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Hypnosis and Pain: Origin and Clinical Tradition

MAURÍCIO DA SILVA NEUBERN

University of Brasilia


The aim of this paper is to point out that the relationship between hypnosis and pain goes back to a clinical origin and tradition that refers to the subjective universe of the Western paradigm. Criticizing the alleged notion of the beginning of a scientific hypnosis, based on experimental perspectives, the article highlights how notions of the subjective universe were at the origin of this practice, together with the thinking of eminent magnetizers and hypnologists. Although they have undergone historical changes, notions such as relationship, subject, autonomy, imagination and language were at the origin of the understanding of the experience of pain, as well as the treatment offered to people suffering from this type of suffering. In this way, the article concludes by highlighting the need to recognize the relevance of past authors, since a large part of the subjective conceptions inherent in treatment, as well as the understanding of pain in current authors, are closely related to earlier works.

Keywords: hypnosis; clinic; pain; history; epistemology


The demands linked to chronic pain occupied a central position in the emergence of animal magnetism and hypnosis, which are considered movements of great importance for the construction of psychology in the 19th century (Carroy, 1991; Chertok & Stengers, 1990; Neubern, 2006,2009). This field was initially linked to medicine, but brought with it a range of notions specific to Western subjectivity, while at the same time questioning the limitations of dominant medical practices, which were very much focused on an organicist view of diseases. Thus, the first magnetizers and hypnotists, seeking inspiration, in part, from the modern project of science and, on the other hand, from Renaissance notions (Koyré, 1971; Michaux, 2001; Peter, 1999), ended up evoking notions specific to the subjective universe, such as imagination, fluids, emotions, morals and will.

The treatments related to pain developed by these figures were therefore strongly influenced by the classic notion of the clinic (Lévy, 1997), i.e. at the bedside, which emphasizes the relational dimension of care as populated by subjective processes and built a tradition that has continued to the present day. Thus, authors such as Puységur, Bertrand, Cloquet and Esdaille at the beginning of the 19th century, Bernheim, Liébeault and Delboeuf at the end of this century and Milton Erickson in the 20th century, despite the particular differences in their works, emphasized the relational and subjective dimension in the treatment of pain in such a way as to remain authentic representatives of the Western clinical tradition. It is also worth noting that these authors, despite being forgotten in much of the historical literature of psychology (Méheust, 1999), were not isolated figures, but central figures in the institutional recognition of their movements, founding institutions, working for the academic recognition of their works, forming disciples and acting in different media of their times, such as books, journals and congresses (Carroy, 1991, 1993).

However, the considerable gap in current bibliographical references on the subject leads to a poor understanding of it, failing to recognize its historical and epistemological relevance to current clinical practices (Neubern, 2006,2007). There seems to be an intense denial in which certain authors associate the creation of scientific hypnosis with positivist proposals in the second half of the 20th century, with an emphasis on statistical scales and experimental procedures (Barber, 1996; Hilgard & Hilgard, 1994). According to them, it was finally possible to produce a context in which the complex relationships between hypnosis and pain could be known in a reliable way, through the security provided by the measurement or control of laboratory variables in order to get rid of the inconsistencies typical of the hypnotic setting.

In the midst of the supposed certainty provided by the reliability of scientific procedures, there is a position of denial of the clinical dimension as well as the historical tradition from which these practices originated. In this way, there is a double exclusion that affects both subjectivity, as a set of fundamental notions for understanding clinical processes, and the work of important authors whose impact was of great relevance in their respective eras. These authors are often little known (Méheust, 1999; Neubern, 2009) or are associated with a nebulous era whose pretensions mixed pre-scientific, mystical and even charlatan contributions, which were soon replaced by a truly rational project such as experimental psychology or psychoanalysis (Gay, 2002; Roudinesco, 1986). In this way, this article aims to highlight that the relationship between hypnosis and pain has its origins and tradition linked to clinical thought (Lévy, 1997) and has been marked by notions typical of Western subjectivity (Santos, 2000), such as subject, autonomy, imagination, relationship, emotions, morality and communication.

To this end, we will highlight, without historiographical purposes, some 19th and 20th century authors whose works were imbued with this subjective universe and ended up having a considerable impact on their respective scientific communities, as well as on the construction of notions and concepts that were of great importance for the maintenance of clinical thought. Specifically, it will be highlighted how these notions were present in the work of these authors and made up their respective ways of conceiving the complex relationships between hypnosis and pain. It is also understood that these notions, despite being marginalized by the dominant tendencies of 19th century organicist medicine (Carroy, 1991), were of central importance for the use of hypnosis in the treatment of pain to be born and remain alive as a clinical practice to this day. Puységur and animal magnetism.

The Marquis de Puységur's therapeutic proposal made significant contributions to the treatment of organic diseases and, specifically, pain of different origins (Carroy, 1991; Méheust, 1999). Following in the footsteps of his master Mesmer, Puységur (1784/2001a) believed in a fluid that existed in nature and in human beings - animal magnetism - and that this could be transmitted between people for therapeutic purposes. However, the famous magnetizer ended up making a series of changes to the traditional treatment that served not only to curb criticism from opponents, but also to spread and deepen a new version of the treatment that had wide repercussions on the social and scientific scene in 19th century France.

Instead of collective work, with cathartic crises in the public eye, the Marquis' proposal individualized treatment, turning it towards a procedural and welcoming relationship that sought to contemplate and meet the particular needs of each patient (Puységur, 1784/2001a). Furthermore, this proposal had matured as a result of the clashes with his master Mesmer's opponents: magnetism no longer appeared to be a panacea for curing any ailment, but it did have limitations and relations with patients, especially women, should be protected by the presence of a trusted figure in order to avoid accusations of harassment, such as those directed at Mesmer (Deleuze, 1813/2004; Laurence & Perry, 1988).

From an epistemological point of view, Puységur (1784/2001a, 1785/2001b) took a different stance from modern scientific rationality, in which man opposes and tries to control nature (Santos, 2000): he saw nature as wise and as an integral part of the human spirit, even though it was not always accessible to his ordinary knowledge and attention. He advocated, in the style of the Renaissance (Koyré, 1971), that the therapist should not oppose nature, but ally with it through a strict moral stance and the cultivation of good feelings (Peter, 1999). The magnetic relationship would be a way of promoting access to this intrinsic nature of the human being, so that artificial somnambulists would be, in his view, a patent way in which this nature revealed itself and demonstrated its power, especially in therapeutic terms. In the state of somnambulistic trance, induced by means of magnetic passes, the subject presented knowledge and perceptions far beyond their ordinary abilities, which were skillfully used in favor of the healing process of both the subjects and other people.

Thus, the context focused on curing organic diseases was marked by some key notions, starting with the therapist's posture, who should have a strong desire to do good, be welcoming, humanitarian and ethical so that nature could become an ally. From there, the therapist would develop a magnetic relationship with their patient - rapport - through which they could partially break through the limits of otherness (i.e. penetrate the subjectivity of the other) and unleash the therapeutic processes offered by nature. Such a relationship would promote a deep bond in which the figure of the therapist was coated with great admiration and affection and his words had a deeper and more intense impact than those of other people (Deleuze, 1813/2004). However, curiously, it was this same relationship that produced the subjects' autonomy, in which they ended up accessing within themselves the resources available in nature that, under normal conditions, would be inaccessible and even unknown.

The somnambulistic experience mentioned above would be a radical expression of this process of encounter with oneself, that is, with nature. However, Puységur's genius often used sleepwalkers to intervene in the therapeutic process of other patients, as if those who were able to connect with this nature could also facilitate the same process in other people (Peter, 1999; Puységur, 1785/2001b).

Therefore, the effective treatment of illnesses depended on a fluid that had a supposedly physical status, but was mobilized by subjective processes, such as the emotional quality of the relationship, the firm will and the moral values of the therapist. In this process, the treatment of pain through animal magnetism came to the fore not only because of the new vision it promoted, but also because of its amazing efficiency (Laurence & Perry, 1988; Méheust, 1999). Since pain is a reflection of disharmony in the body, magnetic treatment could trigger, with the help of nature's wisdom, a new process of organic harmonization and consequent pain relief or cure.

Access, via magnetic rapport, to this intrinsic nature of the subject could favor analgesic processes and even anesthetics in preparation for surgical interventions. Thus, diseases such as hemiplegia, arthritis, rheumatism and inflammation, as well as tumor extractions, were widely treated using magnetic procedures which, despite the variations in understanding among their followers (Esdaille, 1846/1989), ended up returning in their main lines to the assumptions launched by Puységur and his collaborators. Thus, even the appropriation of academics such as Cloquet, Elliotson and Esdaille3 who advocated the need for more studies and pointed out the contradictions of the Marquis' system, ended up maintaining its central assumptions in terms of the magnetic relationship with patients (Bellet, 2002; Méheust, 1999).

Thus, pain and organic diseases led Puységur to establish notions that have great parallels with current psychotherapies, which places him as a precursor of these practices (Peter, 1999). Thus rapport seemed to precede the therapeutic relationship, the construction of the bond and its emotional condition; the client's autonomy, especially in terms of using their own resources, preceded the emancipatory process advocated in the different psychotherapeutic approaches; and the very notion of a dimension of the psyche beyond ordinary knowledge, anticipating the notion of the unconscious (Chertok & Saussure, 1996; Ellenbenger, 1970; Méheust, 1999). In short, the use of animal magnetism for pain was not restricted to the mere application of anesthetic techniques, but encompassed a whole set of assumptions that aspired to scientific legitimacy and placed the pain process and its treatment within complex subjective exchanges.

Imagination and suggestion

The proposal of the existence of a magnetic fluid brought great controversy and dissatisfaction to the academic world, mainly because such a fluid, as a physical agent, was not accessible to experimentation or even suited the explanations of the physics of the time (Chertok & Stengers, 1990; Méheust, 1999). Thus, following the anti-fluidist proposal of the Abbé de Faria and Bailly, the young doctor and engineer Alexandre Bertrand (1826/2004) conceived of magnetic and somnambulistic phenomena through the imagination, which gave him a rather unique position among the debaters of the subject: on the one hand, he was attacked by sympathizers for disbelieving in the existence of the magnetic fluid; on the other, he was attacked by opponents for being interested in such processes, contrary to the canons of academic medicine.

Fleeing from a proposal that, in his view, was inconsistent on the part of magnetism and another that was limited on the part of medicine, Bertrand (1826/2004) founded philosophical medicine or medicine of the imagination, which constituted one of the first proposals for modern psychology that integrated the natural sciences and the humanities and conquered important institutional spaces in 19th century France (Carroy, 1991). Such was the impact of his writings that their influence spread to the beginning of the 20th century, passing through authors such as Maine de Biran, Taine, Bergson, Bernheim, Liébeault, Delboeuf and Coué (Carroy, 1993).

The evolution of the Imaginationist proposal was mainly aimed at explaining the communication process that exists in the therapeutic or even research relationship between the therapist and their patient. At first, Bertrand (1826/2004) advocated communication with clear and explicit signals in which the therapist limited himself to passing deliberate messages to the patient who, through an imaginative process, produced different types of psycho-organic processes, such as cures and anesthetics.

His disciple Maine de Biran (quoted by Carroy, 1993), who was interested in the process of relational influence, conceived the notion of a sympathy between therapist and patient in which there was a kind of complementarity between a therapist who imagines and desires something and a patient who activates their processes of imagination through this exchange. This transmission, in which the therapist transmitted his ideas and desires to the patient, would occur in a subtle way, beyond the deliberate knowledge of the subjects, opening up a perspective of unconscious communication. Under the activated posture of the therapist, communication would lead to the unleashing of resources of the imagination that would lead to significant improvements in the demands brought by the clients, such as processes of anesthesia and analgesia.

In short, imagination was the main vehicle for the treatment of pain of organic origin, in order to promote its relief, improvement, cure or even preparation for surgical interventions. It's important to note that the tendencies based on imagination, unlike the magnetist proposals, conquered very significant institutional spaces and crossed the century, founding a psychology of great importance at the time. The clinical application focused on pain and the treatment of illnesses returned with rigor through authors from the Nancy school, such as Hippolyte Bernheim (1891/1995) and his Belgian confrere Joseph Delboeuf (1885/1993a). These authors, already under the name of hypnotism, emphasized the role of suggestion as a relational process capable of producing psychic and organic phenomena.

In contrast to Charcot in the Paris school, for whom hypnosis was a pathological state and the suggestive relationship was unimportant, the Nancy authors saw hypnosis as a suggestive process in which the therapeutic relationship played a fundamental role (Carroy, 1991). Bernheim (1891/ 1995), for example, understood psychotherapy as a systematic and rational application of suggestion, which was the act by which an idea was introduced and accepted by the subject's brain. Once this acceptance had taken place, it would tend towards some form of realization by becoming a sensation, i.e. a tactile, gustatory, visual or olfactory image, emotion or even movement. As organic functions were subordinated to brain function, it would be possible to produce various types of phenomena, such as anesthesia and analgesia, useful for a wide range of clinical and psychological applications.

Following the dominant medical trend of the time, it is possible to consider that Bernheim (1891/1995) had significant contradictions in his proposal. As he had no conception of the subject and his own notion of the psyche seemed linked to suggestive processes, he ended up looking for biological roots - in this case the brain - to give his system legitimacy, without, however, being able to explain how suggestion could be accepted by the brain and trigger processes. He embodied an epistemological stance typical of hypnosis, in which treatment is carried out in an attempt to produce changes without necessarily knowing the cause of the ailment, which was, incidentally, harshly attacked by Freud (1905/1996a, 1917/1996b) in the construction of psychoanalysis.

At the same time, he gave a special role to the suggestive process and to notions such as imagination (always linked to some physical sense), emotion and idea, in other words, to processes that suggested a subjective dimension. On the other hand, it is important to note that Bernheim (1891/1995) distanced himself from his magnetist and even imaginationist origins by giving a preponderant role to the sometimes authoritarian figure of the therapist and not emphasizing the patient's autonomy during the healing process. On the other hand, his Belgian colleague Joseph Delboeuf (1885/1993a), a philosopher by training, had significantly different conceptions, as his ideas converged with those of the ancient magnetizers, to whom he paid great reverence, whether they were sympathetic to the fluid or to the imagination. At the same time as conceiving the suggestive process as the central explanatory axis of hypnosis, Delboeuf (1885/1993a) brought two concepts of great importance that have significant parallels with current psychotherapies: the relationship and the autonomy of the patient. He gave a secondary role to the therapist, who should only provide the patient with the power that they could not or would not be able to access themselves by their own means. Thus, the patient's problem was not a lack of resources, but a lack of knowledge about how to use them, i.e. the notion of the unconscious that was common at the time.

However, for such a condition to be achieved, the relationship must involve an intense affective exchange, a sharing, as Delboeuf (1893/1993c) points out: "When I am in front of a sick person, I feel his illness very strongly. If he suffers, I share his suffering; if he cries, I cry with him. There is thus a kind of communion between him and me. This sympathy, which becomes a cause when I speak to him, and which I repeat to myself, so to speak, does nothing more than, when he listens to me, make him believe that he hears his own voice? Isn't compassion the secret of those who successfully apply themselves to alleviating the ills of their fellow human beings? (P. 422)"

Therefore, through this welcoming and sympathetic relationship, which produced a psychic communion, the therapist's voice was transformed into the patient's own voice, which allowed them to access and develop their own potential. However, as in Maine de Biran, Delboeuf (1885/1993a) conceived of the autonomous condition of the subject in such a way that he did not become, in trance, an automaton under the orders of a doctor, but someone endowed with a critical and moral sense that he called moi inconscient, that is, unconscious self.

In this condition, in which the subject was immersed in a universe with the same foundations as a common dream, he would be in a position both to position himself in relation to the suggestions transmitted and to trigger the psychic and organic processes that afflicted him. Thus, when faced with a patient with some painful demand, Delboeuf (1890/1993b) adopted an unusual stance among hypnotists of the time, in which there was a privileging of the subject's singularity and an appreciation of their autonomy. When dealing with paralysis or pain, it would be up to the therapist to understand how these processes suggested themselves to the person and how it would be up to them to activate the healthy part of the brain so that the subject could offer themselves a suggestion that would eliminate the negative self-suggestions. Respecting the cadence of the subject's own process, it was not uncommon for the therapist to indirectly suggest the relapse of symptoms until the subject was able to combat them by their own means.

Erickson and naturalistic hypnosis

Milton H. Erickson's proposal for hypnosis made highly relevant contributions to the psychotherapeutic treatment of pain (Carvalho, 1999), despite the fact that his perspectives resulted in numerous ruptures with the modern project of science (Neubern, 2002, 2009). In this sense, instead of giving in to the common trend of his time, Erickson conceived an a-theoretical form of treatment (Erickson & Rossi, 1980), since he never showed any interest or concern in developing a theory to explain the human psyche. His perspective was one of valuing the singularity of subjects who, due to their complexities and unique processes, could not be restricted to a general structure of thought, such as theories. Therefore, when faced with a patient who presented demands related to physical pain, Erickson (1980) was attentive to their unique aspects and also brought important notions that should pragmatically permeate the therapeutic relationship, which brought him closer to the thinking of William James (1987). One of the first important notions in this sense was that of the unconscious, which implied a self-regulated and independent set of learned processes beyond ordinary consciousness that could be activated to their wise and therapeutic potential if there was an appropriate relational context (Erickson & Rossi, 1979, 1980).

In this sense, instead of a standard idea of trance, in which certain subjects would be more or less likely to experience it, Erickson (1958) conceived of it as an everyday and natural phenomenon that each subject would experience in a particular way. Therefore, in a situation involving pain, the therapist should be aware of the various types of learning, usually beyond consciousness, developed to deal with it and also the ways in which the subject could access their unconscious in order to enhance their resources.

Conclusion

This discussion points to a historical and clinical trajectory of hypnosis and its relationship with pain that is not exhausted by a triumphant clinical approach such as psychoanalysis, which has been silent since its advent, nor is it silent in the face of an experimental perspective that claims exclusive scientific recognition for itself. A similar tradition, present in the works of Bernheim (1891/1995), Delboeuf (1885/1993a), Erickson & Rossi (1980) and Puységur (1784/2001a), addressing clinical problems linked to pain and even psychotherapy, highlights the role of the therapist as a facilitator, emphasizing relational and communicational processes, as well as conceiving patients as autonomous, owners of resources that allow the development of a cure or the relief of suffering. In addition, it is from these authors that a central notion for modern clinical practice emerges - that of the unconscious (Chertok & Saussure, 1996) - which was gradually worked on from a vision of nature, as in Puységur (1784/2001a) to Erickson's wise unconscious (Erickson & Rossi, 1980). The contributions originating from this tradition are of great relevance as they highlight how subjectivity constitutes one of the main sets of processes that make up the painful experience, as well as its therapeutic treatment.

By emphasizing the relational dimension between therapist and patient, these perspectives highlight not only the notion of the bond and affectivity, but also the construction of the context as processes of the utmost relevance to the understanding and therapeutic approach to pain (Delboeuf, 1885/1993a).

In addition to giving importance to the technical and ethical dimension (Bernheim, 1891/1995; Esdaille, 1846/1989), these authors also emphasize the singularity of the subjects and the importance of their history in the subjective constitution of the experience of pain (Puységur, 1784/2001a). Their works also show the central importance of mutual influence, whether as a way of accessing affectivity and imagination, or as a way of giving new meanings to the construction of language (Bernheim, 1891/1995; Bertrand, 1826/2004; Delboeuf, 1893/1993c).

Erickson stands as a transition between these authors and current ones, since his work incorporates modern 20th century trends while keeping alive, in his own way, the typical notions of Western subjectivity developed initially by magnetizers and hypnotists (Erickson & Rossi, 1980). In this sense, it is interesting to note how these conceptions continue to be used today in the understanding of pain, which allows us to draw parallels that highlight the relevance of their origins. In addition to the notion of the unconscious already mentioned, we can also highlight how the notion of the bond has been discussed in terms of experiences of health and illness (Gonzalez Rey, 2002), and how the notion of context is fundamental to understanding pain processes (Bellet, 2002; Chertok, 1998; Melchior, 1998; Roustang, 1991).

The uniqueness and history of the subject (Carvalho, 1999; Mahoney, 1991; Rossi & Cheek, 1988) and of the social exchanges themselves (Gonzalez Rey, 2005; Kornblit, 1996) also figure as important processes in the constitution of the subjective experience of someone suffering from physical pain. In short, there is an undeniable kinship between current and ancient conceptions that deserves not only recognition, but also a more in-depth study of the origins of this practice, whose influence is present in other activities such as psychotherapy. It is necessary to review the attitude towards ancient authors, such as those highlighted here, not only in terms of historical or personal consideration, but above all with regard to the relevance of their work, since, as Bachelard (1934/1996) would say, in the scientific spirit the best way to venerate a master is to criticize him.

So, rather than making exclusivist statements that deny the scientificity of clinical thinking, it is more coherent to revisit history in order to learn from it in terms of the origins of many of the conceptions in use today. Rather than excluding these authors, it is necessary to understand what problems they faced, what questions they posed, what difficulties they faced and what solutions they were able to create in a field that still has many more questions than answers. In short, rather than denying them recognition, we should seek a dialogue with them in order to conceive what can lead their current interlocutors to the practice that perhaps most characterizes scientific thought - the possibility of thinking.

Notes

1. This work is the result of research into Hypnosis and Subjectivity, carried out at the Milton H. Erickson Institute in Brasilia, DF.

2. Amand Marie Jacques de Chastenet, or Marquis de Puységur (1751-1825), was one of the most important French magnetizers of the 19th century. Dividing his activities between the French army, where he was a colonel, and the practice of animal magnetism, Puységur was one of the main people responsible for spreading this therapeutic proposal in France, where he influenced various movements of the time (Carroy, 1991; Ellenberger, 1970; Méheust, 1999; Peter, 1999).

3. Cloquet became convinced of the usefulness of animal magnetism after he performed surgery to remove a tumor from a patient's throat, which had major repercussions for the scientific community of the time. Esdaille (1846/1989) worked in India and performed several tumor extraction surgeries under magnetic anesthesia with surprising results, because while the methods of the time had an average death rate of 30% to 50%, his procedures only reached 6%.

4. Although the term hypnosis was introduced by de Henin de Cuvillers, Bertrand's collaborator, in 1823, it gained more popularity with Braid in 1843, who placed greater emphasis on neurological processes (Méheust, 1999). In any case, it was a term that opposed the idea of a fluid.


Maurício da Silva Neubern, PhD in Psychology from the University of Brasília, is an adjunct professor in the Department of Clinical Psychology at the Institute of Psychology of the same university. Address for correspondence: Campus Universitário Darcy Ribeiro, ICC Sul, Instituto de Psicologia, Departamento de Psicologia Clínica; Brasília, DF; CEP: 70910-900. Telephone: (61) 3307-2625, ext. 315. E-mail: mneubern@hotmail.com

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