What is a systematic procedure that typically produces a heightened state of suggestibility?

Suggestibility for Conversion Disorder

While the treatment for most of the somatic symptom and related disorders share common management themes discussed above, treatment for conversion disorder sometimes attempts to capitalize on the suggestibility that some believe underlies this disorder. It is important to remember, however, that there are no systematic, well-controlled, trials supporting the efficacy of any treatment for conversion disorder.73

The most common form of treatment for conversion disorder is to simply suggest that the conversion symptom will gradually improve. It is thought that this intervention is face-saving as well as optimistic.

It is helpful to confidently convey with supportive optimism that recovery is certain, yet may be gradual. Specific suggestions may be offered as well (e.g., for the “blind” patient, suggesting that vague shapes will become visible first; for the patient with lower paresis, that weight bearing will be possible and then steps with a walker and so on, or that strength in squeezing a tennis ball will be followed by strength at the wrist and then elbow joints). When patients are not given information about their diagnosis and treatment, they show no improvement or do worse after work-up.74 Some suggest that the psychiatrist discuss the patient's life stresses and try to detect painful affects to assess the non-verbal interpersonal communication embodied by the symptom.25

Further intervention may not be necessary. However, if the conversion symptom persists, if the precipitating stress is chronic, or if there is massive gain, resolution of the situation becomes a target of the intervention. Because the stressors are often social, couples or family therapy may be instrumental in achieving a final resolution. Behavioral interventions, physical therapy, and reassurance are crucial, particularly for less verbal patients.66 In general, a favorable outcome depends more on the individuals' psychological strengths and on the absence of other psychopathology than on the specific nature of the conversion symptom itself.

6.1 Ethical Challenges

The hyper-suggestibility of recently traumatized individuals has provided an occasion for exercising political influence and manipulating loyalties. Providing care in the mass casualty situation raises ethical questions about the equitable distribution of resources and the moral values to consider in determining their apportionment. Governments in trouble have withheld treatment to minority racial or political groups—clearly an ethical breach. Since governmental terrorism is a common form of terrorism, care providers and leaders must be sensitive to the possibility that disasters will afford tyrants an opportunity to manipulate citizens for their own purposes.

To facilitate command assessment of troop health status, militaries have denied members confidentiality in medical communication. Mental healthcare providers must strike a balance between a promise of privacy that encourages persons to seek care, and responsible reporting to higher command regarding situations that pose danger to larger groups. Thus dual allegiance to both individuals and to the larger community presents an ethical challenge that must be negotiated by the military care provider. Persons in extreme circumstances may behave in ways that they later view as shameful. Shame may contribute to posttraumatic symptoms and disturb one's capacity to use social supports. Disaster triage is frequently carried out in large open areas that allow everyone present to hear what patients say to caregivers. Given the social stigma assigned to the manifestations of psychiatric illness it is easy to understand both patients' reluctance to communicate and doctors' reluctance to inquire. Perhaps re-educating the population can reduce ethical and therapeutic problems associated with stigma. However, altering deeply ingrained cultural expectations is just as challenging as providing privacy in chaotic triage environments.

Abstract

This article provides an overview of hypnosis, suggestion, and suggestibility. It defines hypnosis, hypnotic suggestibility, and the domain of hypnosis, and traces the history of hypnosis from Mesmer to the present, describing oscillating periods of acceptance and rejection by the professional community. The article also examines misconceptions about hypnosis and prominent theories of hypnosis and allied research in the context of historical and contemporary controversies. It concludes with an evaluation of clinical applications and the outcomes of hypnotic interventions, and an examination of forensic aspects of hypnosis, including the impact of hypnosis on memory and the status of hypnotically elicited testimony in the courts.

Physical Findings & Clinical Presentation

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Clinical presentation varies by amount and type of drug used.

Overall presentation includes distortions in body image and sensory perception, as well as rapid, intense alterations in mood; emotions; and suggestibility.

Overdose symptoms may range from acute anxiety, agitation, tachycardia, hypertension, hyponatremia, hyperthermia, severe agitation, rhabdomyolysis, seizure, cardiac dysrhythmia, respiratory failure, and death.

Classic pure hallucinogens: Lysergic acid diethyl amide (LSD), psilocybin (hallucinogenic mushrooms, “magic mushrooms”). Individuals rarely present for medical treatment. The patient usually is conscious, alert, and can provide history of drug ingestion. Serious medical problems have been reported to include seizures, hyperthermia, rhabdomyolysis, and acute renal failure. New trends in self-administered “microdosing” of psilocybin or LSD for treatment of depression or other psychological disorders may present as inadvertent overdose.

Mescaline: Found in many cacti. Similar structure to LSD; however, there have not been reports of medically significant adverse effects directly from the drug.

Peyote: Legal for use by the Native American Church. Adverse effects occur first, prior to hallucinations, and within 1 hour of ingestion include severe nausea, vomiting, abdominal pain, dizziness, ataxia, nystagmus, and headache. Mild adrenergic effects of increased temperature, pulse, and blood pressure occurs after the initial symptoms. Hallucinations begin several hours later.

Methylenedioxymethamphetamine (ecstasy): Not a true hallucinogenic but with similar effects of increased stimulation. Mild increase in temperature, pulse, hypertension, nausea, bruxism, jaw-clenching, dry mouth, muscle aches, ataxia. Severe effects include significant increases in blood pressure leading to intracranial hemorrhage, brain or heart ischemia, arrhythmia, sudden cardiac death, hyponatremia, malignant hyperthermia, DIC, seizures, and rhabdomyolysis. Symptoms are similar to serotonin syndrome.

Phencyclidine (PCP, angel dust): Similar to ketamine with multiple effects that include features of hallucinations. Patients may have CNS stimulation or depression. The most common signs are mild hypertension and vertical nystagmus in 60% of patients. Other important warning signs for the safety of staff and physicians include severe agitation, physical violence, unpredictable behavior, and decreased response to pain. Disassociation, seizures (up to 3%), rhabdomyolysis with resulting acute renal failure, dystonic reactions, hyperthermia causing hepatic necrosis, and multiorgan failure are also possible.

Cathinone derivatives (bath salts): Similar to PCP, with sympathomimetic effects of elevated temperature, blood pressure, pulse, sweating. Patients also may be severely agitated, aggressive, and violent toward staff. Severe medical effects include severe hyperthermia, hyponatremia, seizures, and rhabdomyolysis.

Salvia: Adverse effects are mild and may include slurred speech, dysphoria, headache, nausea, vomiting, dizziness.

Datura genus (Jimson weed, angel’s trumpet): Anticholinergic alkaloids with symptoms consistent with anticholinergic poisoning: Hyperthermia, delirium, hallucinations, mydriasis, blurry vision, dry mouth, tachycardia, urinary retention.

Dextromethorphan: Most commonly used by adolescents because of availability in over-the-counter cold and flu products; likely to be associated with salicylate, antihistamine, and acetaminophen overdose due to combination of cold and flu product ingredients.

Suggestions for Future Research

Much of the research on children’s testimony has focused on suggestibility of child witnesses. Yet an important area related to reliability that should be examined is whether increased levels of suggestibility influence children’s capability to offer reliable testimony (Gudjonsson et al. 2010; Ceci & Bruck, 1993). Since children are increasingly being relied upon to provide testimony, research must find the optimal techniques that limit the emotional stress that could compromise the reliability and credibility of their testimony (Gudjonsson et al. 2010; K. Bussey et al., 1993). Research on this topic should also examine which of these situations will provide a fair trial. Lamb et al. (2008) emphasize that more research is needed to clarify the risks and benefits of repeated interviewing with child victims and witnesses. It seems that CCTV is one step toward minimizing child witnesses’ stress while increasing the reliability of their testimony, yet there has not been enough empirical analysis to reach any definite conclusions (Batterman-Faunce & Goodman, 1993; Troxel et al., 2009). Continued research needs to be done on CCTV as a possible solution to the problem of traumatizing children and whether it provides a fair trial. Another focus of research should examine how to prepare children to testify more competently and with minimal stress (Troxel et al., 2009). If it is found that closed-circuit television is an unfair procedure, then children will have to continue to face their alleged abusers in court and to provide reliable testimony.

Practice Update Section: Child Custody Evaluations and Juvenile/Family Court

The work of forensic psychologists who interact with courts is subject to a high degree of scrutiny, perhaps none more than the child custody evaluator. This practice update section will summarize the article by Martindale (2001) entitled Cross-examining mental health experts in child custody litigation. The title alone is enough to raise anxiety levels but the points made serve to not only better prepare the attorney but also the mental health professional for cross-examination. The intense emotions and hostility that is often a part of heated custody battles serves to critically impair the objectivity of the parents involved. The “non-favored” litigant will not uncommonly register complaints with his or her attorney that the child custody evaluator did not consider all information that was presented; complains of irregular methods of evaluation; and insists that the evaluator was not impartial (p. 484). Although some parents seek custody for their own agendas far from the best interest of the child, the vast majority view themselves as the more capable parent and are profoundly disappointed, confused, and quite angry when the child custody evaluator recommends otherwise. Martindale (2001) maintains that the non-favored parent will often search for causes outside of their own potential parenting deficiencies or strengths of the other parent for the recommendation made by the evaluator. Some consider errors made by the evaluator as the likely culprit. Although this is a claim far too frequently made, in some instances they may have been placed at a disadvantage by a biased evaluator or one who was insufficiently trained to consider all relevant factors.

Cross-examination by the non-favored litigant’s attorney is one opportunity to expose such biases or substandard practices. The forensic psychologist who conducts custody evaluations must be very mindful of the potential implications of their procedures and own preconceptions about “family” prior to engaging in this work. It is critical that the evaluator does not let their own biases prevent them from adequately assessing all factors and considering all hypotheses based on the data collected from each evaluation on a case-by-case basis. It is the job of the mental health expert to assist the trier of fact in making a custody determination. While it is the judge who makes the decision on the ultimate issue, research has demonstrated that the opinions offered by the evaluator often heavily influence the final decision.

During the discovery phase of the court process, the attorneys should have familiarized themselves with the evaluator’s curriculum vitae and the agreement the evaluator made with the parties involved (Martindale, 2001). Martindale (2001) encourages attorneys to look for any training in the forensic specialty area of child custody, including conferences, workshops, and coursework. He states (p. 485): “It is inappropriate for a mental health professional whose background is treatment oriented to accept forensic assignments without first having secured education and training aimed specifically at preparing one for forensic work.” As forensic psychology programs are relatively new, it is rare for a mental health professional to have originally received their education and training in a forensic specialty. If an evaluator lacks sufficient training on relevant issues by any of the previously mentioned methods, his or her credibility could be challenged at trial. The evaluator should also be very careful of listing “vanity boards” that do not conduct a thorough assessment of a candidate’s expertise (e.g. work samples, oral and written examinations) on their vitae (p. 486). Attorneys are encouraged to follow up on claims of board certifications in order to gather information about the credentials-granting process.

The forensic mental health expert should also be very familiar with the subpoena process and the potential for their complete file, including evaluation notes, to be requested and the possibility of being part of the discovery process at trial. Martindale (2001) also suggests to attorneys to attempt to obtain a reasonable number of the expert’s previous custody evaluation reports and to scan them for identical passages, as well as for inconsistencies in rationales for recommendations. He proceeds to suggest that if the descriptors used to describe the interaction of one litigant and their child is repeatedly used to describe other litigants, it is important to challenge the evaluator on “corner cutting” and whether or not they explored all relevant individual differences (p. 490).

Forensic psychologists are also cautioned to evaluate any other individuals who are presently playing a parent role or will likely in the future (e.g. a fiancé of one of the litigants). Martindale (2001) indicates that to do otherwise would be offering an opinion on insufficient information. One critical difference between the forensic evaluator and the more typical treatment provider is the necessity to investigate all self-reported information by the litigants by following up with collateral information (e.g. records, uninvested collateral sources, etc.). Particularly in custody evaluations, the litigants are quite motivated to present themselves in the most favorable light. The forensic evaluator is obligated to list in their reports all collateral sources used and the information gleaned from each within the body of the report.

The suggestions for the mental health expert to avoid impeachment at trial provided in this practice update section are far from exhaustive but highlight the degree of inquiry to be expected for the child custody evaluator. Refer to Chapter 1 for more information on expert testimony. Ultimately it is the child who may suffer the greatest consequences based on the opinions offered and decisions made on their behalf. “The best interests of the children are ill served when flawed reports go unchallenged and become the basis upon which the trier of fact rests her judicial decision” (Martindale, 2001, p. 504).

Related Websites

www.familylaw.org

This website has links for family law code for all 50 states, questions about custody section, and a complete display of the Uniform Child Custody Jurisdiction Act.

www.hg.org/family.html

This website defines family law, and also gives definitions for various terms that relate to the family law.

www.dc4k.org

Website providing resources for divorcing parents with children and assistance finding support groups for children of divorcing parents.

www.helpguide.org/mental/children_divorce.htm

Website providing information to help parents support their children during a divorce.

http://parentsupportforchildsexualabuse.com

A website providing support and information regarding child sexual abuse and its effects on children and families.

www.d2l.org

A website providing information on child sexual abuse for individuals, families, and organizations as well as information on treatments.

Suggestibility

The degree to which someone is susceptible to the influence of another person defines suggestibility (Zaragoza, Belli, & Payment, 2007). The study of suggestibility has focused mainly on memory in children (Binet, 1894, 1900; Loftus, 1979; Loftus, Coan, & Pickrell, 1996; Loftus & Ketchum, 1994; Loftus & Palmer, 1974), eye witness testimony provided by children (Ceci & Bruck, 2006; Ceci, Papierno, & Kulkofsky, 2007; Volpini, Melis, Petralia, & Rosenberg, 2016), police interrogation and false confessions (DeClue, 2005; Gudjonsson, 1991), and assessment of an individual’s appropriateness for treatment with hypnosis (Page & Green, 2007).

Gudjonsson (1984) identified two types of suggestibility: (1) the extent to which people are susceptible to suggestive questions and (2) the tendency of people to change their replies to questions once interpersonal pressure was applied. He and his colleagues (Gudjonsson & Lister, 1984; Tata & Gudjonsson, 1990) found that mood, self-esteem, negative feedback, and perceived competence of the person asking the questions affected the degree of suggestibility. The largest effects occurred when the subjects perceived a large difference between themselves and the person asking the questions in terms of competence, power, and control. That is, people tended to doubt the accuracy of their thoughts and inferences most when they were confronted with someone of perceived higher status. Nembhard and Edmonson (2006) found that differences in professional status affected the degree to which less experienced or educated members of medical treatment teams would raise questions in treatment team deliberations. That is, people were more likely to believe the opinion of the team leader as function of status (suggestibility) and were less likely to challenge their conclusions. Ioannidis (2012) challenged the notion of science as self-correcting and suggested that many researchers are suggestible, tend to believe established research findings/researchers, and were reluctant to challenge or ‘upset the status quo.’

Hypnotic versus nonhypnotic suggestibility

Hypnosis and suggestion have long been linked; we talk, for instance, of hypnotic ‘suggestibility’ as an individual difference ability and of hypnotic ‘suggestions’ to create particular responses. But is suggestibility in and out of hypnosis the same? And to what degree do different forms of suggestion belong within the domain of hypnosis? Some researchers have argued that hypnotic responding is quite different from responding due, for instance, to conformity, gullibility, and persuasibility. Other researchers have argued that hypnotic suggestibility is simply nonhypnotic suggestibility given a small boost from expectancy and motivation. By this second view, the hypnotic induction adds little or nothing, because (with or without an induction) subjects respond mainly on the basis of their nonhypnotic suggestibility. But the induction does add something. Hypnotic subjects certainly can experience hypnotic-like effects without one, but the onset of these effects is more rapid and their impact more compelling following an induction. Perhaps more tellingly, whereas absorption correlates most strongly with difficult hypnotic items (as noted above), nonhypnotic suggestibility (e.g., direct and indirect measures of placebo effects) correlates most strongly with easy hypnotic items. This implies that suggestibility inside and outside hypnosis is not the same, especially the hypnotic ability needed to respond to demanding perceptual-cognitive items.

Within the domain of suggestion more broadly, there is increasing evidence that the many different suggestibilities do not resolve into essentially one form of suggestibility. Researchers have distinguished between primary suggestibility (involving direct verbal suggestions for bodily movements), secondary suggestibility (involving indirect, nonverbal suggestions for sensory-perceptual experiences), and tertiary suggestibility (involving conformity, persuasion, and other forms of social influence), as well as between specific concepts such as placebo effects and interrogative suggestibility. Recent data collected across large sets of suggestibility tasks (including the HGSHS:A) have indicated that hypnotic suggestibility is an independent phenomenon – related to a set of unique abilities (perhaps cognitive, as described above), but unrelated to other measures of suggestibility.

Hypnotizability

Early in the scientific study of hypnosis, scales were constructed to predict hypnotic suggestibility. Commonly used tests are the Hypnotic Induction Profile (Spiegel 1974), Harvard Group Scale of Hypnotic Susceptibility (Shor and Orne 1962), and the Stanford Hypnotic Susceptibility scale (Weitzenhoffer and Hilgard 1959). In these tests, subjects first undergo a hypnotic induction and are then rated on their responses to a series of behavioural suggestions. Hypnotizability is assessed by the number of suggestions subjects follow, with the assumption that responses are involuntary.

The predictive value of these scales in studies of hypnotic analgesia has been mixed. Subjects classified as high hypnotizables have shown greater pain relief than low hypnotizables in studies of conditions such as headache (Andreychuk and Skriver 1975, Cedercreutz et al 1976, Friedman and Taub 1985), labour pain (Harmon et al 1990), treatment-induced temporomandibular joint pain (Stam et al 1984), and burn pain (Schafer 1975). However, other studies failed to show a correlation between hypnotizability and responsiveness to suggested analgesia in conditions such as headache (Nolan et al 1989, Spanos et al 1994), obstetrical pain (Rock et al 1969, Samko and Schoenfeld 1975, Venn 1987), and dental pain (Gillett and Coe 1984).

Results are also variable in research on paediatric populations. For example, Hilgard and LeBaron (1982) found that following hypnotic induction, children previously identified as high hypnotizables showed less reported and observed procedural pain during bone marrow aspiration (BMA) than low hypnotizables, while no such relationship was found during BMA in a study by Wall and Womack (1989).

Spanos and colleagues (1994) argue that hypnotizability test results influence subjects' responses to suggestion by creating expectations about their ability to reduce pain in hypnotic situations. In research designed to investigate this question, subjects who scored low on the scales but did not know that results were expected to predict ability to reduce pain following suggestion, or who were led to expect they would do well in responding to suggestions for analgesia despite test results, reported pain reductions similar to highly hypnotizable subjects (Spanos and Voorneveld 1987, Spanos et al 1988, Andrews and Hall 1990). As well, several studies found no relationship between hypnotizability and pain relief when hypnotizability was measured after hypnotic intervention (Spanos et al 1993, Lang et al 1996). Furthermore, there is evidence that ability to control pain can improve with training in hypnoanalgesia (Lewis 1992, Crasilneck 1995), indicating that susceptibility to hypnotic suggestions may not be a stable trait.

Hypnosis

Hypnosis involves the induction of an altered state of consciousness, including focused attention and high suggestibility. In research studies, the application of hypnosis to influence the immune system is often through hypnotic suggestion to affect an allergic response. The participant first has an allergen injected under the skin. A hypnotic state is then induced, and the hypnotized participant is instructed to either enhance or suppress his or her response to the allergen. In most hypnosis interventions, the direction of effect is specified. Following such interventions, hypnosis has successfully suppressed, but not enhanced, the immune response. Studies have also shown that hypnotic suggestions can lead to changes in the ANS such as alterations in heart rate and blood pressure. In medical contexts, hypnosis has been used to manage chronic pain and to enhance adjustment to physical conditions and illnesses. There are great differences in people's susceptibility to hypnosis, and highly hypnotizable individuals have the strongest immune changes.