In the foregoing treatment we have expressed the view that all persons are accessible, in principle, to profound hypnosis. But we do not go so far as to say that all persons may be put into profound hypnosis under the conditions of ordinary medical office hours According to Liebault, about 16 per cent enter into profound sleep-according to Ringier, about 35 per cent. Hilger has given similar figures. Tromner even obtained in one series 52 per cent of profound hypnoses. We cannot ourselves indicate percentages since in a great number of cases, as we shall explain later, we do not aim in advance at profound sleep, and give indication even in the formulation of our introductory words of this fact. In general, in our experience, the percentages given as profound sleep hypnoses are probably too high. Furthermore, these statistics really constitute a motley array of the most heterogeneous material, with the result that their value is quite relative. Besides, according to our experience, the depth of sleep depends in great measure on the time of life! According to Tromner, whose exposition we are here following children are very easily brought into profound slumber, middle-aged persons present some difficulty in hypnotizing them, old persons as a rule are very hard to influence. According to the experiences of the present authors, which are in perfect agreement, the number of patients who are absolutely refractory is very slight, perhaps between 2 and 6 per cent. Here again figures depend to a great extent on the nature of the material, and for this reason have no absolute value. In the case of children under five years old, it is not an easy matter to decide on hypnotic treatment, as a rule, as it is difficult to determine a suitable suggestion formula. Also, it is questionable whether there is any sense in carrying out a hypnotic procedure at a period in which even the waking life presents similar cleavages of instinct as are found in hypnosis. We admit, however, that to our knowledge there is a lack of sufficient observations concerning hypnoses in early childhood.

Hypnosis may be applied therapeutically in many ways. We shall distinguish for the present between three such applications.

1. The hypnotically induced sleep is used directly as a healing factor.

2. The suggestion given in hypnosis is directed outright against the psychic or physical symptom which is to be eliminated.

3. Forgotten experiences are brought back to memory in hypnosis and are made accessible to the consciousness (cathartic hypnosis).

Notes on 1. Wetterstrand calls our attention to the fact that patients who are run down physically may be excellently calmed by means of long hypnoses extending even for days at a time. He recommends this procedure also for neuroses. We also are convinced of the direct healing effect of sleep and for this reason extend profound sleep hypnoses for several hours, if the physical circumstances permit, and if we are convinced that there is no danger of the patient's passing into the exceptional state of somnambulism. But even after light hypnoses it is expedient in many cases to permit the patients to sleep on for some time (a few minutes, at most a quarter of an hour) their hypnotic slumber, after the hypnotic procedure proper, under the suggestion that they should sleep on peacefully, " switch off " all thought, concentrate on themselves, etc. We thus attain a natural transition, a gradual passing from the hypnotic state to the state of waking, and avoid too sudden an awakening, We have observed only the most favorable effects from this after-sleep after the hypnotic procedure proper, in many cases even a strengthening of the suggestions communicated in hypnosis by means of the susbequent sleep. Only in a few cases have we been able, as is recommended by Wetterstrand, to permit the patients to sleep for more extended periods and wake them only for their meals, etc, This hypnotic sleep cure has been of excellent effect in our practice, among other things, in the treatment of an abdominal neurosis. The patient in question, a woman, came to the clinic completely run down, and very much emaciated, suffering from vomiting, psychogenically motivated, which ensued upon taking either solid or liquid food. The hypnotic sleep cure in this case registered striking results within a few days, soon rising to a normal consumption of food without vomiting. At times this sleep cure may be ably supported by administering small doses of soporifics. By means of a combination of long-time hypnoses and soporifics, the patients may often be kept for days in a condition of sleep, which has afforded us excellent results particularly in the treatment of stubborn tics,(*) even when of organic origin and motor stimulus phenomena in general (compare also long-time narcotic sleep in schizophrenia as practiced by Klasi). Such sleep cures will in general be applicable only where it is possible to secure suitable supervision. Even in hypnosis by soporifics, the immediate sleep effect will also be of value. We believe that,' in addition to the physical effect of the sleep, the psychic elaboration which the person devotes during sleep, to his experiences, also has value. It is self-evident that only very profound degrees of hypnosis are valuable for the utilization of the sleep effect as such. Notes on 2. The direct suggestion may be made and become effective in superficial sleep as well as in profound sleep. It may be addressed against the symptom as such and may in these cases be given in great detail. For instance, if we are combating insomnia, it will not be sufficient for us to say to the patient: " You will sleep well," but, depending on his habits of life we must say: "You will get tired and sleep at this hour or that; you will go to bed; you will feel a heaviness in all your limbs; you will feel sleepy; your eyes will close; you will fall into a profound, sound sleep; you will sleep throughout the night without any disturbing dreams and you will wake up refreshed in the morning at this hour or that." Sometimes it is even expedient to add that the patient, after satisfying a bodily want, will go on sleeping peacefully.

(*)In a number of my tic cases the results with hypnotic suggestion together with the use of relaxation exercises have been very gratifying and is surely the best method of treatment available for these cases — Trans.

If the suggestion is intended to combat attacks of hysteria, it will be useful to have the patient describe precisely his feelingsbefore the beginning of the hysterical attack and then to give him the suggestion that these sensations do not ensue even when excitement is present and that for this reason the hysterical attack will not take place. These suggestions must be given with the utmost detail, and be based on a meticulous observation of the patient's condition of life. If it is desired to influence organic symptoms, or symptoms of uncertain psychogenesis, the path of direct suggestion described above is the only one available. But if we are dealing with symptoms of known psychogenesis or of reasonably certain psychogenesis, it is desirable not to attack the symptom by means of direct suggestion, but if possible to aim the suggestion against the psychic factors which are responsible for the appearance of the symptom. We shall there fore prefer, in general, to suggest to a female patient, who has attacks of hysteria every time she sees a certain person, not only that she is to remain calm on such occasions, but we shall be at pains to learn whence this person has obtained his or her symptom-producing effect, we shall investigate the reminiscences which may perhaps crop up at each new appearance of this person and attempt to deprive them of their power. We recently treated a young man who always failed at examinations owing to a feeling of acute fear and terror. It turned out that whenever he was present at an examination, he experienced a revival of his fear of his oversevere father. The suggestion was therefore aimed not only against his fear of examinations, but also against his attitude of terror toward his father. It is therefore our effort always to get down to the psychic causes and to combat these psychic causes by means of suggestion. But it is evident at once that such a treatment absolutely requires an intimate association with the patient. We are of the view that such intimate association with the patient will be more fruitful if the physician has a knowledge of psychoanalysis and is capable of applying the psychoanalytic technique in the conversations preceding the hypnosis. We shall have a little more to say on this subject later.(*)

(*) Analysis of a case of hysterical blindness revealed that when going under anesthesia for the removal of an affected eye with glaucoma, the patient thought of her mother dead 20 years, who also became blind from a shock which she had received on hearing of patient's elopement with the man her mother bitterly opposed her marrying. The patient feared dying and displaced her remorse in having caused her mother's affliction by herself becoming blind.—Trans.

Notes on 3. The foundation of cathartic hypnosis is the assumption that the neurotic symptom is based on inhibited obstructed affects. Hypnosis abolishes inhibitions and obstructions and liberates the obstructed affect (Breuer). We have already discussed this as a principle. We have also pointed out that hypnosis only opens up a path to the experiences of the system of the preconscious mind, but not to the experiences of the system of the unconscious. But the latter is the chief source of neurotic symptoms, and at once our attention is called to the fact that cathartic hypnosis has frequently turned out to be insufficient. The catharsis enables us to eliminate traumatic material of superficial location, which may under certain circumstances result in healing, but are often powerless when faced with more basic, more profoundly displaced material. As a matter of fact, our own results obtained by means of cathartic hypnosis have not been very satisfactory. But we must state that other authors, for instance Kohnstamm and Friedermann, Frank and Bezzola, have obtained much more favorable results and that cathartic hypnosis must after all be considered as a serious therapeutic method Very frequently, however, as we have already stated, the patient will not give any different indications in hypnosis than in the waking . state, or he will state only things that he himself has already known but withheld, and finally, the material that had really been forgotten and was dug out by means of hypnosis has often been of comparatively slight importance. Only neuroses are of course involved in treatment by means of cathartic hypnosis; organic disturbances are completely inaccessible to this treatment. In general, catharsis requires profound hypnosis. But Freud has stated that patients inaccessible to profound hypnosis may obtain associations as a result of slight suggestive measures. These reminiscences attained by means of suggestive influence lead directly to the later method of psychoanalysis, the method of free association. Let us emphasize that the method of free association is doubtless by far the more penetrating and fruitful of results. Frank also makes use of superficial hypnosis for bringing on catharsis. We append a few remarks on the technique of cathartic hypnosis which may be applied also in the illumination of amnesias, where such illumination appears desirable for any reason. We must assume that the illumination will not require more than a single session or several sessions, but will rather be attained piecemeal with great effort. In this connection we refer to the observation of Nef who illuminated a great amnesic gap piecemeal. In the illumination of amnesic lacunae we must choose some point of departure, as in the case of penetration to the causes of a neurotic symptom. In the case of amnesic lacunae we may either proceed from the last recalled situation or from the first recollection after the return of the normal state. From this point of departure we must feel our way forward step by step, always bearing in mind that this statement or that may be incorrect. It is therefore expedient to begin all over again from the indicated points of departure at times.

In the cathartic treatment of neuroses, the symptom is the natural point of departure. The earliest observations of Breuer and Freud already showed that it is not sufficient to disclose any random psychic cause for a symptom, but that all the occasions must be revealed under which the symptom has put in its appearance. In most cases the course of reamnesation will consist in a progress of the investigation from the latest occasions back into the past, even into childhood. Here again we must constantly ask whether the memories communicated by the patient are memories or imaginings. Very often it is hard to draw the line. Nor is it of much consequence for the therapeutic effect; since cathartic hypnosis is concerned not so much with the determination of historical truth and since significant psychic realities may be concealed behind the figments of the imagination; and even the veiled reference made in the imaginings may be of therapeutic consequence for the patient. The principle applying to all cathartic treatments of neuroses must be to uncover as many as possible, even all,* of the psychic causes of a symptom before the symptom will finally disappear. We have no right to expect, therefore, that a symptom will disappear if only this occasion or that has been uncovered.

(*)Strictly speaking, the uncovering of all causes is an impossible task.

On the basis of all the foregoing treatment, we consider the method of direct therapeutic suggestion to be the most important. It is not only applicable to the widest extent, but is on the whole the most effective. We are accustomed to apply this procedure as the norm. In purely organic symptoms, the mode of treatment is extremely simple. The hypnosis is made as profound as possible, and once the desired profundity has been attained, the therapeutic suggestion attacking the symptom is formulated with the utmost incisiveness and clarity. The treatment must often be repeated. If we are treating a neurosis, we usually devote a few (two or three) hours to a psychoanalytically planned conversation with the patient. Only then do we begin our hypnotic seances, always preceded, however, by questioning. Material obtained by these questions is used in the formulation of the suggestion. In the succeeding sessions also we devote much of the time at our disposal to such questions and make sure to formulate the question to fit the individual case closely. In neuroses, we usually attach no particular importance to a deepening of the hypnosis, and concentrate our energy on the psychic illumination of the patient. In general, the first signs of improvement in cases that react therapeutically appear quite early, approximately after the third or fourth hypnotic session. As a rule, improvement then proceeds rapidly. The elimination of the symptoms does not mean that treatment should be stopped at once. Relapses after the first liberation from symptoms are frequent; in fact, we must be prepared for the first relapse and not consider the case cured until the first relapse has been overcome. It is obvious that such treatments by hypnosis cannot be completed in a short time. We count, on an average, on from 15 to 25 sessions of one hour where the neurosis is at all serious. We shall have occasion later to remark that hypnosis is not sufficient in very serious neuroses. Here psychoanalysis must be called upon. We shall say more in our more detailed section, on when the hypnotic treatment is indicated. Particular stress must be laid in every hypnotic treatment on urging the patient not to give up his symptoms to please the physician, but to overcome his symptoms in his own interest. We must force the patient to gain a more or less complete grasp of the meaning of his symptoms and to learn to dispense with them. In fact, in general, in using the method of direct suggestion we must give heed, beginning with a certain phase of the treatment, to informing the patient that he must make the symptoms disappear on the basis of his own adjustment, and securing his cooperation in this direction. Of course, it will not be well to overemphasize the patient's independence in the earlier phase of the treatment, but the reference to the patient's own will must be emphasized in the later formulation. _ Never will there be any cases of such conditions of abject subordination of the hypnotized on the hypnotizer, of that subjection of the hypnotized toward his physician, which were so often attempted by the old-style hypnotizers and which are rightly feared as abuses of hypnosis. One of the present authors, at the beginning of his medical career, found a number of instances of such hypnotic bondage as a remnant of the earlier period. Certainly such phenomena are not of the essence of hypnosis, and a correct technique can easily obviate such products of the art. In fact, we may go so far as to say that it would require special effort in this perverse direction to secure such conditions It should not be the ambition of the hypnotizer and psychotherapeutist to attach the patient to himself as powerfully as possible Any psychotherapeutic attachment of the patient to the physician must in the last analysis have the purpose of enabling the patient to have his own individual experience and to free him from those obstructions that impede the development of his personality. Any psychotherapeutic connection must therefore be broken and one of the important phases of all psychic therapy is a correct breaking of this contact. We owe our understanding of the nature of these processes to Freud's theory of transference, which we seriously recommend to the reader.

We have again and again emphasized that hypnosis is a regressive condition, a return to an undifferentiated and formless being. We might ask what sense there is in obtaining such a giving up of differentiations. We should not ignore the important meaning of chaos, or of the primitive, for it is from these sources that all new-formulations emanate. Here in this sphere of Freud's system of the unconscious lie the sources of the creative. The physician's hypnosis melts down perverse differentiations and forces the individual to reconstruct a psychic life of higher accommodation and with a better understanding of reality. This reconstruction is conducted under the supervision of the physician's personality, for the relation of the rapport is an essential ingredient of hypnosis. Herein, and in the relatively slight depth of the return to the unformulated, in the reservations of the hypnotized, is found that peculiar weakness of the hypnotized person, which places him so far below the really creative person and the really loving person.

This is the proper point for devoting a few more words to the theory of Coue and Baudouin. Both these men are guilty of a fundamental psychological error in failing to recognize the role of the fellow human in suggestion and hypnosis. Baudouin is also mistaken when he assigns to the decision of the will of the individual a fundamentally obstructing influence. He is wrong in advocating the view that a decision of the will strengthens the neurotic symptom. Even decisions of the will are based on forces emanating from the realm of the unconscious and awaken such powers in the individual. The decision of the will may have disturbing influence if it is not properly supported by the material of the unconscious. But we have no reason to dispense with this powerful support to decisions of the will. And particularly in the second phase of the treatment, we appeal without hesitation even to the rational personality of the patient, both in the superficially and in the profoundly hypnotized. In other words, we by no means scorn, in certain phases of the treatment, to unite our mode of influence with a dialectic process, in superficial as well as in profound hypnosis, a process approximately resembling the Dubois persuasion method.