Hypnotic Ego-Strengthening Procedure

Originally created to (pre-therapeutically) strengthen his patients' inner resources — "analogous to the medical setting in which a patient is first strengthened by proper nutrition, general rest, and weight gain before a radical form of surgery is performed" (Torem, 1990, p. 110) — specifically to enhance the therapeutic efficacy of his (subsequent) symptom-removal hypnotherapy, Hartland later discovered that his "ego-strengthening procedure" could successfully address a wide range of circumstances, on its own, as the sole form of therapy.

Hartland's 1965 article, "The Value of "Ego-Strengthening" Procedures Prior to Direct Symptom-Removal under Hypnosis" was significant for positioning the concept of "ego-strengthening"; and "ever since then, the concept could be unequivocally named, identified, investigated, productively discussed, and generally understood by all concerned". The article was also significant for introducing the convention of ". . ." to indicate pauses in the operator's delivery of the monologue.

"Ego-strengthening suggestions are designed to increase the patient’s ability to cope with his difficulties or to encourage him to stand on his own feet. There are three kinds of ego-strengthening suggestions: (a) general ego-strengthening suggestions, (b) specific ego-strengthening suggestions to facilitate the discovery and enhancement of the patient’s inner coping strategies, and (c) specific suggestions to foster the patient’s sense of self-efficacy. ..."
"Ego-strengthening suggestions, while seemingly simplistic, are quite valuable. Hartland and many others believe that in certain instances ego-strengthening suggestions alone can bring about a successful treatment outcome without [any need to resort to either] symptomatic or dynamic hypnotherapy. Some patients experience spontaneous alleviation of symptoms when they feel strong enough to cope without the symptoms. Direct suggestions for coping, therefore, are sometimes more effective than direct suggestions for symptom change." (Brown & Fromm, 1986, pp. 194, 195)

 

The insights, observations, technical developments, and procedural innovations of Émile Coué (1857-1926), the scientist, apothecary (i.e, both a first-contact prescribing pharmacist and a dispensing chemist), hypnotist, and psychotherapist in relation to his understanding, conceptualization, realization, and application of hypnotherapeutic suggestion have greatly influenced the theories and practices of hypnotism throughout the English-speaking world.

"Continuously, unjustly, and mistakenly trivialised as just a hand-clasp, some unwarranted optimism, and a 'mantra', Coué's method evolved over several decades of meticulous observation, theoretical speculation, in-the-field testing, incremental adjustment, and step-by-step transformation. It tentatively began (c.1901) with very directive one-to-one hypnotic interventions, based upon the approaches and techniques that Coué had acquired from an American correspondence course. As his theoretical knowledge, clinical experience, understanding of suggestion and autosuggestion, and hypnotic skills expanded, it gradually developed into its final subject-centred version—an intricate complex of (group) education, (group) hypnotherapy, (group) ego-strengthening, and (group) training in self-suggested pain control; and, following instruction in performing the prescribed self-administration ritual, the twice daily intentional and deliberate (individual) application of its unique formula, "Every day, in every way, I'm getting better and better". (Yeates, 2016c, p. 55)

Liébeault and "Suggestive Therapeutics"

 

In 1885, Coué's father-in law, Victor Lemoine, introduced him to Ambroise-Auguste Liébeault, a medical practitioner in nearby Nancy, France. Liébeault, who had earlier dabbled with animal magnetism, and who, now, promoted what he termed "suggestive therapeutics" — "an imperfect re-branding of the 'dominant idea' theory that James Braid had appropriated from [his Edinburg teacher,] Thomas Brown" (Yeates, 2016a, p. 12) — based, in part, on an extended, laborious, monotonous, "sleep, sleep, sleep" induction of "hypnosis", and the consequent state of "charme" (i.e., "spellbound") that it produced. Greatly impressed, Coué moved to Nancy, and studied with Liébeault in 1885 and 1886 (Baudouin, 1920, p.13). He returned to Troyes in 1886, and resumed his pharmacy (which had declined in his absence). Convinced of the value of Liébeault's "suggestive therapeutics", he began to experiment with Liébeault's "hypnosis" with his Nancy clientele. Having soon discovered that Liébeault’s techniques were hopeless in practice, he abandoned Liébeault’s "sleep"-based "hypnosis", and hypnotherapy altogether.

Correspondence Course

In 1901, fifteen years later, with the hope of improving his Apothecary business, Coué sent for an advertised free book, Hypnotism as It is (Sage, 1899), which offered to disclose "secrets [of the] science that brings business and social success" and "the hidden mysteries of personal magnetism, hypnotism, magnetic healing, etc.”. His dormant interest in hypnotism reawakened, he purchased the associated correspondence course material produced by the stage hypnotist, "Professor Xenophon LaMotte Sage, A.M., Ph.D., LL.D.", of Rochester, New York (i.e., E. Virgil Neal, the US entrepreneur).

Neal's course, which was firmly based upon Braid's (Cartesian-reflex) upwards and inwards squint induced "hypnotism" (rather than the dormez, dormez, dormez suggestion-induced "hypnosis" of Bernheim and Liebeault), and the "mental therapeutics" of Thomson Jay Hudson (see Hudson, 1893, 1900, 1903), continuously stressed that suggestion produced outcomes. Its approach was entirely consistent with both Braid's "psycho-physiology" (1855, p.855) and Hudson's "mental therapeutics", and concentrated on the transformative power of the subject's mind — the complete opposite of the Liébeault/Bernheim approach, which was centred on the view that, rather than amplifying the effectiveness of suggestion, "hypnosis" made suggestion inescapable, and, consequently, their approach concentrated on the coercive power of the operator's suggestion.

 

John Heywood Hartland (1901–1977), B.Sc. (Birmingham, 1921), M.B. Ch.B. (Birmingham, 1925), M.R.C.S. (England, 1925), L.R.C.P. (London, 1925), was initially a G.P., practising in West Bromwich, a town in the industrial West Midlands region of England. He later became a consultant psychiatrist, and served as vice-president of the British Society for Medical and Dental Hypnosis, and as editor of the British Journal of Clinical Hypnosis.

Convinced that hypnotherapy could be usefully applied, by G.P.s, to a wide range of clinical conditions, regardless of their familiarity with hypnotic theories and practices, at a time that "for many, hypnotism was far from respectable, regardless of whether delivered by a medical practitioner, or not" (Yeates, 2014a, p. 5), Hartland delivered lectures, demonstrations, and seminars towards the end of his career throughout the U.K., France, Sweden, Australia, USA, and Singapore.

Hartland was greatly influenced by Lewis Wolberg, a strong advocate of the use of hypnotism for symptom-removal, whose approach was derived from that of Ambroise-Auguste Liébeault and Hippolyte Bernheim of Nancy, France.

"Wolberg’s interventions were strong and authoritarian; involving a dramatic induction procedure (to enhance therapist prestige), followed by direct (prestige) suggestions that the subject’s symptoms would disappear upon de-hypnotizing".

This "symptom removal" approach (Wolberg, 1948a) was widely used until, at least, the 1980s: see, for instance, Meares (1960), Slater and Flores (1963), Clawson (1964), Weitzenhoffer (2002), Weitzenhoffer (2004), and Ball (2006), etc.

According to his own account, Hartland had regularly used "hypnosis" in his general practice, since the 1940s, "to facilitate the treatment of various psychosomatic complaints", with his "main object being the removal or alleviation of symptoms to achieve the rehabilitation of the patient and his early return to work".

According to Hartland, because the time pressures of his busy general practice clearly "excluded any serious attempt to employ hypno-analytical techniques" and, having discovered that "direct symptom removal [was] both difficult and unsatisfactory in many cases", he set about "[trying] to evolve a series of standard psychotherapeutic suggestions which [he] could employ at every session before trying to tackle the main symptoms".

Once he had been appointed (in the 1950s) as a consulting psychiatrist to the Hallam Hospital, in West Bromwich, and began working with "six half-day sessions per week in its psychiatric out-patient department", he began to address his professional efforts towards "the more serious psycho-neurotic illnesses". Given that, in the 1960s, according to Barrios (1970), standard psychotherapy (such as Lewis Wolberg’s "short term psychotherapy" and Joseph Wolpe's "behavior therapy") typically involved 20 to 22 sessions, Hartland's initial (conventional) approach was 20 half-hour sessions, with 7-8 minutes of suggestions each hypnotherapy session (1971b, pp. xiv, 203).

Because these interventions demanded a considerable hypnotic "depth", Hartland spent the first three to four of those 20 sessions ensuring that his patients were appropriately prepared/trained — such that, later, they “[could] be induced deeply enough to enter the hypnotic state immediately it was suggested that they should do so" (1971b, p. xiv).

Hartland, the medical student and emerging hypnotist, would have been very familiar with Coué, the content and rationale of his "Methode", and his contributions to an understanding of "suggestion".

Coué had visited England (conducting group clinical sessions, demonstrations, and lectures) on at least eight occasions between November 1921 and November 1925 (Rapp, 1987). The translation of his Nancy Clinic’s hand-out (1922a) was widely available (1922b, pp.  5-35), with an abridged, rapidly-delivered versions of his presentation available as gramophone recordings (1923a). A further, detailed explanation/elaboration of the rationale behind his "ego-strengthening" suggestions was provided at Coué & Orton, 1924, pp. 80-88. Also, in addition to the many newspaper/magazine reports, a wide range of Coué-centred items were readily available for Hartland’s edification, including reports of Coué’s lectures, eye-witness accounts of visits to Coué’s clinic at Nancy and observations of his interactions with his patients, more detailed accounts of his methode by his 'followers'; as well as the items associated with the Coué-Orton Institute.

The first version of Hartland's approach/procedure, and its constituent monologue, was published in 1965 (Hartland, 1965), and reprinted in 1966 (Hartland, 1966). His second version was published in 1967 (Hartland, 1967). The third and final version of his monologue was revealed in a 1970 lecture (Hartland, 1971c); and was reprinted (with appropriate variations for British readers) in the second edition of his textbook (Hartland, 1971b), where the history, structure, rationale, and clinical delivery of his approach were also described. His third version of the monologue was reprinted, without change, in the two posthumous editions of his textbook: viz., Waxman (1989, pp. 219-224), and Heap & Aravind (2001, pp. 127-129).

Hartland was emphatic that the published version of his "ego-strengthening" monologue (a direct transcription of one of his interventions) was provided to deliver an understanding of the suggestive sequence (its critical feature), and that alone — a guide to the "principles underlying the construction and usage of this type of technique" (viz., the "important factors" worth "attention"). He stressed that it must never be used exactly as published.

"It is certainly not intended that this [transcript] should be adopted in the precise form that has been described. It is the principle that is worthy of attention, and the sequence [I have] outlined should be regarded simply as a guide to the individual therapist in framing his own suggestions to conform with his own personality, method of approach and style of delivery. It is impossible to suggest here the varying inflections of the voice, but the same cardinal rules of construction, stresses and pauses etc. should be used in order to maintain a rhythmical quality from start to finish."
"In the construction of an ego-strengthening technique, quite apart from the actual suggestions themselves, it is essential that particular attention should be paid to such significant factors as ‘rhythm’, ‘repetition’, the interpolation of appropriate ‘pauses’, and the ‘stressing of certain important words and phrases’. …[also, in order to] avoid excessive monotony … you will notice that [within my version] repetition is often achieved by expressing the same fundamental idea in two or three different ways." — Hartland (1971b), pp.203, 198 (emphasis in original).

"Improved" versions of Hartland's monologue

A number of "improved" versions of Hartland's "ego-strengthening" monologue have been published — with, perhaps, the most extraordinary being the "Poetic Hypnogram" of Samuel Silber, M.D. (1900–1988), the "Poet Laureate of the American Society of Psychosomatic Dentistry and Medicine" — including, for example, those of Gorman (1974), Stanton (1975), Stanton (1977), Gibbons (1979a), Hutchison (1981, pp. 72-73), Pratt, Wood, and Alman (1988, p. 122-123), Gregg (1990), and Heap (Heap & Aravind, 2001, pp. 129–130), etc., etc.

"Improvisations" upon a theme suggested by Hartland's monologue

A number of different versions of the "ego-strengthening" monologue, better understood as "improvisations", have also been published: including, for example, those of Jabush (1976), Susskind (1976), Gibbons (1979b), Stanton (1979), Stanton (1989), Barber (1990a), Barber (1990b), Carich (1990), Garver (1990), Torem (1990), Watkins (1990), Wilson and Barber (1990), McNeal and Frederick (1993), Stanton (1997), Milne (1994, pp. 114-117), and Herber (2006, pp. 55-64), etc., etc.

The American Psychological Association (APA)'s 2002 policy on "treatment guidelines" ("specific recommendations about treatments to be offered to patients"), recommended that treatments be evaluated from two perspectives:

• Treatment Efficacy: "the systematic and scientific evaluation of whether a treatment works"; and
• Clinical Utility: "the applicability, feasibility, and usefulness of the intervention in the local or specific setting where it is to be offered".

Although there's a lot of anecdotal evidence suggesting that Hartland's approach is effective, it has never been rigorously evaluated using scientific methods. This is because there haven't been any well-designed and productive experiments; not because existing experiments failed to find evidence of its effectiveness.

Conceptual issues of "measurement"

Assuming that whatever "measurement" (presence, absence, degree of change) made of an object/attribute has been made with a reliable, accurate device, and that the device has delivered a precise value of so-and-so, two important conceptual issues arise in relation to abstractions such as "ego-strengthening":

• to what degree is the precise value produced by the device (e.g., the height of a column of mercury in a sphygmomanometer) an accurate measure of the attribute (e.g., blood pressure) in question?
• to what extent is the accurately measured value of the selected attribute (blood pressure) an index of the abstract concept (e.g. ego-strength) that is the ultimate item of interest?

Given the wide range of distinctly different referents to which the expression "ego-strengthening" has been applied by its different users, any appraisal of the efficacy of "ego-strengthening" involves two embedded questions.

• "What is being strengthened?": which immediately demands recognition of the expression’s overall equivocality:
  • Is "ego-strengthening" a generic, qualitative, umbrella term that broadly identifies an overall approach?
  • Is "ego-strengthening" a specific, quantitative term, with "ego" modifying (as a sub-set) the activity denoted as "strengthening"?
    • Does it centre upon the inappropriate "reification" (in the manner of Whitehead's "fallacy of misplaced concreteness") of the abstract concept, "ego"?
    • Is the intervention being delivered from an operator mind-set that seeks the reduction of a perceived "ego" deficit, or is with one seeking the enhancement of whatever "ego" strength is currently present?
• "How is the strength of that entity being measured?": which immediately raises a number of concerns:
  • To what extent is the attribute being measured (e.g., self-esteem) related to the concept ("ego-strength") under scrutiny?
  • To what extent is the measured attribute (e.g., self-esteem) a reliable and valid index of the concept ("ego-strength") under scrutiny?
  • To what extent is the (before- and after-intervention) rating of the measured attribute (e.g., self-esteem) a reliable and valid measure of the (before- and after-intervention) "strength" of the concept ("ego") under scrutiny?

Experimentation

Setting aside the complex issues of determining precisely how a "genuinely productive experiment" might (or might not) possibly be constructed — or how, where, and upon whom a relevant, informative, and useful study might (or might not) be designed and performed — and, if were to be conducted, how its results might be measured and appraised, there is the even-more-significant question of the extent to which any such findings could have any practical application at all, due to the differences in contexts identified by Gorman (1974):

• Subjects of "hypnosis under experimental conditions" are "participating voluntarily" in an experiment, have "a detached state of mind", and are not "intimately and vitally" affected by the results of the experiment.
• Subjects of "hypnosis under therapeutic conditions" are undergoing therapy, and are "acutely aware of the fact that the results of therapy may have a most important effect upon [their] subsequent feelings of well-being"; "[their] state of mind is therefore not detached, but, on the contrary, [they are] both anxious and critical".

In 1977, in perhaps the only investigation that ever attempted to measure the efficacy of Hartland's monologue within a clinical setting, Calnan's study reported that the ten psychiatric patients (test population: 40) who had received Hartland's monologue, under hypnosis, 12 times in 6 weeks, demonstrated (per medium of "psychological tests") considerable progress (i.e., compared to the other 30); the most interesting/relevant outcome of his interventions was that:

"[all of the] subjects who received Hartland’s entire treatment procedure … reported feeling more relaxed and self-confident. Very often they described their changes in exactly the same words as those used by Hartland in his ego strengthening suggestions and yet none of the subjects mentioned or seemed aware of their origin." (Calnan, 1977, p. 117, emphasis added).

Hartland's overall "ego-strengthening" approach, clinical strategies, explanations, and his descriptions of the suggestive sequences (for within-hypnotic influence and post-hypnotic influence) he delivered in practice, have made a considerable contribution to modern hypnotherapeutic practice. Despite the difficulties in determining its efficacy, Hartland's approach satisfies the APA's tripartite criteria for clinical utility:

• Generalizability: "the extent to which an effect of a treatment is robust and therefore will be replicated even when details of the context ... [such as] patients’ characteristics, health care professionals’ characteristics, [etc.] ... are altered."
• Feasibilty: "the extent to which a treatment can be delivered to patients in the actual setting", including considerations such as "the acceptability of the intervention to potential patients", "patients' ability and willingness to comply with the requirements of the intervention", and "the ease of administration of the intervention".
• Cost considerations: these include "the direct, indirect, short-term, and long-term costs to the patient, to the professional ... [including] the cost of any technology or equipment involved in the intervention, and the cost of training ... and to the health care system, as well as the costs associated with withholding treatment" as well as the "cost savings" that might accrue from the intervention's "prevention of future disorders" or its "mak[ing] other treatments unnecessary".

Hartland's overall approach

There are many reports of hypnotherapeutic interventions, directed at a wide range of conditions, that describe the valuable contribution that the adoption of an overall ego-strengthening approach has made to their treatment outcomes, in relation to building confidence, enhancing self-esteem, facilitating behavioural change, arousing dormant resources, promoting overall well-being, increasing a sense of self-efficacy and self-empowerment, and strengthening the sense of an internal locus of control: including, for instance, Gardner (1976); Stanton (1979); Darken (1992); Stanton (1993); Bennett (1994); Vanderlinden & Vandereycken (1994); Moss & Oakley (1997); Daniel (1999); Frederick & McNeal (1999); Hornyak (1999); Linden (1999); Lynch (1999); Mutter (1999); Barber (2001); Phillips (2001); Lavertue, Kumar & Pekala (2002); Stafrace & Evans (2004); and Gafner (2016), etc., etc.

Hartland's published monologue

The literature also contains many reports of Hartland's published ego-strengthening monologue being successfully applied, precisely as written, to a wide range of complaints: including, for instance, Rose (1967); Basker, Anderson and Dalton (1978); Wakeman and Kaplan (1978); Freeman and Baxby (1982); Gould and Tissler (1984); Finkelstein (1991); Torem (1995); and Spiegel (1996), etc., etc.