Psychology of Consciousness: Theory, Research, and Practice © 2014 American Psychological Association

2014, Vol. 1, No. 2, 105–122 2326-5523/14/$12.00 http://dx.doi.org/10.1037/cns0000019

Hypnosis and Beyond: Exploring the Broader Domain of Suggestion

Peter W. Halligan David A. Oakley

Cardiff University University College London

Despite its many influence on numerous features of human behavior and conscious-
ness, suggestibility, the ubiquitous disposition to generate and modify experiences,
thoughts, and actions remains one of the least researched aspects of human
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

cognition. As a critical feature of hypnosis, much research on suggestion and

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suggestibility has understandably focused on hypnotic suggestion with compara-

tively little exploration of the larger rich domain of suggestibility. From a research
perspective, suggestibility, can be regarded as comprising a range of bio–psycho–
social processes that facilitate or enhance the probability of a suggestion being
accepted and believed. Suggestion, on the other hand, can be seen as a form of
communicable ideation or belief, that once accepted has the capacity, (like other
strong beliefs) to exert profound changes on a person’s mood, thoughts, percep-
tions, and ultimately their behaviors. Although studies of hypnotic suggestion have
historically provided much productive research, the comparative neglect of the
broader domain of suggestion seems surprising, given its demonstrable potential as
a causal explanatory framework for many aspects of human behavior from the
placebo effect to advertising. In addition to discerning the potential adaptive
value(s) of suggestibility, it is now timely, given the growing interest from
neuroscience in hypnotic suggestion, to revisit previous attempts to elucidate
potential shared underlying psychological properties.

Keywords: hypnosis, suggestion, suggestibility, placebo, expectation

Hypnosis has successfully harnessed the forms of human behavior, (Schumaker, 1991)
powerful effects of attention, expectation, and as well as a key element responsible for gen-
suggestion to produce, modify, and enhance a erating the broad range of subjective experi-
broad range of subjectively compelling experi- ences and behaviors produced in hypnosis
ences and behaviors (Oakley & Halligan, 2013). (Kihlstrom, 2008), suggestibility has received
It has also captivated scientific interest for as comparatively little attention (Gheorghiu et
long as there has been a scientific psychology al., 1989; Lundh, L., 1998; Kirsch et al.,
(Kihlstrom, 2013). Recent reviews confirm 2011; Michael, Garry, & Kirsch, 2012; Schu-
that hypnotic suggestion has made a signifi- maker, 1991) and still does not feature in the
cant contribution to many areas of cognitive Oxford Companion to the Mind.
and social psychological research including Accordingly “suggestion has not yet become
cognitive neuropsychology (Barabasz & a truly independent domain of psychological
Barabasz, 2008; Halligan & Oakley, 2013; research”(Gheorghiu & Kruse, 1991) and most
Kihlstrom, 2013, 2014; Oakley & Halligan, current research comprises the “juxtaposition of
2009, 2013). Nevertheless, despite being a suggestion and hypnosis” (Gheorghiu, 1989, p.
common and significant feature in many 4) with the result that “the manifestation and
nature of suggestion have been discussed in the
literature primarily in connection with hypnotic
events”(Gheorghiu et al., 1989, p. 4). Conse-
Peter W. Halligan, Cardiff University; David A. Oakley, quently, fundamental aspects of suggestion and
University College London. suggestibility have been relatively unexplored,
Correspondence concerning this article should be ad-
dressed to Peter W. Halligan, School of Psychology, Cardiff
and “the importance of treating suggestion as an
University, Cardiff CF10 3AT. E-mail: Halliganpw@ important domain in its own right has been
cardiff.ac.uk largely ignored” (Kirsch et al., 2011).
105
 106 HALLIGAN AND OAKLEY

Neglect of Suggestion revolution” (Hilgard, 1965, 1975) and the re-

vival of interest in the “cognitive unconscious”
Writing in 1991, Schumaker lamented the (Kihlstrom, 1987, 2013).
fact that “suggestibility is a sorely neglected Despite including many important medical
area of study” and noted that at the time, there articles, the third and most recent period (1999 –
was only one entry for suggestibility in Psycho- 2013) can be best characterized by what Kihl-
logical Abstracts. A brief scan of the published strom (2013) termed “neuro-hypnotism,” given
journal papers listing the terms “hypnosis” us- the growth in hypnosis-based articles from neu-
ing Scopus, (the largest abstract and citation roscience. This emergent interest from the cog-
database of English language peer-reviewed lit- nitive neurosciences and “researchers whose
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erature) in 2014 and comparing these with those primary interest lies outside the domain of hyp-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

listed under “suggestion, suggestibility,” over

nosis”(Kihlstrom, 2013) has helped overcome
the past 100 years, confirms Schumaker’s ob-
the earlier reserve from more mainstream neu-
servation and demonstrates the striking devel-
roscience and has contributed to the growing
opmental lag and differential scale of research
interest in favor of hypnosis. acceptance of hypnosis as a safe and controlla-
The publication profile listed under “hypno- ble tool for experimentally delivering targeted
sis” shown in Figure 1/Table 1 can be divided suggestions (e.g., Del Casale, et al., 2012; Ja-
into three time periods, with much of the pub- mieson, 2007; Oakley & Halligan, 2013; Raz &
lished journal based research (96%) stemming Shapiro, 2002; Terhune, & Cohen Kadosh,
from the 1960s onward. The first period from 2012; Walsh et al., 2014).
the late 19th century up until the mid 20th When the same analysis is carried out for
century comprises a comparatively small num- published journal articles listed under “sugges-
ber of articles from a small number of pioneer- tion,” “suggestibility”, the profile reveals a
ing clinicians and psychologists that focused striking, historically later and significantly
mainly on medical applications and the nature lower publication volume.
of hypnosis. The second period, from the 1960s Although, the publication profile seen in Figure
until the late 1990s, shows a substantial growth 2/Table 2 can also be divided into the same time
in hypnosis research, and in particular seminal periods as Table 1/Figure 1, (for comparison), the
contributions from the field of psychology, in- published outputs cover two main time periods.
cluding research driven by the “Consciousness The first, up until the 1990s comprise a relatively

Figure 1. The Scopus publication profile for the term “hypnosis” for “all fields” (article and
review) from 1891 onward. The color version of this figure appears in the online article only.
 HYPNOSIS: EXPLORING THE BROADER DOMAIN OF SUGGESTION 107

small number of articles and authors with a focus

J. M. Schneck, A. A. Moss, M. M. Suslova

N. P. Spanos, T. X. Barber, E. R. Hilgard
(unlike hypnosis) coming from academic psychol-

M. Schredl, M. P. Jensen, D. Spiegel

ogy and few outputs listed under medicine. The
following period, from the 1999s onward, how-
ever, shows a substantial growth in research in the
Top authors areas of psychology, medicine, social science, and
neuroscience.
One conspicuous exception to this neglect of
suggestibility domain phenomena, however,
can be seen in the case of the placebo effect.
Scopus Search (Feb., 2014) of Documents (Article or Review) Using the Term “Hypnosis” for “All Fields” from 1891 onwards
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Using the search term “placebo effect” (see

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Figure 3) it is possible to find publications list-

ing the term from 1942 onward on the Scopus
database and a large volume of published arti-
cles that grows to over 40,000 publications per
year during the last decade, compared with less
than 1,000/year for hypnosis. Many of these
Medicine 46.1% Psychology 31.7% Neuroscience 5.0
Medicine 38.9% Psychology 20.3% Neuroscience 9.5
Medicine 57% Psychology 16.3% Neuroscience 2.4

may be due to the inclusion of clinical trials

where placebo is used as a control rather than as
the explicit focus of study.
Main Scopus subject areasⴱ

Hypnosis and Suggestion

Despite being closely linked to the history and

effectiveness of hypnosis, suggestion was never
the unique preserve of hypnosis (Gheorghiu, Net-
does not sum to 100

ter, Eysenck, & Rosenthal, 1989; Schumaker,

1991). According to Hilgard (1991, p. 37), “the
concept of suggestion had a history in sociology
and psychology before it came tied to hypnosis by
Bernheim.” Indeed, Bernheim, one of it’s early
and most influential pioneers, considered hypnosis
to be “the induction of a peculiar psychical con-
ⴱ

dition which increases susceptibility to sugges-

tion” and where “suggestion . . . rules hypnotism”
(Bernheim, 1888, p. 15). According to Gheorghiu
No of articles

Total:18,300

(1989), suggestion acquired a more prominent sta-

tus from the work of Bernheim and the Nancy
822
8,486
8,992

School of Hypnosis. Fifty years later, Clark Hull,

wrote in the first major modern scientific book to
specialize in the study of hypnosis that “no phe-
nomenon whatever can be produced in hypnosis
that cannot be produced to lesser degrees by sug-
gestions given in the normal waking condition”
and that “the essence of ‘hypnosis’ was due to a
‘change in suggestibility’” (Hull, 1933, p. 391).
Although much of the research on suggestion
that Hull and others carried out did involve hyp-
notic induction procedures, both Bernheim and
Hull maintain a distinction between hypnosis and
1891–1959
1960–1999
2000–2013

suggestion, which can be seen in the respective

Table 1

titles of their books; Hypnosis and Suggestion in

Psychotherapy: A Treatise on the Nature and
 108 HALLIGAN AND OAKLEY
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Figure 2. Scopus publication profile for “suggestion, suggestibility” for “all fields” (article
and review) from 1891 onward. The color version of this figure appears in the online article
only.

Uses of Hypnotism (Bernheim, 1988/1973) and facilitated communication (Spitz, 1997), pla-
Hypnosis and Suggestibility: An Experimental Ap- cebo effects (Kirsch & Sapirstein, 1998), psy-
proach (Hull, 1933). chopathology (Groth-Marnat, 1991), illness
Suggestibility remains a common element in by suggestion (Lorber, Mazzoni, & Kirsch,
many forms of human behavior with few areas of 2007), religious experiences (Ward & Kemp,
human experience and social influence that could 1991), immunity (Shea, 1991), implicit learn-
not be described or explained as involving directly ing and decision-making (Michael et al.,
or indirectly different types of suggestion/ 2012), changing beliefs (Mazzoni, Loftus, &
suggestibility. The majority of these lie outside the Kirsch, 2001), conformity, persuasion and in-
formal domain of hypnosis (Hilgard, 1973; terrogative suggestibility (Groth-Marnat,
Kirsch, 1985; Lundh, 1998; Michael et al., 2012). 1991), distortions of memory (Toland, Hoff-
These include ideomotor movements man, & Loftus, 1991), advertising (Gould,
(Gauchau, Rensink, & Fels, 2012), response 1991), psychotherapy (Lundh, 1998), educa-
expectancies (Kirsch, 1999), psychosomatic tion, (Shuck, 1991), magic and the experi-
interactions (Kihlstrom, 2007), choice blind- ences of the paranormal (Wilson, 2011).
ness (Hall, Johansson, Tarning, Sikstrom, & The comparative neglect of this wider domain
Deutgen, 2010), postural sway, (Hull, 1933), of suggestion/suggestibility in the published jour-

Table 2
Scopus Search (Feb., 2014) of Papers (Article or Review) Containing the Term “Suggestion,
Suggestibility” for “All fields” from 1901 onwards
No of
articles Main Scopus Subject areasⴱ Top authors
1901⫺1959 42 Psychology 37% Arts/ Humanities 27.4% W. D. Scott, J. D. Ingham, T. A. Williams
Medicine 9.7
1960⫺1999 508 Psychology 47.6% Medicine 30.2% Social T. X. Barber, G. H. Gudjonsson, I. Kirsch
science 11.8
2000⫺2013 1,245 Medicine 24.1% Psychology 44.5% Social M. B. Powell, S. J. Ceci, I. Kirsch
science 9.0 Neuroscience 6.9
ⴱ
Total 1,795 does not sum to 100
 HYPNOSIS: EXPLORING THE BROADER DOMAIN OF SUGGESTION 109
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Figure 3. Scopus search (Feb, 2014) of papers (article or review) using the term “placebo
effect” for “all fields” from 1942 onward. The color version of this figure appears in the online
article only.

nal literature for much of the 20th century, how- responded to without hypnosis (i.e., without the
ever, seems surprising given: need for an individual to be taken through a
1. “The existence of the phenomena of sug- formal hypnotic induction procedure (Braffman
gestion and suggestibility has never been seri- & Kirsch, 1999; Gandhi & Oakley, 2005; Hil-
ously disputed in psychology”(Gheorghiu, gard, 1965; Hull, 1933; Kirsch, Mazzoni &
1989, Preface p. ix). Montgomery, 2007; Mazzoni et al., 2009; Lynn,
2. “The investigation of suggestive influences Kirsch, & Rhue, 2010).
was a central topic when scientific psychology 7. From a medical and therapeutic perspec-
was young” and when “nearly every important tive, “the effectiveness of suggestion has been
psychologist in those earlier days dealt with this demonstrated over and over again in every field
subject and made useful contributions to our un- of medicine and human behavior. In fact, in
derstanding of the suggestion process” (Gheo- practically every instance of research on drugs
rghiu & Kruse, 1991, p. 51). with humans, suggestion has been proven effec-
3. Babinski’s proposal in 1901 to abandon tive. In many cases . . . more effective than the
the word “hysteria” in favor of the new term pharmaceutical being tested!” (Henderson,
“pithiatism” (curable by persuasion) recognized 2003, p.170).
the significant role that suggestion played in the 8. Most “randomized controlled trials employ
genesis and treatment of medical disorders such concealed allocation of placebo to control for ef-
as hysteria (Babinski, 1901; Shorter, 2006). fects not due to specific pharmacological mecha-
4. Sidis’s claim as far back as 1898 that “the nisms. As a result, nearly all of evidence-based
fact of suggestibility existing in the normal indi- medicine derives from principles and practices
vidual is that of the highest importance in the based on placebo” (Barrett et al., 2006).
theoretical fields of knowledge, in psychology, in
sociology, ethics, history as well in practical life in Defining Suggestibility, Suggestion, and
education, politics and economics” (p. 17). Related Phenomena
5. Suggestibility’s demonstrable potential as a
powerful causal explanatory framework for many It is possible, that not unlike the relatively late
aspects of human behavior ranging from placebo, development of consciousness studies, the “strug-
expectation, unconscious systems of control and gle to understand the process of suggestion” may
monitoring, memory and pain control to advertis- have actually been “hampered by its ubiquitous
ing, magic, and the paranormal. and all-pervasive nature” (Schumaker, 1991). This
6. The fact that it was well established, early was highlighted by Sidis (1898) who maintained
on, that the same hypnotic suggestions could be that suggestibility “is present in what we call the
 110 HALLIGAN AND OAKLEY

normal state . . . and is a constituent of our nature: Following the modern scientific study of hyp-
it never leaves us: it is always present in us [al- nosis, initiated by Clark Hull in the early part of
though] it rarely attracts our attention” (pp. 15–17) the 20th century, hypnosis has been operation-
(Table 3). ally defined by the administration of a hypnotic
Such omnipresence, has also contributed to the induction procedure (Kirsch et al., 2011), which
subject being less accessible for scientific investi- in turn provided for distinguishing between
gation, and is not different from the research his- “trance” (the product of induction) and the dis-
tory of some other intact high level cognitive crete test, or “targeted,” suggestion stages of
processes (e.g., selective attention) which only hypnosis (Oakley & Halligan, 2013). The rela-
really began to attract neuroscience interest when tion between trance and suggestion is nicely
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probed experimentally or when used to explain depicted in Figure 4 (from Hypnosis and Sug-
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perturbations following pathology (e.g., stroke) gestion Web site, Whalley, 2014). Although the
that produced some form of quantifiable clinical two elements of hypnosis, trance and sugges-
construct (e.g., hemispatial neglect). Other chal- tion, are operationally distinct, a close exami-
lenging factors that contributed to the neglect of nation reveals how they are procedurally and
suggestion/suggestibility include the lack of an conceptually related.
accepted taxonomy of suggestibility dimensions The aim of induction is to achieve a greater or
and previous unsuccessful efforts to discover a more focused attentional state (“trance”) that is
common unitary dimension. assumed to facilitate subsequent targeted sug-
With a view to expanding the more traditional gestions, and, conversely, trance-related sug-
domain of hypnotic suggestion, it is helpful to gestion is typically deployed as part of the in-
provide some working definitions of key features duction procedure to achieve or enhance the
of the wider domain (see Table 3). A good starting “hypnotic” state. Classically, during the induc-
point for suggestion comes from the work of Boris tion phase, along with instructions, the hypno-
Sidis (1867–1923), the American psychologist tist provides implicit and explicit trance-related
who studied under William James at Harvard Uni- suggestions for relaxation, eye closure, height-
ened alertness, and expectation such as: “listen
versity. In his classic book, The Psychology of
to the sound of your breathing [instruction] and
Suggestion: A Research into the Subconscious
as you do so your mind becomes clearer [sug-
Nature of Man and Society (1898), Sidis provides
gestion]” or “as you listen to the sound of my
the following helpful definition of suggestion as:
voice [instruction] you will begin to notice the
“the intrusion into the mind of an idea; met with
muscles in your body becoming less tense [sug-
more or less opposition by the person; accepted gestion]”. These trance-related suggestions
uncritically at last; and realized unreflectively, al- have been regarded as qualitatively different
most automatically” (p. 15). His definition of sug- from subsequent “targeted suggestions” used in
gestibility is equally useful as “that peculiar state hypnosis to demonstrate classical hypnotic
of mind which is favorable to suggestion” (p. 15). “phenomena” [for example, in arm levitation
For Sidis, then suggestion was basically a com- –“as you pay attention to your left hand you
municable idea—a form of belief—that under cer- notice it becoming lighter and beginning to float
tain levels of suggestibility could be communi- upward all by itself”] or in an experimental
cated directly or indirectly resulting in automatic setting to achieve research-related experiential
and rapid, temporary or permanent alterations in a changes. For example, to create the experience
subject’s experience or behavior. of “alien control” in a fMRI study modeling
psychiatric and cultural possession phenomena,
The Role of Suggestion in Hypnosis and Deeley et al. (2014) used the suggestion “When
Conflation of Hypnotizability you hear the word ‘MOVE’ you will have the
and Suggestibility experience of your right hand being remotely
controlled by a fully functional machine oper-
With a view to locating hypnotic suggestion ated by its engineer and the joystick will be
within the broader family of suggestion-based moved to the right and then to the left once each
phenomena (Kirsch et al., 2011; Michael et al., time”.
2012), it is useful to review the procedures For many, the exercise of administering the
classically involved in hypnotic inductions. induction procedure itself is considered a form
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Table 3
Working definitions of the wider domain of Suggestibility /Suggestion
Some working definitions
Hypnosis “Hypnosis is a process in which one person, designated the hypnotist, offers suggestions to another person, designated the
subject, for imaginative experiences entailing alterations in perception, memory and action . . . . These experiences are
associated with a degree of subjective conviction bordering on delusion, and an experienced involuntariness bordering on
compulsion” (Kihlstrom, 2008, p. 21).
Hypnotic trance The cognitive end state produced by a hypnotic induction procedure.
Suggestion A form or type of communicable belief capable of producing and modifying experiences, thoughts and actions. Suggestions can
be (a) intentional/nonintentional, (b) verbal/nonverbal, or (c) hypnotic/nonhypnotic.
Posthypnotic suggestion A suggestion administered during hypnosis but intended to take effect following termination of the hypnotic experience.
Suggestibility The facilitative cognitive propensity that brings about experiential changes or actions in relation to different types of suggestion.
“Hypnotizability” (Hypnotic An individual’s responsiveness to the type of standardized suggestions used in classic hypnotic susceptibility scales following a
suggestibility) hypnotic induction procedure.
Imaginative suggestibility An individual’s responsiveness to the type of standardized suggestions used in classic hypnotic susceptibility scales when they
are not preceded by a hypnotic induction procedure (also termed “waking suggestibility”).
Interrogative suggestibility The tendency of an individual to change their beliefs and behaviors in the course of intense questioning in a closed social
situation.
Placebo effect Refers to the proportion of the positive outcome of a treatment or procedure that cannot be attributed directly to the
physiological, physical or psychological components of the intervention itself.
Expectation A powerful form of prepackaged or endogenous suggestion, in which dependent on differential levels of suggestibility, subjects
possess the capacity to “activate the reserve capacities of the mind and memory” (Bancroft, 1976).
HYPNOSIS: EXPLORING THE BROADER DOMAIN OF SUGGESTION
111
 112 HALLIGAN AND OAKLEY

of suggestion (Kihlstrom, 2008), conveying the (i.e., to be “hypnotized,” Braffman & Kirsch,
suggestion “to enter a hypnotic state” (Mazzoni, 1999). Accordingly, scales of “hypnotizability”
Venneri, McGeown, & Kirsch, 2013; Wagstaff, are best characterized as measures of “hypnotic
1998). suggestibility.”
Expanding on this latter point, and viewed
from the broad domain of suggestion, the induc- Responding to Suggestion Outside Hypnosis
tion procedure can be seen as harnessing the
subject’s latent expectations including their be- Another important aspect of hypnosis is
liefs regarding hypnosis itself, all of which have when subjects respond to suggestions that are
been shown to significantly influence or facili- given during hypnosis, but subsequently en-
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tate potential responsiveness to suggestion. Ac- acted after the hypnotic induction has been for-
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cording to Gibbons and Lynn (2010), subjects mally terminated (posthypnotic suggestion).
subsequent responsiveness to specific test sug- When suggestions were used to modulate the
gestions “depends less on the nature and success Stroop effect, for example, hypnotized subjects
of a particular induction than on” the subject’s received the suggestion that when the experi-
prehypnotic “motives, expectations, and beliefs, menter clapped his or her hands, the subject
as well as their trust and confidence in the would see words (presented in a colored font on
therapist.” Going further they claim that “the a screen) as meaningless symbols. After hypno-
preliminary discussion with clients concerning sis was terminated, the hand-clap subsequently
the nature of the experiences they are about to resulted in temporary eliminating the Stroop
undergo is “more important than the induction effect (Raz, Shapiro, Fan, & Posner, 2002).
itself”(Gibbons & Lynn, 2010). An example of Some researchers argue that such posthypnotic
this can be found in the study by Gandhi and suggestion offers a “cleaner” experimental ma-
Oakley (2005), which showed that labeling an nipulation (Raz & Shapiro, 2002) based on the
induction procedure as “hypnosis” produced a assumption that the resultant change occurs in
significant increase in subject’s subsequent re- the context of a more “normal” nonhypnotic
sponsiveness to suggestion when compared mental state, even though the targeted sugges-
with labeling the same procedure “relaxation.” tion was previously communicated under hyp-
Finally, although the procedures of induction nosis (Lifshitz, Campbell, & Raz, 2012).
and suggestion are traditionally distinguished in Even more compelling is the large evidence
hypnosis, the classic measures of “hypnotic sus- base for response to suggestions that do not
ceptibility” (or “hypnotizability”) refer to the require or involve any explicit hypnotic induc-
number of standardized suggestions that an in- tion (Braffman & Kirsch, 1999; Hull, 1933).
dividual successfully experiences and reports Responsiveness to suggestions as measured by
after a hypnotic induction procedure and not an traditional hypnotic susceptibility scales has
individual’s ability to enter a hypnotic state been shown to strongly correlate with respon-

Figure 4. Whalley’s figure depicting the overlap and differentiation of the 3 hypnotic
components. (http://www.hypnosisandsuggestion.org/). The color version of this figure ap-
pears in the online article only.
 HYPNOSIS: EXPLORING THE BROADER DOMAIN OF SUGGESTION 113

siveness to the same suggestions given without fails to open his or her eyes when told to try
a hypnotic induction procedure. Hilgard (1973) to do so); (c) cognitive (for example, Item 9
referred to this as “waking suggestion” and “Fly Hallucination” where the suggestion is
Kirsch labeled the phenomenon as “imaginative that there is a fly buzzing a round the partic-
suggestibility” (Braffman & Kirsch, 1999) to ipant’s head and that it is becoming annoying.
distinguish it from “hypnotic suggestibility.” In- A positive response is scored if the participant
deed subjects’ responsiveness to suggestions makes some overt response such as grimacing
without hypnosis is one of the best predictors of or trying to brush the “fly” away). These
their responsiveness to hypnotic suggestions, as verbal suggestions are delivered directly by
well as their independently assessed response the experimenter or via an audio-recording.
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expectancy (Braffman & Kirsch, 1999). These To meet the criterion of being a “classic sug-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

findings imply that “hypnotic” and “imagina- gestion effect” (Weitzenhoffer, 1980) the re-
tive” suggestibility share one or more common sponse needs to be experienced by the partic-
processes and that whereas experiencing a hyp- ipant as effortless and involuntary.
notic induction procedure may enhance respon- Although retaining the notion that suggest-
siveness above and beyond the same targeted ibility, as a general characteristic of human cog-
suggestion without hypnotic induction (Der- nitive functioning, may share a range of com-
byshire, Whalley, & Oakley, 2009), the induc- mon features, it can also manifest in a variety of
tion does not appear necessary or sufficient to ways depending on the context, the form of
produce suggested responses. Moreover, al- influence or interaction involved. In addition to
though hypnotic inductions have been shown to hypnotic/imaginative suggestibility, two other
produce changes in brain activity, “. . . [these] candidate “suggestibilities” that have been in-
changes are not required for the experience of vestigated experimentally, for example, are in-
hypnotic suggestions or their neural correlates” terrogative suggestibility and the placebo effect.
(Mazzoni et al., 2013). As such, hypnotic sug- Interrogative suggestibility refers to the ten-
gestibility can be conceptualized as a form of dency of individuals to accept messages com-
imaginative suggestibility, different only in that municated during formal questioning within a
the former is measured following the adminis- closed social interaction, with resultant changes
tration of a hypnotic induction procedure. in their behavioral response (Gudjonsson &
Clark, 1986). The placebo effect is evident,
Types of Suggestion classically in medical and therapeutic contexts,
when the positive health outcomes of a treat-
It is possible to consider hypnotic and ment regime cannot be fully explained by the
imaginative suggestibility as subvarieties of physical or pharmacological components of the
the same form of suggestibility, typically intervention itself but are attributable in part to
measured by the sort of suggestions used in the beliefs and expectancies that the individual
traditional hypnotic susceptibility scales. The receiving the treatment holds about its likely
12 suggestions included in scales such as the efficacy (Kirsch, 1997). It is also arguable that
Harvard Group Scale of Hypnotic Suscepti- individuals are capable of demonstrating most if
bility (Shor & Orne, 1962) are of three types: not all of these suggestibility’s and that their
(a) ideomotor (for example, Item 7 “Hands predictive degree of responsiveness to each of
Moving Together” involves a suggestion that them will vary within the population, possibly
the participant’s outstretched hands are being in the form of a normally distributed trait, as is
drawn together by a force acting upon the case with hypnotic/imaginative suggestibil-
them—a positive response being recorded if ity. It does not necessarily follow, however, that
the hands move toward each other); (b) ideo- an individual will show similar levels of respon-
motor challenge (for example, Item 10 “Eye siveness across each of the suggestibilities. In
Catalepsy” where the suggestion is that the fact, measures of placebo suggestibility and in-
participant’s eyelids are becoming more and terrogative suggestibility do not correlate with
more tightly closed [ideomotor suggestion], hypnotic/imaginative suggestibility measures
so tightly closed that the participant could not (Kihlstrom, 2008). There is also evidence that
open them even if they tried [challenge]—a one at least of these other suggestibilities does
positive response is recorded if the participant not constitute a homogeneous category. Placebo
 114 HALLIGAN AND OAKLEY

responsiveness appears to vary within an indi- (curable by suggestion; Merskey, 1995). Cen-
vidual depending on factors such as the context tral to Charcot’s explanation was the concept
in which the placebo is presented. As a conse- that “fixed” ideas were symptoms derived from
quence, in contrast to hypnotic/imaginative sug- the unconscious based on suggestion or auto-
gestibility, individuals cannot be classified as suggestions (Bell et al., 2011). In hysteria, the
consistently high or low placebo responders, patient’s belief of not being able to move the
indicating that “there may not be one placebo affected limb was part of Charcot’s influential
response but many” (Whalley, Hyland, & explanation of hysteria. This functional paraly-
Kirsch, 2008). Although this potential complex- sis in hysteria was seen as the consequence of
ity may represent a challenge it does not negate the patient acceptance (suggestibility) of a mal-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

the view that there is a broad trait of suggest- adaptive idea (belief/suggestion) thought to
This document is copyrighted by the American Psychological Association or one of its allied publishers.

ibility underlying various manifestations It is originate from the patient’s unconscious and in
also notable that creating a particular mental response to a potential psychological stressor.
state or expectancy (in this case by using a Charcot’s account was strongly influenced
formal “induction” procedure) can serve to en- by the earlier work of the English neurologist,
hance responsiveness to the same suggestions, John Russell Reynolds who wrote “that some
although such effects are relatively small of the most serious disorders of the nervous
(Braffman & Kirsch, 1999). It seems likely that system, such as paralysis, spasm, pain, and
similar effects of mental state manipulations otherwise altered sensations, may depend
will be found in other forms suggestibility. In upon a morbid condition of emotion, of idea
what follows we will concentrate on core fea- and emotion, or of idea alone . . . they some-
tures of human suggestibility as an overarching times associate themselves with distinct and
concept without considering its subvarieties in definite diseases of the nervous centers, so
detail. that it becomes very important to know how
much a given case is due to an organic lesion,
Pathology as a Window on Function and how much to morbid ideation”(Reynolds,
1869, p. 483).
Although Bernheim (1888) emphasized the Following the concept of “psychical paral-
importance of suggestion and associated hypno- ysis” introduced by Reynolds (1869), Charcot
sis within normal psychological function, some stressed the importance of the idea, conclud-
of the earliest discoveries of modern psychol- ing that hysterical (and by extension hypnotic
ogy were inspired by attempts to understand the paralysis) originated when “the idea comes to
relationship between hypnotic suggestion and the patient’s mind that he might become par-
psychopathology (Groth-Marnat, 1991). Sidis alyzed: in one word through autosuggestion,
recognized the work of Pierre Janet and Alfred the rudimentary paralysis becomes real”
Binet on hysteria and hypnosis as being respon- (Charcot & Marie, 1892, p. 630). Recently,
sible for helping open up “new regions in the and in a similar vein, De Vignemont (2009)
psychical life of man”(p. 16). In particular, sus- suggested that patients with conversion paral-
ceptibility to suggestion was long identified ysis may suffer from a delusion (false belief)
with hysteria (more recently labeled “conver- that they are paralyzed—in the same way that
sion disorder”). Pierre Janet, considered sug- anosognosic patients have the delusion that
gestibility to be the tendency for a simple idea they are not paralyzed (Davies, Aimola Da-
(internally or externally generated), to develop vies, & Coltheart, 2005). A similar, more
into automatous complex chains of association recent clinical take on Charcot’s psychogenic
that exert an effect over the body and are out- account is provided by Hurwitz and Prichard
side the patient’s conscious control (Poole, (2006) who suggest that hysterical conversion
Wuerz, & Agrawal, 2010). occurs when an “idea of illness forms in the
A contemporary of Janet, the neurologist mind of a patient and commandeers neuronal
Jean–Martin Charcot claimed that similar brain machinery to impose a pattern of inhibition or
processes were responsible for both hysteria and activation which follows that particular per-
the pseudo–neurological behaviors produced by son’s idea of illness.”
hypnosis. Joseph Babinski, a pupil of Charcot’s, Considering hysteria as a good example of
went so far as to rename hysteria “pithiatism” autosuggestion, Oakley (1999) developed a
 HYPNOSIS: EXPLORING THE BROADER DOMAIN OF SUGGESTION 115

working cognitive model inspired by Norman and expectancies. Kirsch and Lynn (1997)
and Shallice’s influential contention schedul- propose that subjects in a hypnotic situation
ing/supervisory attentional model of execu- adopt a generalized response expectancy (a
tive function. According to Oakley’s model, type of belief) to follow the hypnotist’s in-
the supervisory attentional system only inter- structions and produce behaviors that are ex-
venes in nonroutine situations to control or perienced as involuntary. Hence, subjects are
modulate actions by deploying top– down at- likely to attribute hypnotic responses to ex-
tentional resources. Being automatic, well re- ternal causes (i.e., the hypnotist) and experi-
hearsed actions are triggered by environmen- ence them as involuntary. According to this
tal circumstances acting directly on lower theory, hypnotic responses are initiated by the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

level executive structures with little con- same mechanisms as voluntary responses, the
This document is copyrighted by the American Psychological Association or one of its allied publishers.

scious involvement. Building on this back- difference being how the behaviors are ulti-
ground, Oakley’s model proposed a system mately experienced and attributed by the sub-
level of full awareness (“Level 1” or personal ject.
level of awareness) that involved limited ca- As such, the clinical symptoms seen in hys-
pacity, analytical processing, and conscious teria could be activation of stored or learned
self-reflection. Oakley’s second system ideas, packaged as beliefs that allow for the
(“Level 2”or the subpersonal level) is essen- easy and nonvolitional influence on phenome-
tially the supervisory attentional system and nology (Brown, 2002). Exploiting the capacity
contention scheduling system described by to produce experiential changes and behaviors
the Norman and Shallice model, but with the using hypnotic suggestion, Charcot was in-
additional component of selecting a subset of spired to produce similar symptoms in patients
currently active representations for process- by communicating such ideas to the same pa-
ing in the “Level 1” self-awareness system tients using hypnosis (Merskey, 1986). Recent
which could be the subject of consciously work (Bell et al., 2011) has broadly supported
reflection. Employing this model, “sugges- the view that hypnotic suggestion can be used to
tions” can be seen to influence processing at produce plausible analogues of hysterical con-
the “Level 2” system and can include envi- ditions (e.g., paralysis) accompanied by similar
ronmental prompts, one’s own and other be- brain changes.
liefs, motives, and expectancies. The process Seen from the broad “domain of suggestion,”
can be further enabled by shaping attention hypnotic suggestion comprises one important
systems to disattend to external stimuli and element of the suggestibility continuum. Given
might include suggestions as shaping the per- the success that hypnosis has had in many areas
ception of different stimuli. Anything that of clinical practice (Spiegel, H., & Spiegel, D.,
results from influences acting directly on the 1987) and the fact that hypnosis is gaining trac-
“Level 2” system is likely to appear to the tion in the cognitive neurosciences (Halligan &
“Level 1” system as automatic or uninten- Oakley, 2013), it seems timely to explore the
tional. Hence, in Oakley’s model, both hyp- broader elements of the suggestion/suggestibil-
notic and hysterical symptoms are produced ity continuum with a view to seeing if the dif-
by suggestion-driven alterations in activity at ferent forms of hypnotic and nonhypnotic sug-
the Level 2 system, which in turn influence gestibility provide some basis for elucidating an
the consciously aware content at the Level 1 underlying, shared psychological capacity or
system. In this model, hysterical symptoms trait.
can be characterised as predominantly an au-
to-suggestive disorder, whereas hypnotic Facilitating Acceptance of a Communicable
symptoms result from the strategic communi- Belief: Suggestibility
cation provided by another person. Unlike
patients with hysterical symptoms, who re- Although there is a significant body of work
main largely unaware of any self-suggestions demonstrating the powerful effects of the pla-
or mental states, in hypnosis the subject is cebo response for medical interventions “few
typically aware of the target suggestion and contemplate the significance of suggestion in
such suggestions normally include the use of the development of their own patient’s symp-
a focused attentional state, internal imagery, tomatology” (Trimble, 2004). Turning this
 116 HALLIGAN AND OAKLEY

around, several authors have highlighted the dently of the participants’ expectancy, and was
potential benefits of using “suggestion” as a correlated with an increase in the participants’
treatment strategy to change beliefs in patients imaginative ability following nitrous oxide ad-
with psychogenic movement disorders (Lim, ministration (Whalley, & Brooks, 2009).
Ong, & Seet, 2007; Shamy, 2010). It is also
interesting that the last article published by Going Beyond the Suggestion Provided
Charcot dealt with autosuggestion as a means of
self-therapy and cure rather than as a precipitant As an experimental tool, targeted hypnotic
for illness (Goetz, 2006). suggestions are commonly used to generate a
One area where suggestibility has begun to range of clinically informed clinical analogues,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

make its mark outside hypnosis in association including blindness, achromatopsia, limb paral-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

with medication has been in the treatment of ysis, emotional numbing, memory loss, analge-
patients with hysterical symptoms. Interviews, sia, auditory hallucinations, hypnotically sug-
carried out under the influence of drugs were gested pain, and more recently temporary
developed as a simple alternative to hypnosis delusions about the self and the world including
and were thought to render individuals hyper- clinically relevant hypnotic analogues of delu-
suggestible, with hysterics being uniquely sug- sions of alien and anarchic limb control and
gestible (Tilkin, 1949). Employing a systematic mirrored self-misidentification (Oakley & Hal-
and meta-analysis review of studies published ligan, 2013). In 2009, Oakley and Halligan
in english, Poole, Wuerz, and Agrawal, (2010) pointed out that this instrumental use of hyp-
described the use of drug interviews (mainly notic suggestion required at least a good under-
abreaction) for treating conversion/dissociative standing and a clear specification (by the re-
disorders. In some of these studies, the physi- searcher) of the key phenomenological
cian suggested that symptoms would resolve experiences associated with the clinical condi-
during the interview, in others, that the motor, tion (i.e., informed by clinical patient’s descrip-
sensory, or other body functions would be grad- tions of what it is like to have such a condition
ually restored. The most striking finding of this and by associated clinical observations) under
review was the effective use of verbal sugges- study, to craft the relevant targeted suggestions.
tion when eliciting a specific nonvolitional re- Nevertheless, such suggestions can only convey
sponse experienced by the subject. Suggestions a selective and small number of propositions—
were found to be statistically associated with a whereas the subject’s responses often produces
good outcome in all of the large studies re- a much richer, more comprehensive set of ex-
viewed. periences and responses (see supplementary
Some of these studies employed a change in data in Oakley & Halligan, 2009) requiring sub-
the background state of the subject’s conscious- ject’s to go beyond and supplement the specific
ness as a form of “induction like” procedure suggestion with existing or prior knowledge to
ahead of the target treatment-orientated sugges- produce the eventual clinical analogue. Evi-
tions. In a study by Hafeiz, (1980) involving a dence from placebo and nocebo studies also
total of 61 patients who received treatments suggest that the subject’s cultural knowledge
aimed at removing a wide range of hysterical regarding medicine (e.g., beliefs) and its prac-
symptoms (e.g., aphonia), the authors employed titioners may not only provide for therapeutic
a simple method of suggestion but a range of interventions but also help to generate condi-
enhanced suggestibility techniques including tions of illness by activating latent expectations
(a) Faradic stimulation (applied briefly to lower (Hahn, 1997). In the hypnotic analogues cases,
or upper limbs); (b) Somlec: an electro-sleeping the enhanced suggestibility provides the oppor-
machine that produced relaxation; (c) Sodium tunity for subjects to harness their additional
amylobarbitone; 250 mg in 5 ml given intrave- semantically informed reconstructive imagina-
nously; and (d) Methylamphetamine (Methe- tive process which can collectively supplement
drine) 10 mg intravenously. Interestingly, ni- the specific hypnotic suggestions.
trous oxide inhalation has also been shown to There is evidence that subjects can harness or
increase imaginative suggestibility (as mea- make use of high-level semantic information
sured by a hypnotic susceptibility/suggestibility (“expectations”) regarding symptom/condition
scale without a hypnotic induction) indepen- presentations with and without direct experi-
 HYPNOSIS: EXPLORING THE BROADER DOMAIN OF SUGGESTION 117

ence. Subjects can possess common or shared our perception of the world is naturally ambig-
symptom-related expectations and these can be uous and unstable and that the process of nor-
recruited to help shape hypnotically informed mal experience and action is one of continuous
clinical analogues. For example, Mittenberg et conscious and subconscious disambiguation,
al. (1992) conducted a study with 223 subjects Gheorghiu and Kruse (1991) proposed that sug-
with no personal experience or knowledge of gestibility is largely involved in facilitating this
head injury, and asked participants to complete disambiguation. Suggestive influences thus pro-
an affective, somatic, and memory checklist vide a specific interpretation in a situation
regarding their expectations of symptoms 6 where there are multiple competing outcomes.
months after a head injury. A similar checklist Kirsch’s (1985, 1999, 2004) influential work
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

was provided to 100 patients with head injuries on response expectancies, which demonstrated
This document is copyrighted by the American Psychological Association or one of its allied publishers.

for comparison. Predicted concussion symp- how humans employ “perceptual templates or
toms in the naive controls reliably showed a expectancies to resolves stimulus ambiguities,”
coherent cluster of symptoms virtually identical assumed that such anticipations provided adap-
to the postconcussion syndrome reported by tive advantage in allowing humans to interpret
patients with head trauma, leading the authors and respond to their environment more effec-
to conclude a possible etiological role for ex- tively and efficiently (Kirsch, 1999, pp. 6 –7).
pectations. Schumaker (1991), on the other hand, proposed
that the evolutionary value of suggestibility in-
Suggestibility as an Important cluded the potential to transcend reality, to
Adaptive Trait function as social creatures and operate in an
economical and energy-conserving fashion with
Much experimental interest in hypnosis has dissociation (disengagement of higher order
understandably centered on a small number of cognitive functions) as the prime process that
individuals who score very highly on hypnotic renders subjects responsive to suggestion.
suggestibility, often referred to as “High Hyp- Important in this context, is the question of
notizables” (Heap, Brown, & Oakley, 2004). It the biological utility of our brain’s ability to
is worth noting, however, that studies using provide “real” experiences as second hand, and
standardized hypnotic suggestibility measures how this may assist us in developing knowl-
such as the Harvard Group Scale of Hypnotic edge, beliefs, and intentions that are important
Susceptibility (HGSHS; Shor & Orne, 1962) in understanding the world and minds of others.
have reliably shown that hypnotic suggestibility These internally generated experiences trig-
is not only a stable trait, but is normally distrib- gered by external events (which include the
uted in the population and has cross-cultural varied forms of suggestion) may underlie the
validity (Barnier & McConkey, 2004). There is important developmental process of imitation
also evidence that it is hereditable and associ- (possibly via mirror neurons), pretence, role-
ated with specific genotypes linked with pre- playing and the emergence of a Theory of Mind
frontal cortical executive functions and working (see also Kihlstrom, 2014). In the case of hyp-
memory (Laurence et al., 2008). To the extent notically suggested effects, for example, there is
that these data primarily relate to suggestibility good evidence that the suggested experience of
measured following a hypnotic induction pro- pain not only feels “real,” but also is accompa-
cedure, it has been easy to dismiss them as nied by corresponding changes in relevant brain
having no significance outside the domain of areas (Oakley & Halligan, 2013). In this regard,
hypnosis. Given the emerging view offered it is interesting that one of the few personality
above that what is being measured by HGSHS traits to correlate with hypnotic/imaginative
is an exemplar of a more general trait of sug- suggestibility is empathic responsiveness (e.g.,
gestibility independent of the hypnotic process, Wickramasekera & Szlyk, 2003). A number of
the question arises as to the broader psycholog- authors have speculated on the adaptive signif-
ical relevance of suggestibility and especially icance of hypnotic/imaginative suggestibility.
its adaptive significance. Spiegel (2008) for example reviews evidence
Several authors have speculated as to the that high hypnotic/imaginative suggestibility is
potential adaptive value or evolutionary benefit associated with a number of positive social and
of suggestibility. Based on the assumption that individual traits, in particular being trusting of
 118 HALLIGAN AND OAKLEY

others, having the capacity for intense imagina- as a powerful psychological and social causal
tion and a tendency to live in the present, rather mechanism, it still remains surprising that the
than worrying about past and future. Dienes and domain of suggestion and suggestibility has not
Perner (2007), interpreting hypnotic responsive- evolved to become a more significant topic of
ness in the context of their Cold Control theory research for mainstream psychology and cogni-
of mental function, noted that hypnotic-like ex- tive neuroscience. Perhaps (paraphrasing Bi-
periences are very common cross-culturally and siach & Rusconi, 1990) . . . it might be the case
the capacity to have these experiences, associ- that we find certain aspects of suggestion puz-
ated for example with religious belief and spirit zling, because we do not find the whole busi-
possession, has long served a range of useful ness of suggestion puzzling enough.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

sociological functions. Coincidentally, two re-

This document is copyrighted by the American Psychological Association or one of its allied publishers.

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