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American Journal of Clinical

Hypnosis
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Suggestibility, Expectancy,
Trance State Effects, and
Hypnotic Depth: I. Implications
for Understanding Hypnotism
a b
Ronald J. Pekala , V. K. Kumar , Ronald Maurer
a a a
, Nancy Elliott-Carter , Edward Moon & Karen
a
Mullen
a
Coatesville VA Medical Center , Coatesville, PA,
USA
b
West Chester University of Pennsylvania , West
Chester, PA, USA
Published online: 21 Sep 2011.

To cite this article: Ronald J. Pekala , V. K. Kumar , Ronald Maurer , Nancy Elliott-
Carter , Edward Moon & Karen Mullen (2010) Suggestibility, Expectancy, Trance State
Effects, and Hypnotic Depth: I. Implications for Understanding Hypnotism, American
Journal of Clinical Hypnosis, 52:4, 275-290, DOI: 10.1080/00029157.2010.10401732

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 American Journal of Clinical Hypnosis Copyright © 2010 by the American Society of Clinical Hypnosis
52:4, April 2010

Suggestibility, Expectancy, Trance State Effects, and Hypnotic

Depth: I. Implications for Understanding Hypnotism

Ronald J. Pekala1, V. K. Kumar2, Ronald Maurer1,

Downloaded by [George Washington University] at 09:09 06 January 2015

Nancy Elliott-Carter1, Edward Moon1, Karen Mullen1

Abstract
This paper reviews the relationships between trance or altered state
effects, suggestibility, and expectancy as these concepts are defined in
the theorizing of Weitzenhoffer (2002), Holroyd (2003), Kirsch (1991),
and others, for the purpose of demonstrating how these concepts can
be assessed with the PCI-HAP (Phenomenology of Consciousness
Inventory: Hypnotic Assessment Procedure; Pekala, 1995a, b). In
addition, how the aforementioned variables may relate to the nature of
hypnosis/hypnotism as a function of self-reported hypnotic depth are
discussed, along with how the PCI-HAP may be used as a means to
measure hypnotic responsivity from a more phenomenological state
perspective, in contrast to more traditional behavioral trait assessment
instruments like the Harvard, the Stanford C, or the HIP. A follow-up
paper (Pekala, Kumar, Maurer, Elliott-Carter, Moon, & Mullen, 2010)
will present research data on the PCI-HAP model and how this model
can be useful for better understanding hypnotism.

Keywords: Altered states of consciousness, consciousness, expectancy,

hypnosis, hypnotic depth, hypnotism, psychophenomenology,
suggestibility, trance.

Address correspondences and reprint requests to:

Ronald J. Pekala
Coatesville VA Medical Center, Coatesville, PA
Biofeedback Clinic (116B)
Coatesville VA Medical Center
Coatesville, PA 19320
[email protected]

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 Suggestiblity, Expectancy, and Trance State Effects

What is Hypnosis/Hypnotism?
This is a question that has haunted the scientific investigation of hypnotism since
its inception with Mesmer over 200 years ago. To address this question, this paper reviews
relevant concepts that various theorists have proposed are related to hypnosis/hypnotism
and then shows how these concepts can be assessed with an instrument developed to
measure hypnotic responsivity from a more phenomenological perspective than has
traditionally been done in the past.
In recent decades prominent views concerning the nature of hypnosis have
variously stressed alterations in consciousness, the use of imagination and fantasy, and
suggestion and expectancy (Baker, 1990). The fact that hypnosis seems to involve various
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different processes has suggested to some researchers that hypnosis is really a pluralistic
phenomenon subsuming several different domains. Such a conclusion was endorsed by
Wagstaff over 25 years ago:
Having spent some years studying the literature on hypnosis I had to
admit that no single “mundane” concept seemed capable of explaining all
hypnotic effects. . . . Instead, we might have a collection of phenomena
bound together in name only by the term ‘hypnosis,’ but which demand a
number of different explanations (Wagstaff, 1981, p. ix).
Consistent with Wagstaff’s view, Brown and Fromm (1986) in their classic text,
Hypnotherapy and hypnoanalysis, defined the “domain” of hypnosis as composed of three
aspects: altered states of consciousness (trance), expectation and suggestibility, and the
hypnotic relationship.
The view that more than one concept is required for understanding hypnosis has been
echoed by Kihlstrom (2003), when he suggested that as hypnosis moves into the 21st century, we
must move from monolithic to pluralistic approaches to hypnosis. Given the complexity of the
phenomenon of hypnosis, “each of us will work out a part of the puzzle, a puzzle that has intrigued
psychology from the time of James, and Freud, and Pavlov, to now” (p. 183).
A somewhat similar pluralistic approach was offered by Woody, Barnier, and
McConkey (2005) when they discussed their notion of “multiple hypnotizabilities.” They
reported evidence of a general hypnotizability factor and four specific factors: direct motor,
motor challenge, perceptual-cognitive, and post-hypnotic amnesia. Thus, there is a general
skill and several component subskills needed to respond to different types of hypnotizability
test items. They concluded that “(O)ur perspective on hypnotizability is that each
distinguishable ability involves the combination of general hypnotizability with a more
specific, unique component” (p. 210), suggesting that these four different components involve
“feelings of knowing” that are “qualitatively distinct from one another” (p. 210), and yet
combine with a general hypnotizability factor.
The notion of a plurality of factors influencing hypnotic response has contributed
to disagreements as to what hypnosis is and how to define and assess it. This conundrum
concerning definition was addressed by Nash (2005): “When we fail to make the distinction
between procedure and product in our field, we compromise discourse where clarity is at a
premium” (p. 267): “Ironically, our field has not even come to grips with the word hypnosis . . .
The terms hypnosis and hypnotized are both ambiguous, sometimes meaning “a procedure”
and sometimes meaning “the product of a procedure” (p. 267). “The field deserves an
optimally heuristic definition (of hypnosis) that preserves pluralism . . . “ (p. 265).
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 Pekala, et al.

Weitzenhoffer (2002), also concerned about having a good definition of hypnosis,

distinguished between hypnosis and hypnotism: “I will otherwise generally reserve the term
hypnosis for the state, and the term, hypnotism, for the production, study and use of suggestion
with the state of hypnosis presumably being present, whether or not it adds anything tangible
to the situation” (p. 210). Weitzenhoffer considered hypnotism to be a result of a combination
of suggestibility and “hypnosis” or trance state effects. (For the purposes of this article we
will adhere to Weitzenhoffer’s distinction between hypnosis and hypnotism.)

Hypnotic Depth
Another important issue in understanding hypnotism concerns defining and
understanding the notion of hypnotic depth. Hypnotic suggestibility or susceptibility is
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usually meant to define how responsive a person is as assessed by the passing of various
items on hypnotizability tests, such as the Harvard Group Scale of Hypnotic Susceptibility:
Form A (Shor & Orne, 1962), the Stanford Scale of Hypnotic Susceptibility: Form C
(Weitzenhoffer & Hilgard, 1962), or the Hypnotic Induction Profile (HIP; Spiegel & Spiegel,
2004). Hypnotic depth is a different construct.
Tart (1970, 1979) regarded hypnotic depth as a theoretical construct inferred from the subject’s
experiential and behavioral responses to hypnotism. He regarded hypnotic depth as “a momentary
state of the S [subject] along some dimension of ‘profundity’ of the hypnotic state” (1970, p. 105).
Integrating Tart’s (1979) work on hypnotic depth with their own, Brown and Fromm (1986) suggested
that subjects “feel more deeply hypnotized” to the extent that (a) they believed there were alterations
in subjective experience during hypnotism, and (b) they were responsive to the suggestions.
Over 75 years ago, Davis and Husband (1931) described a point system to measure
depth of trance. LeCron (1953) was possibly the first to use a simple self-report, single-item
scale to experientially measure hypnotic depth. He asked his subjects to enumerate during
hypnotism, using numbers from 1 to 100, their depth of trance when asked, “How deep are
you?” Other systems have also been offered, with 40-point, 4-point, and 10-point anchors
(see Brown & Fromm, 1986). Tart’s (1970) review of hypnotic depth scales delineated six self-
report scales anchored on a “1 to 10” or a “0 to 100” point system.
Over 20 years ago Laurence and Nadon (1986) suggested that the elucidation of
“hypnotic depth is a complex task involving the interaction of experiential, cognitive, and
contextual variables” (p. 215). Weitzenhoffer (2002) in his classic paper, “Scales, scales, and
more scales,” noted that hypnotic depth scores are “lacking in solid evidence” (p. 214), due
to problems with demand characteristics (Orne, 1962), and problems with such introspective
self-reports. In contrast, and in support of self-report depth scales, Wagstaff, Cole, and
Brunas-Wagstaff (2008) suggested that depth scales may serve as a useful alternative to
conventional suggestion-based tests of hypnotizability: “they correlate well with
conventional suggestion-based measures and enable the presence of hypnosis to be indexed
independently of formal hypnotic induction procedures” (p. 119). Wagstaff et al., suggested
that such self-report depth scales are less confounded by nonhypnotic suggestibility, and
allow for the estimation of being hypnotized in ostensible nonhypnotic contexts. The PCI-
HAP (see below) generates a self-reported hypnotic depth (srHD) score, somewhat similar to
measures of hypnotic depth like that of LeCron (1953), Tart (1970, 1979) or Wagstaff et al.
(2008). However, it also generates a hypnoidal state score that we believe is less prone to
“distortion from response sets and demand characteristics” (Wagstaff et al., 2008, p. 127)
with which such self-report hypnotic depth measures are usually prone, due to the nature of
the phenomenology that the hypnoidal state score is measuring.

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Trance State/Altered State Effects and Hypnosis/Hypnotism

The term trance is often used interchangeably with the term hypnosis. Weitzenhoffer
(1989) pointed out that there has been a tendency to use the term trance as synonymous with
hypnosis since the time of Braid, but especially so in modern times. Trance appears to be a much
broader and older concept than hypnosis according to Weitzenhoffer, and “denotes various
states of being that have the appearance of consciousness but seem to differ from normal
consciousness. . .as being a sleeplike, or a half awake, half asleep state” (1989, p. 298).
Weitzenhoffer also suggested that some writers have equated both hypnosis and
trance because both are “frequently defined as altered states of consciousness” (p. 300).
Additionally, he reported that it is not unusual for individuals, said to be hypnotized, to
“describe themselves in a state of altered perception of themselves and the world” (p. 300).
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The question as to how much of hypnotic behavior is due to an “altered or trance state
of consciousness” is a controversy that has raged for decades. Lynn and Kirsch (2006) have
succinctly summarized the controversy. State theorists, like Hilgard (1977), Bowers (1992), Kihlstrom
(2003), Woody (Woody & Bowers, 1994), Gruzelier (1996), and Tart (1979), generally espouse
some variant of altered state effects or a “special process” (Spanos, 1982) as necessary for
understanding hypnosis/hypnotism. In contrast, nonstate theorists, like Sarbin (1950), Barber
(1969), Spanos (1991), Lynn (1997), and Kirsch (1991), suggest that “subjects’ beliefs, expectations,
and imaginings about hypnosis, and their interpretations of the suggestions of the hypnotist, are
sufficient to explain hypnotic response” (Pintar & Lynn, 2008, p. 126). That is, one does not have
to imply an altered state to explain so called hypnotic behavior; rather such behavior can more
simply be explained as some aspect of expectancy and social interaction. A major problem
concerning the theorizing of both of these groups of theorists/researchers is that they are inferring
or alluding to altered state or special process effects, but such effects are not well defined.
This controversy (Kirsch, 2004) has not subsided due partly to a recent surge of
interest in the psychobiology of altered states of consciousness (ASC) via the neurosciences
(De Pascalis, 2007; Gruzelier, 1998, 2000; Jamieson, 2007a, b; Raz, 2005). Vaitl et al. (2005) have
summarized that research, suggesting that with “increasing knowledge of the neural correlates
of consciousness, the formerly strange and hard to explain phenomena of ASC become
increasingly understandable as a natural consequence of the workings of the brain” (p. 119).
Kallio and Revonsuo (2003, 2005) readdressed the altered state controversy
suggesting that a neurobiological basis for altered states of consciousness could be
definitively confirmed only if there is a consensually agreed upon definition for consciousness,
altered states of consciousness, and related phenomena, such as hypnotism:
If such phenomena as ‘hypnosis,’ ‘consciousness,’ or ‘altered state of
consciousness’ exist at all, then for science to describe and explain them
coherently, surely the relevant research community in psychology and
cognitive neuroscience should aim at developing an internally coherent
and widely shared theoretical vocabulary to make genuine progress in
their scientific explanation (Kallio & Revonsuo, 2005, p. 51).

After considering the various commentaries on their original article, Kallio and Revonsuo
(2005) concluded that “the concept of altered state of consciousness (ASC) still lacks a
commonly accepted definition and is in need of further clarification” (p. 46). Thus, the
controversy continues concerning the nature of hypnotism and to what extent alterations in
consciousness or “trance” effects contribute to the experience of hypnotism.

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 Pekala, et al.

The eye-roll sign of the Hypnotic Induction Profile has been regarded as a behavioral
neurobiological marker associated with state-trait correlates of hypnotizability (Spiegel &
Spiegel, 2004). We believe that if and when neurophysiological markers are found to be
associated with high hypnotic suggestibility/susceptibility (Kirsch, 2004), the search for
such markers would still require some measure of subjective experience with which such
neurobiological markers would be compared or correlated. As Lutz and Thompson (2003)
reported, “a growing number of cognitive scientists now recognize the need to make systematic
use of introspective phenomenological reports in studying the brain basis of consciousness”
(p. 31). Additionally, there is a growing realization “that it will not be possible to make
serious headway in understanding consciousness without confronting the issue of how to
acquire more precise descriptive first-person reports about subjective experience” (Zelano,
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Moscovitch, & Thompson, 2007, p. 2).

Given the history of distrust in the behavioral sciences regarding subjective data
(Holt, 1964; Kukla, 1983; Lieberman, 1979; Singer & Kolligian, 1987), it is imperative that we
investigate this subjective side of consciousness reliably and validly. Consciousness is
“phenomenal consciousness” (Chalmers, 2007), a subjective or “first person” phenomena.
A subjective or phenomenological marker of trance depth or “altered state” effects, if reliable
and valid, could surely help with the quandaries associated with hypnotism as defined by
Kallio and Revonsuo (2003, 2005). We (Pekala, 1991a; Pekala & Kumar, 2000, 2007), have
previously reported on a psychophenomenological approach to phenomenological
assessment (Hilgard, 1980) using reliable and valid methodologies for quantifying,
diagramming, and statistically assessing subjective experiences associated with a variety of
psychological phenomena.

A Review of Research on Measuring Trance Depth Phenomenologically

Although there may be different types of trance associated with hypnotism, there may
be at the same time some commonality across these different types of trance, analogous to
Spearman’s (1904, 1923) “g” factor for general mental ability, vis-à-vis different types of intelligence,
a la Gardner (1983).
Trance can be operationally defined as the subjective state the highly hypnotizable
person reports in response to a hypnotic induction. In attempting to derive a general measure of
trance that includes the assessment of subjective states in relation to hypnotizability, Pekala &
Kumar (1984, 1987) derived a multiple regression equation to predict Harvard Group Scale (pHGS)
scores, Form A, from the (sub)dimensions of the Phenomenology of Consciousness Inventory
(PCI) (Pekala, 1982, 1991b), a self-report instrument for measuring subjective experience. The
multiple regression equation (Pekala & Kumar, 1984) was cross-validated in two subsequent
studies, yielding criterion validity coefficients of .62 (Pekala & Kumar, 1987) and .67 (Forbes &
Pekala, 1993). 1 Additionally, a validity coefficient of .86 (Hand, Pekala, & Kumar, 1995) was found
when correlating the actual Stanford C Scale (Weitzenhoffer & Hilgard, 1962) scores obtained by
subjects with their predicted Harvard Group Scale (pHGS) scores. The aforementioned results
provide evidence concerning the criterion-related validity of the pHGS score in predicting hypnotic
susceptibility as measured by both the Harvard and Stanford C Scale scores.
The pHGS scores, based on regression weights assigned to particular PCI
(sub)dimensions, can be assumed to reflect individual differences in subjective experiences
assessed by the PCI. The pHGS score was subsequently defined as an estimate of a person’s
“hypnoidal state” (Pekala, Forbes, & Contriascini,1988; Pekala & Nagler, 1989) or “depth of
trance” that individuals with varying levels of susceptibility are likely to experience during

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hypnotism. The hypnoidal state score is a phenomenologically based measure of trance that
is primarily a function of state effects, although influenced by trait factors (Kumar & Pekala,
1988, 1989; Kumar, Pekala, & Cummings, 1996).
Table 1 shows the unstandardized regression weights for the PCI (sub)dimensions
used in computing the predicted Harvard Group Scale score (hypnoidal state score) and the
relative percentages of variance accounted for by each of the variables (Pekala & Kumar, 1984).2
An advantage of using the regression based approach is that the hypnoidal state scores can be
readily computed for any (hypnotic) experience in which the PCI is administered. (See Pekala,
1991a, for the methodological and statistical limits for the use of the PCI-based scores.)
An instrument has construct validity to the extent that it assesses the underlying
conceptual variable that it intends to represent (Bryant, 2000). The PCI-based hypnoidal
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state score has demonstrated criterion-related validity inasmuch as it predicts the Harvard
Group Scale scores, Form A. However, the hypnoidal state (pHGS) score has also shown
some evidence of construct validity as high hypnoidal state scores reflect the extent to
which an individual reports increased alterations in experience and an altered state of
consciousness, along with losses in volitional control and self-awareness, consistent with
the way a hypnotic experience is traditionally described (see Table 1).

Table 1: Hypnoidal State (pHGS score) Regression Equation

Unstandardized Regression Relative %

PCI (Sub)Dimension x Coefficient

Altered Experience x + .35 17%

Altered State x + .31 15%
Volitional Control x - .28 13%
Self-Awareness x - .27 13%
Rationality x + .23 11%
Absorption x + .19 9%
Memory x - .14 7%
Altered Time Sense x + .13 6%
Internal Dialogue x - .11 5%
Altered Body Image x - .07 3%

Constant +4.51
Note: Percentages indicate relative magnitude of the coefficient. Each PCI (sub)dimension is rated
on a “0” to “6” scale with “0” indicating “none or little” and “6” indicating “much or complete.”

Additionally, high hypnoidal state scores are associated with increased absorption,
but decreased memory and internal dialogue. Most of the variables listed in Table 1 are in the
direction and magnitude endorsed by various theorists concerning how hypnotism is associated
with a loss of control (the classic suggestion effect - Weitzenhoffer, 1974), alterations in experience
and state of consciousness, and increased absorption (Barabasz & Watkins, 2005; Hilgard,
1965; Spiegel & Spiegel, 2004; Weitzenhoffer, 1989). The variables in the regression equation
are also those processes that, we believe, clinicians would say are present at least some of the
time in most highly hypnotizable clients during their hypnotic experience.
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 Pekala, et al.

Only the regression weights associated with two of the variables in the regression
equation appear counterintuitive; that concerning the positive coefficient for rationality and the
negative coefficient for body image (the actual Pearson rs for these variables are opposite that
listed). Both variables appear to be functioning as suppressor variables (Grimm & Yarnold, 1995),
more highly correlated with the other independent variables than the criterion variable. That is,
they allow for more of the variance to be accounted for than would otherwise be the case: “the
effect of a suppressor variable is to partial out of the other predictors’ variance that is irrelevant to
the criterion, resulting in larger relationships with, the prediction of, the criterion” (p. 63).
Although more research needs to be done to further demonstrate the construct
validity of the hypnoidal state score, the aforementioned review suggests that the hypnoidal
state score may be used to get an estimate of trance state effects, a la Weitzenhoffer (2002), for
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a variety of stimulus conditions.

Trance Depth, Suggestibility/Imagination, and Expectancy

In a provocative article Barber (2000) suggested that there are three “types” of
highly hypnotizable individuals: the “fantasy prone” high, the “amnesia-prone” high, and
the “positively-set” high hypnotizable. Whereas the fantasy prone high is especially good
at “fantasizing vividly and realistically” (Barber, 2000, p. 208), the “amnesia-prone” individual
appears “passive and close to sleep, manifesting a marked loss of muscle tone, lethargic
movement, and a tendency to fall out of their chairs” (Barber, 2000, p. 219), highlighting
alterations in consciousness and experience associated with this particular type. The third
type, the “positively-set” high, is characterized by a “hypnosuggestive readiness,” which
includes positive attitudes, positive motivation, and positive expectancies.
Along somewhat similar lines as Barber, but addressed to processes, as opposed to
“types,” Holroyd (2003) suggested that three variables: trance or altered state of
consciousness, imagination/suggestibility, and expectancy contribute to a person’s response
to suggestions. From a synthesis of research on the neurophysiology of hypnosis (Crawford,
2001; Crawford & Gruzelier, 1992) and its phenomenology (Cardeña, 2005; Pekala & Kumar,
2000), Holroyd distilled three factors that she thought accounted for most of the effects we
see in hypnotism: imagination/suggestibility, altered state effects, and expectancy. Holroyd
(2003) suggested imagination/suggestibility and altered state effects interact with expectancy
to account for how individuals experience hypnotism: “Suggestion without an altered state
is just an invitation to use imagination and fantasy. An altered state without suggestion is
just trance or meditation. Not only are altered states and suggestibility interactive contributors,
but they also interact with expectancy,” (p. 121) to produce hypnotic phenomena. (Here,
“interaction” is used figuratively; it is not meant to suggest a statistical interaction effect,
Holroyd, personal communication, April, 2008).

Suggestibility
Suggestibility means different things to different researchers and theorists. The
interested reader is invited to peruse Schumaker (1991) for a comprehensive review of these
very different viewpoints. According to Weitzenhoffer (1989), Braid (1843) was the first to
introduce the notion that suggestibility is a characteristic of the hypnotized person. Hilgard
(1991) defined suggestion as a type of influential communication. Weitzenhoffer defined
suggestibility more specifically as the “capacity to produce what I call the classical suggestion
effect (Weitzenhoffer, 1974); that is, a nonvoluntary (or avolitional) response relevant to the
content of a communication intended to be a suggestion” (2002, p. 210), hence highlighting

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his viewpoint of suggestibility as nonvolitional in nature. Given the charge by some that
hypnotism is “only” suggestibility, Killeen and Nash (2003) responded: “Although changes
in suggestibility are one of the main effects of hypnosis, suggestibility is not one of the
causes of hypnosis.” (p. 204)
Kirsch and Braffman (1999) distinguished two types of suggestibility: “if ‘hypnotic
suggestibility’ is responsiveness to suggestions given after hypnosis has been induced;”
(p. 226) then ‘nonhypnotic suggestibility’ may be used “to denote responsiveness to
suggestions administered without the prior induction of hypnosis” (p. 226). They also
emphasized the role of fantasy and imagination in suggestibility. They defined “imaginative
suggestions” as “requests to experience an imaginary state of affairs as if it were real”
(Kirsch & Braffman, 2001, p. 59), and “imaginative suggestibility” as the “degree to which
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the person succeeds in having the suggested experiences” (p. 59) whether such experiences
occur within, or outside of, hypnotism.

Suggestibility and Imagination

Josephine Hilgard (1979) envisioned “imaginative and sensory-affective
involvements” as being “closely related to the capacity to experience hypnosis” (p. 483),
with imaginative involvements “expressing individual interests in a variety of experiences
whereby imagination and fantasy provide the individual with highly satisfying experiences”
(pp. 483-484). Sheehan (1979), in a comprehensive review of the relationships between
imagination and hypnotism, suggested that imaginative activity is a major, but not the only,
predictor of hypnotic responsivity. In addition, one needs to consider cognitive, motivational,
and personality attributes. Hence, imaginative suggestibility, as conceptualized by Kirsch
and Braffman (1999, 2001), may be a major, but not the only, aspect of being hypnotizable.
Because there are individuals who “seem to respond to suggestion solely on the basis of
imaginative involvement - good ability to imagine or fantasize” (Holroyd, 2003, pp. 120-121),
it is likely that there are moderately to highly hypnotizables who use their fantasy or imagery
ability to achieve hypnotic effects and yet do not necessarily experience an altered state of
consciousness during hypnotism (see Pekala & Kumar, 2000, 2007).

Expectancy
Kirsch (1991) has made expectancy a central tenet in his theorizing concerning
hypnotism. According to Kirsch “hypnotic inductions can best be understood as expectancy
modification procedures” (p. 448): “the capacity of people’s beliefs and expectations to
bring about changes in experience may be the ‘essence’ of hypnosis, and attempts to eliminate
expectancy as ‘artifact’ may be doomed to failure” (p. 461). Kirsch (1985) hypothesized that
hypnotic responses are determined by the person’s expectancy of their occurrence.
Participants expect and experience hypnotic responses as a function of: belief that the
response is appropriate to the hypnotized subject’s role, judge the situation to be one in
which hypnotic behavior should occur, and believe themselves to be good hypnotic
participants.

Attitude versus Aptitude in Hypnotizability

Besides looking at hypnotism from a “state versus nonstate” perspective, hypnotism
can also be evaluated from the “attitude versus aptitude” perspective, well articulated by
Benham, Woody, Wilson, and Nash (2006). Benham et al. suggest that whereas “aptitude-
centered theories posit that the highly consistent individual differences in hypnotic
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 Pekala, et al.

performance reflect the direct and substantial operation of a latent cognitive ability” (p. 343),
“attitude-centered theorists view hypnotic responsiveness as based primarily (and perhaps even
exclusively) on the direct operation of social learning, or social-cognitive, variables (expectations,
motivation, attitude, and role enactment; Spanos, 1991)” (p. 343). To evaluate differences between
these two perspectives, Benham et al. evaluated a model integrating ability, expectancy, and
hypnotic response while measuring and assessing expectations and hypnotic performance
throughout a hypnotic protocol. Their results generated the following conclusions:
(a) Expectancies showed significant stability across the course of the
hypnosis protocol; (b) expectancies influenced subsequent hypnotic
responses, even controlling for latent ability; (c) hypnotic responses, in
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turn, affected subsequent expectancies; and (d) a latent trait underlay

hypnotic responses, even controlling for expectancies. As such, the results
indicate a fairly complex but quite plausible web of effects interconnecting
these important variables (p. 347).

The Benham et al.’s article was one of 3 papers reviewed by Barabasz and Perez (2007)
as to whether hypnotizability as a trait really matters. The laboratory study by Benham et al.
(2006), a treatment analogue study by Milling, Reardon, and Carosella (2006), and a hospital-
based randomized clinical trial (Liossi, White, & Hatira, 2006) were all found to converge to
suggest “in identifying hypnotizability unambiguously as a powerful predictor of outcome”
(Barabasz & Perez, 2007, p. 377): “there appears to be a latent cognitive ability that strongly
influences the extent of an individual’s hypnotic response and operates along side the more
modest influence of situation and attitude” (p. 376). How much of this latent cognitive ability
is related to altered state trance effects and/or suggestibility was not addressed in these
articles. However, a hypnotic assessment instrument, the PCI-HAP (Phenomenology of
Consciousness Inventory - Hypnotic Assessment Procedure; Pekala, 1995a, 1995b), allows for
aspects of both of these processes to be operationally defined, in addition to expectancy.

Operationalizing the Assessment of Hypnotism via the PCI-HAP

The previous review has highlighted the importance of suggestibility, altered
(“trance”) state effects, and expectancy, as important variables in understanding hypnotism.
These are variables that Holroyd (2003), Kirsch, (1991), and Weitzenhoffer, (2002), among
others, have identified as important to better understand the nature of hypnotism, as defined
by Weitzenhoffer (2002). In contrast to cognitive-behavioral instruments like the Harvard
Group Scale of Hypnotic Susceptibility (Shor & Orne, 1962), or the Stanford, Form C
(Weitzenhoffer & Hilgard, 1962), which measure participants’ responses to passing or failing
various items during hypnotism, the PCI-HAP, via the hypnoidal state score and the PCI
(sub)dimension scores, measures the nature of the content of subjective experiences during
a sitting quietly period embedded in hypnotism from a more phenomenological perspective.
Whereas the Harvard and the Stanford C can be conceptualized as measuring
“trait” effects of hypnotism (within a state context), the hypnoidal state score of the PCI-
HAP is measuring the “state” effects of hypnotism, while still subsuming trait influences
(Kumar, Pekala, & Cummings, 1996). By adding items on expectancy and items on
suggestibility (the imagery vividness dream item and the eye catalepsy item) to the PCI-HAP,
we hoped to generate an instrument for measuring hypnotic responsivity that would help
assess the concepts of trance, suggestibility, and expectancy, and also be more clinically
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 Suggestiblity, Expectancy, and Trance State Effects

relevant (Pekala, 2006; Pekala & Kumar, 2007; Pekala & Wickramasekera, 2007) than the
commonly employed traditional scales.
Obviously, by having fewer suggestibility items than the traditional scales, the PCI-
HAP is not meant to be used as a measure of hypnotic suggestibility (responses to suggestions)
or hypnotizability (“the skill or talent a person has that enables him or her to respond to hypnotic
tasks, such as suggestions on standardized scales,” Wagstaff et al., 2008, p. 129). Rather, it was
developed to be used as a measure of hypnotic responsivity from a more state perspective. As
such, the PCI-HAP is not meant to replace existing cognitive-behavioral instruments, but to
possibly complement them. Furthermore, it can be used in clinical settings where the client’s
phenomenological experience (loss of volitional control, feelings of altered consciousness, positive
and negative affect, internal dialogue, imagery vividness, etc.) is judged to be more important
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than which behavioral items on a standardized hypnosis scale are passed.

The PCI-HAP3 includes a pre-assessment, administration of the induction and
suggestions, the subsequent completion of the PCI (Pekala, 1982, 1991b) in reference to a sitting
quietly period embedded in the hypnotic induction protocol, and also a post-assessment
(debriefing form). For the pre-assessment, participants report whether they experienced hypnotism
before and if so, how hypnotizable they felt they were at that time. They also are asked to estimate
their subsequent level of hypnotic depth on a “1” to “10” scale (estimated hypnotic depth).
Additionally, participants are told to visualize themselves in a hot tub and estimate the vividness
of their kinesthetic and visual imagery. Finally, they are asked to estimate how helpful the
hypnotic session is going to be to help them with their problems and concerns.
The hypnotic induction consists of a “body scan” (progressive relaxation but without
the tensing), and a “mind calm” (counting back from “10” to “1” while “you let your mind become
more and more calm, more and more empty”). After the mind calm, participants are asked to go on
vacation in their mind and “have a wonderful and relaxing time.” After this mental vacation (the
imagoic suggestibility item), participants are told to raise their left index finger when asked to do
so (the finger raising item is intended to obtain a measure as to whether participants may have
been unresponsive at this point in time). Participants are subsequently given the suggestion that
their eyes are “heavy like lead” and are asked to try to open their eyes (the eye catalepsy item).
Participants are then told to sit quietly and “just continue to experience the state you are in right
now.” After the 2-minute sitting quietly period, participants are asked to pause for 15 seconds and
make a mental note of what they were experiencing during that time. Participants are then counted
out of the induction, using a “1” to “5” scale, and then complete the PCI in reference to the two
minute sitting quietly period and the debriefing questionnaire.
As mentioned, the PCI-HAP generates a pHGS score or “hypnoidal state” score
(Pekala & Nagler, 1989) that may be construed as a “general measure of trance” (Pekala &
Kumar, 2000, p. 112). The PCI-HAP includes self-report measures of two types of expectancies:
pre-hypnotic estimated hypnotic depth and pre- and post-hypnotic therapeutic efficacy. In
addition, the PCI-HAP assessment protocol also includes a measure of “imagoic suggestibility”
that is assessed via an imagery vividness dream item. Imagoic suggestibility is an aspect of
imagination and fantasy as defined by Sheehan (1979), or “imaginative suggestibility” as
defined by Kirsch and Braffman (2001): “requests to experience an imaginary state of affairs as
if it were real” (p. 59). (Imagoic suggestibility we conceive as one aspect of imaginative
suggestibility, since the latter may include many other aspects of suggestibility.) The PCI-HAP
post-assessment debriefing form allows participants to estimate their hypnotic depth in the
spirit of LeCron (1953) via a self-reported Hypnotic Depth (srHD) score. The post-assessment
form also assesses responses to several other items: a finger response item, an eye catalepsy
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item, and a “fell asleep” item. Additionally, there is a measure for reliability.
Over 20 years ago Laurence and Nadon (1986) suggested that “more sophistication
in the experimental inquiries of hypnotic depth is required in order to further our understanding
of the cognitive and affective structures underlying the hypnotic experience” (p. 215). In a
subsequent paper (Pekala, Kumar, Maurer, Elliott-Carter, Moon, & Mullen, 2010) we present
a study wherein self-reported hypnotic depth was predicted using the PCI-HAP in a group of
substance dependent individuals. This research offers initial support for the importance of
suggestibility, expectancy, and trance (altered) state effects in helping to better understand
the nature of self-reported hypnotic depth. We believe this data can help us better understand
the “the cognitive and affective structures underlying the hypnotic experience,” which in
turn, can help to better illuminate the nature of hypnotism.
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Footnotes
This research is partially based on two $5,000 grants received from the Veterans
Administration Stars and Stripes (VISN4) Healthcare Network. This paper is based, in part,
on a presentation given at the Annual Meeting of the American Society of Clinical Hypnosis
and the Society of Clinical and Experimental Hypnosis in Dallas, Texas, January, 2007. The
authors wish to thank the staff of wards 39A and 39B for their support in doing this research.
The authors also wish to thank Stephen Lankton and Dr. Edward Frischholz for their
suggestions and remarks, and Drs. Jean Holroyd and Erik Woody for their comments and
suggestions on an earlier version of this paper. The content of this presentation does not
represent the views of the Department of Veterans Affairs nor the United States Government.
1
Multiple regression analysis was used, instead of exploratory/confirmatory factor
analysis, so as not to blur the distinction between PCI (sub)dimensions, which would have
been the case had factor analysis been utilized instead.
2
The original research (Pekala & Kumar, 1984) used all 26 dimensions and
subdimensions of the PCI in the regression analysis. By doing this we were able to increase
the R over and above that obtained when using only the 12 PCI major dimensions. Because
of multicollinearity, several of the variables were more highly correlated among themselves
than with the criterion variable, which resulted in these variables functioning, we believe, as
suppressor variables (Grimm & Yarnold, 1995), and hence increasing the resulting R.
3
Copies of the PCI (Pekala, 1982, 1991b), the PCI-HAP, the therapist and self-report
pre- and post-assessment forms, the administration (Pekala, Kumar, & Maurer, 2009), and
interpretative (Pekala, 2009) manuals, and the EXCEL scoring program are available at
www.quantifyingconsciousness.com.

Author’s Note

1
Coatesville VA Medical Center, Coatesville, PA
2
West Chester University of Pennsylvania, West Chester, PA

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