percent passing on the Harvard Group Scale
of Hypnotic Susceptibility: Form A (HGSHS:A) by Shor and Orne (1962). In a later study,
Vingoe (1973) compared 186 undergraduates on the HGSHS:A and the GAT. The correlation
was r = .68. The author suggests that researchers and clinicians can use different inductions
depending on whether an arousal increase (alert induction) or decrease (traditional induction)
is more appropriate.
The early reports of alert hypnosis may have stimulated some new ways to think
about hypnosis. Working from a sociocognitive perspective, Gibbons (1979) theorized that
hypnosis happens when a subject is given some expectations for a change in awareness, the
operator specifies the changes, and provides a cue for the change to happen. From that
perspective, suggestions of sleep would lead to counter productive reduction of awareness.
Gibbons developed his hyperempiria induction with suggestions for increased alertness,
exhilaration, mind expansion, and increased sensitivity. He talks about relaxation, but never
uses the metaphor of drowsiness or sleep. In a typical induction, (Gibbons, 1974) the operator
would ask the subject to imagine a warm sandy beach, alertly notice the tangy salt air, feel an
exhilarating sense of arousal and responsiveness. When the hyperempiria and traditional
inductions are compared using standard susceptibility scales, the results were very similar.
Gibbons’ contribution is an expanded notion of how to manage an induction to hypnosis.
Éve Bányai was convinced that hypnosis had nothing to do with sleep, and so
could be induced alertly. Her understanding was driven in part by a theoretical disagreement
with Pavlov’s dogma that hypnosis was a type of cerebral inhibition (Windholz, 1996) and
in part by her work on the differences of EEG in hypnosis and sleep (Bányai, É., Meszaros,
I., & Greguss, A.C., 1983). She and Hilgard (Bányai & Hilgard, 1976) described “active-
alert hypnosis”. They developed a standardized induction that involved open eyes, no mention
of relaxation or sleep, and measurable physical activity. During the induction their subjects
pumped a stationary bike under heavy load. As script for the induction, Bányai used the
SHSC:B (Weitzenhoffer & Hilgard, 1959) with suggestions for alertness, attentiveness and
freshness instead of sleep and drowsiness. The same students also were given a traditional
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induction. In each condition, after the induction, the students were tested with eight items
from the SHSC: Form A or B (Weitzenhoffer & Hilgard, 1959). For the active-alert condition,
the 50 subjects achieved a M = 4.94 (SD = 2.18) and for the counterbalanced traditional
induction the same subjects achieved M = 5.16 (SD = 2.06), a non-significant difference.
Later Bányai (Bányai, E., Zseni, A., & Tury, F.T., 1993) report on the use of active alert
inductions in psychotherapy. The technique was helpful when treating 200 patients with
depression, generalized anxiety, panic, conversion reactions, and phobia.
There were other applications for Bányai’s innovation. Miller (Miller, M.F.,
Barabasz, A.F., & Barabasz, M., 1991) demonstrated that active alert bicycle induction and
suggestion could be used to develop cold pressor anesthesia. Both types of induction, active
alert or traditional, were equally effective. High hypnotizables were better at pain control
then lows, but the type of induction made no difference.
The positive effect of a waking induction and suggestions for alertness seemed
reliable. Wark wanted to show his college students how to use hypnotic techniques in a
practical education application. Since closed eyes would make study impossible, some from
of alert, eyes open induction was mandatory. He taught them to use “alert self-hypnosis” to
improve their skills to read, listen, take notes, and write exams. Students were randomized
into alert hypnosis treatment or waiting list groups. Following training in an eyes-open
induction, treated subjects were coached to create and give themselves suggestions for better
comprehension while reading in hypnosis. After training, all subjects were tested on a
standardized reading comprehension test (Raygor, 1970). Students in the control group scored
at the 52 percentile, but student in the trained group reading in alert hypnosis scored at the
73 percentile, p < 01 (Wark & laPlante, 1991). In a later study, students in an actual college
courses learned to listen, read, and take tests in alert hypnosis. Using grade point averages
(GPA) calculated from their transcripts, students made an average gain almost one half a
grade from the quarter before to the quarter after training (M GPA = .448, SD = 1.024, p =
.005). Interestingly, the more hypnotizable students, who scored in the highest third on the
Creative Imagination Scale (Wilson & Barber, 1978), made an average gain of over one whole
grade (M GPA = 1.03, SD = .846, p <. 01).
In an innovative development based on sociocognitive principles, Amigó, Capafons
and their colleagues (Amigó, 1994; Capafons & Amigó, 1995) developed a technique of
alert hypnosis called Emotional Self Regulation Therapy (ESRT). There are several variations
of their procedure, but all the methods share an innovative three phase structure. In the first
phase the subject is presented with stimuli (cold water, heavy book, lemon juice) to produce
a recallable response (numbness, fatigue, unpleasant taste). The subject is asked to associate
the responses with a simple cue (word, image, sound). In the second phase, the subject
recalls the response to the cue, but without the physical stimulus. The therapist may tap a
bell and ask the subject to remember the sensation of numbness. These exercises are repeated
with various cues until the response is produced with a feeling of automaticity. For the final
phase, the subject is told that their nervous system has been made more active and receptive
by the exercise. It is now possible for the subject to experience any suggested response
without new training. They can experience, for example, a suggested sense of warmth or
energy.
ESRT was reported in several treatment studies. In one, the technique was used to
treat depression (Amigó, 1994). A patient was given 20 mg of ephedrine and trained to
recall the energized feeling. Using a cough drop as a cue, the patient was able to bring back
the sensations of energy and scored lower on measures of depression and anxiety. In another
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series, a variation of the basic method was used to help clients stop smoking. Results were
mixed, but generally positive (Capafons & Amigó, 1995). Capafons (1998) also developed
a three-step variant of ESRT called Rapid Self Hypnosis.
Breaking new ground, Barabasz (Barabasz & Barabasz, 1996) used alert hypnosis
in conjunction with brain wave neurofeedback. The goal was to teach attention deficit
disordered (ADD) patients to read more effectively. When ADD patients read text, their
brain waves shift to slow 4 to 8 Hz activity. When non-disordered students read, they shift to
faster 14 to 32 Hz pattern, and show increased response in the right frontal lobe.
Neurofeedback treatment involves allowing the ADD subject to monitor their brain waves
while reading, and shift toward the faster response. To enhance the effect of the biofeedback,
the subjects were trained by alert induction and hypnosis to attend to the meter. Following
the induction, subjects received suggestions to “focus your attention and concentrate as
completely as you desire”. Subjects who received the alert induction plus suggestions to
attend reached the faster EEG criteria in fewer trials. They were in active hypnosis during
the treatment.
Cardeña (Cardeña, E., Alarcon, A., Capafons, A., & Bayot, A., 1998) used a set of
energizing exercises to prepare subjects for an “active hand” induction. In the preinduction
exercises, the subject was asked to recall or imagine experiences designed to increase heart
beat, respiration, wide visual expansion. The actual induction involved moving the right
hand vertically up and down rapidly and then suggesting the increased heart beat, respiration
and alertness. The authors found that subjects were significantly more responsive and more
likely to stay in the program than when using Bányai’s bicycles induction.
Athletic achievements can be increased with alert hypnosis. Robazza applied the
idea of alert induction to raise an archer’s precision. In his model (Robazza & Bortoli,
1994), the athlete in alert hypnosis receives suggestions for body awareness, imagery
rehearsal, focus on relevant cues for the event, and smooth automatic execution. The impact
of all these suggestion is enhanced by alert hypnotic induction and suggestion during practice,
followed by a total review later, in traditional hypnosis. In an uncontrolled N = 1 case study,
the authors (Robazza & Bortoli, 1995) reported an experienced archer seen one day a week
for 20 weeks. Mean scores and mean errors were tabulated for two base sessions before
training and six tests during. The data showed solid improvement by an athlete with 17 years
of practice and experience.
Alert induction can be part of a covert, patient controlled treatment. Iglesias and
Iglesias (2005) used awake-alert self-hypnosis to teach a client panic control in social
situations. The client was a recognized philanthropic leader, with self-esteem organized
around public recognition and acceptance. The panic attacks, with heart rate and respiration
increase, stomach upset and sweating occurring in public situations, were very embarrassing.
The client needed a covert way to deal with the panic since traditional self-hypnosis, eyes
closed and body relaxed, would not be acceptable. The authors developed an eyes open
alert induction. The signal for the alert induction was to gaze at or just imagine an expensive
and beautiful Waterford crystal goblet. The client learned to enter eyes open hypnosis and
suggest that her body was “woodsy” and numb, that the physiological symptoms were
gone. The patient reported satisfactory control of the panic attacks.
How do traditional and alert inductions compare?
The effects of an alert induction are similar to those produced by traditional
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techniques. There are 8 controlled studies reporting a total of 52 different responses. The
responses include subjective measures such as reports of self-awareness (Vingoe, F.J., Hobro,
N., & Milner-Whitaker, I., 1993; Bányai & Hilgard, 1976; Fellows & Richardson, 1993) or
facial appearance, (Ludwig & Lyle,1964), behavioral measures such as finger lock and arm
rigidity (Malott, 1984); and autonomic or physiological effects such as enhanced or diminished
cerebral hemisphere response (Cikurel & Gruzelier, 1990) and cold pressor pain (Miller,
M.F., Barabasz, A.F., & Barabasz, M., 1991). For 39 measures there are no statistical or
practical differences between the responses to suggestions following traditional or alert
inductions. For a detailed review, beyond the needs of this paper, see Wark (1998).
A few significant differences appeared on 13 response measures. Traditional
inductions were more effective in producing a feeling of relaxation (Fellows & Richardson,
1993; Vingoe, F.J., Hobro, N., & Milner-Whitaker, I., 1993) verbal inhibition and calmness
(Bányai & Hilgard, 1976), and hallucinated sound (Bányai, 1980). On the other hand, alert
hypnosis produced greater effect on these variables: discomfort and spontaneous movement
(Ludwig & Lyle, 1964), edginess, (Fellows & Richardson, 1993), movement, and feelings
of alertness (Bányai & Hilgard, 1976). Interestingly, alert inductions were significantly
associated with reports of joyful dreams and active participation (Bányai, 1980).
What can we conclude about the techniques of alert induction compared to the
traditional procedures? Regardless of the type of induction, the effects of hypnotic suggestion
are generally similar. There are some differences associated with the more active induction:
some discomfort, a greater sense of activity and joy of participation.
Case Report
The following case illustrates the use of alert hypnosis to deal with an extreme,
long standing case of anxiety. Lynn was a youthful looking 51-year-old woman, very
intelligent, lively and quick in conversation. Her movements were sure and confident. It was
no surprise that she reported enjoying skiing, volunteering for social action causes and did
competitive dancing. When she described her achievements in athletics, community
organizing and competition, she relaxed and smiled warmly.
She presented because although she graduated from law school 18 years ago and
failed her law board three times, she now wants to try again. In the intake interview, whenever
she talked about reading for or taking an exam, her breathing got labored and she was in
frank respiratory distress. Her reaction to reading seemed unconnected to the rest of her life.
Lynn reported a lifetime of health challenges, including asthma, allergies, arthritis,
temporary paralysis, and sensitivity to chemicals and smoke. She said that her respiratory
allergies were the cause of her failed law board exams. She could not breathe in the smoke
polluted room. She became totally disabled in 1987, a few years after graduation from law
school. In 1995, she had recovered enough to enroll in a professional healthcare training
program.
On the Test Anxiety Survey (Sarason & Ganzer, 1962) she scored 11 indicating
significant reading test anxiety (Wark, D.M., Bennett, J.M., & Wolinski, J, 1980; Wark,
D.M., Bennett, J.M., Emerson, N.M., & Ottenheimer, H., 1981; Wark & Bennett, 1981).
The item responses indicate concern about both the past [consequences of failing] and the
future, [how badly she would compare to other students].
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Treatment plan
As long as Lynn focused on the present time, or something pleasant, she maintained
good control. I wanted to teach her how to stay attentive while controlling her anxiety during
her reading, study and test taking. Desensitizing the law exam would reduce the anxiety, but
would she internalize that control? Suggestions in hypnosis could integrate the feeling of
control and her strong sense of social and physical competence. Alert eyes open hypnosis
seemed important so she could read and respond to the exam, maintaining her integrated
control.
I did an alert induction with strong “here-and-now” focus. I had her alertly attend
to the feelings of her body in the chair, sound of my voice, the pattern of her breathing, and
her sense of current control. Then I suggested an age regression to the last exam, but asked
her to hold an image of herself relaxing and breathing. My goal was to modify the recall of
the test, so as to disrupt the associations between the test, feelings of anxiety and labored
breathing. We repeated the exercise several times. At the end of the session, she said she
could recall the exam with less discomfort.
After she learned to induce eyes open alert hypnosis and to read while in hypnosis,
we turned our attention to the upcoming bar exams. At the next session, we talked about her
hypnotic suggestions. She said that for her, the positive suggestion was to feel her competence
and pleasure in her work and study. She did an alert induction and I suggested she experience
that joy. I could see her smile increase as her mouth relaxed and her lips turned up.
At the next session, we reviewed her pattern using alert hypnosis. She said she was
able to enter hypnosis and give herself supportive suggestion. But any image or suggestion
associated with past negative experience was disruptive. During the session when I said,
“You are doing well”, she popped out of hypnosis. At my words, she had flashed on her
father’s attempt to manipulate and control her.
We discussed her transference response. She had not yet developed a mature
mechanism to deal with associations from the past while in present alert hypnosis. So we
built that new strategy. Whenever she felt an intrusion from me or any other source, instead
of fighting it, she was to stop and do a new alert induction focusing on the here and now.
This was designed to “clear the screen” and momentarily erase the past negative message.
Then she was to give herself supportive and positive suggestions. She practiced several
times in the office.
On one occasion between sessions, Lynn called to say her shoulders hurt. I asked
her to associate to the feeling. She said she felt a lot of burdensome guilt from her past
failures. I asked her to do what we had planned: stop, alert focus on the now, and relax the
shoulders. Insightfully, she said she realized the whole process is confronting demons from
the past.
Session before bar exam.
I suggested that her goal for the 2 days of test taking was to read questions while in
alert hypnosis and stay calm. She said her goal was to pass the bar, but that she didn’t feel
she’d had enough time to do a thorough enough study. I asked if she could change the goal.
She then said her goal would be simply to stay calm and clear-minded during the exam.
Session after the bar exam.
We processed her experience taking the test. She said that during the 2 days of 6 hour
exams she was able to stay in alert hypnosis. She needed her inhaler only once during the 2 days.
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Most importantly, she was able to stay with the current exam. She did not regress to the past, but
stayed alert and in the moment. She passed the exam and has an active legal practice.
Discussion
This review leads to an interesting observation. The inductions reviewed here can
be arranged along an ordinal dimension from relaxation to activity. Well’s (1924) lecture
induction is characterized by very little physical activity. Inductions by Vingoe (1968), Iglesias
& Iglesias (2005) and Gibbons (1974) all involve a slight increase in physical activity. They
use a traditional relaxation induction, but without any mention of sleep or drowsiness.
Arguably a bit more physical activity is part of Barabasz & Barabasz (1996) induction. The
subject is asked to roll eyes up, hold the tension, and then relax. Wark’s (1996) induction
involves structured physical exercises. The subject is asked to change posture, inhale and
hold, then exhale and relax. Cardeña’s (1998) active hand falls a bit further toward the
physical end of the scale. Robazza’s (1995) archery practice and Bányai and Hilgard’s (1976)
exercise bicycle are clearly physical and energetic inductions. Ludwig and Lyles’s (1964)
very strenuous physical exercises in a prison courtyard are probably the current anchor
point at the energetic end of the dimension.
Arranging these inductions along the dimension of relaxed to energetic offers a
fruitful way to conceptualize hypnotic inductions. Many kinds of active response can be
used as an induction and set the stage for increased suggestibility. Focusing while walking
down a long office corridor to a difficult meeting could be preparation for self-hypnotic
suggestions to be a good listener or an assertive speaker. Gentle, slow, repetitive romantic
touching could be an active, arousing induction for suggestions of pleasure and better sexual
performance. Stretching and warm up exercises for athletes can be an induction that facilitate
the use of suggestions for increased endurance in a workout or increased concentration in a
competition. The suggestions can come from the athlete or a coach. In the case report,
sitting up right, gazing at a point on the floor and breathing deeply set the stage for Lynn’s
suggestions of control and presence in a long examination.
This review demonstrates that there are ways to induce hypnosis beyond the
traditional eye fixation and relaxation. Thus, the terms “alert” or “waking” are terms of
encouragement to expand the ways hypnotic interventions can be planned and carried out.
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