Relaxation, Guided Imagery, Willful Dissociation, and Hypnosis: Practical Strategies for Primary Care Providers

Have you ever wished that you could enhance the placebo effect of your treatments by making suggestions to your patients? Have you wondered whether you could use willful dissociation to facilitate behavioral change and relieve pain? Have you been reluctant to try these techniques because your colleagues might think that you were practicing quackery? If you have, the following case vignette and discussion should prove useful.

CASE VIGNETTE

Mr A, a 45-year-old man, was admitted to the medical intensive care unit (MICU) with hypotension due to a large anterior wall myocardial infarction. Unfortunately, the MICU team was struggling to place an arterial line that was needed for monitoring of his cardioactive agents. The psychiatrist in the MICU saw that Mr A was anxious and uncomfortable and that the MICU team was frustrated by their inability to complete the procedure. He asked Mr A, “If you could be anywhere in the world right now that you would find to be completely relaxing, where would you be?” Mr A replied, “I would be sitting on a mountain, overlooking a gorgeous green valley.” The psychiatrist then asked about the sounds, smells, weather, physical surroundings, and whether he was alone or with others; he followed that with a request, “OK, can you close your eyes and see and feel yourself on that mountain (filling in the details that he had just learned) with the gentle breeze and the smell of pine? The psychiatrist then guided Mr A through slow, relaxed breathing, muscle relaxation, and tension relief. Then, he added, “You might notice a mosquito flying nearby; it might even alight upon you, but you don’t need to brush it away, as you continue to enjoy the view of the valley.” After several minutes of engaging in guided imagery, the psychiatrist told Mr A that he could open his eyes and continue to feel as relaxed as he had been on the mountain. Upon opening his eyes, while still feeling calm, he noticed that an arterial line had been placed (as the team had inserted the line painlessly as the mosquito landed upon Mr A’s wrist). Mr A and the members of the MICU team were thrilled.

DISCUSSION

What Is Dissociation, and How Can It Be Viewed as Existing Across a Continuum?

Dissociation refers to a reversible uncoupling among components of consciousness (eg, attention, memory, perception, sense of self, and agency). It exists along a continuum, from common and adaptive shifts of mental focus (daydreaming), to deliberately cultivated states that are used in therapy (hypnosis), to maladaptive experiences that accompany trauma-related psychopathology (posttraumatic stress disorder [PTSD]), to pharmacologically induced alterations (eg, by psychedelics). Contemporary cognitive neuroscience reframes this continuum in terms of dynamic interactions among large-scale brain networks. Chief among these are the default mode network (DMN), the salience network (SN), and the central executive network (CEN), which together choreograph the balance between internal mentation and externally directed task engagement.¹ Understanding how these networks are reconfigured across states clarifies what dissociation is, why it can be used creatively and therapeutically, and when it can be pathological.

In normal waking consciousness, the DMN (involving the medial prefrontal cortex [PFC], the posterior cingulate cortex, and the angular gyrus) supports self-referential processing, autobiographical memory, and the “narrative self.” The CEN (encompassing the dorsolateral PFC and the posterior parietal cortex) sustains working memory and goal-directed attention, while the SN (mediated by the anterior insula and the anterior cingulate) functions as a switchboard that tags salient internal or external events and coordinates transitions between the DMN and the CEN. A hallmark of this architecture is the dynamic anticorrelation between the DMN and the CEN: When one is upregulated, the other tends to be suppressed. The SN gates these transitions, preserving flexible, adaptive engagement with both inner and outer worlds.¹ Within this framework, dissociation can be conceptualized as a perturbation of typical network relationships—either by strengthening internally directed dynamics at the expense of external focus, weakening the SN’s regulatory control, or reducing the integrity of the network that underwrites one’s stable sense of self.

Is Daydreaming an Adaptive Form of Dissociation?

Daydreaming (mind wandering) is an everyday, adaptive form of dissociation in which attention drifts from the immediate environment toward internally generated content (eg, memories, plans, fantasies). Neuroimaging studies have demonstrated that during mind wandering, connectivity within the DMN tends to increase, while the typical anticorrelation between the DMN and the executive/attention networks weakens.² During daydreaming, time may feel fluid, and one’s situational awareness may feel blunted; cognitively, associative processes are loosened, facilitating creativity and future simulation. Clinically, daydreaming exemplifies the benign end of the dissociation spectrum. It is transient, reversible, and typically preserves metacognitive awareness (ie, the ability to recognize that one has drifted). Importantly, its network signature—an internally coherent DMN alongside softened boundaries with executive systems—foreshadows elements found in more pronounced or clinically leveraged states, without the loss of control or functional impairment.

What Is Willful Dissociation?

For the purposes of this article, willful dissociation refers to hypnosis (ie, a state voluntarily entered through focused attention and suggestion). Ellenberger described hypnosis as “the oldest psychotherapeutic technique in Western medicine.”³ Hypnotizability is a stable,⁴ multifaceted trait representing one’s ability to experience physiological, sensory, behavioral, and emotional phenomena in response to suggestions given during hypnosis.⁵ The main characteristic of high hypnotizability is the heightened tendency to accept hypnotic suggestions as salient and “true” and successfully experience the suggested phenomena.⁶

Phenomenologically, hypnosis is marked by a narrowed scope of attention, an increased responsiveness to suggestions, and a reduction in spontaneous critical appraisal, features that have long been emphasized in clinical observations.⁷ Neuroimaging studies have revealed that its mechanisms are nuanced and context-dependent. Resting-state studies in highly hypnotizable individuals have shown altered DMN dynamics, including increased coupling between the posterior cingulate and medial prefrontal nodes and a reduction in the typical anticorrelation with dorsal attention networks (DANs).⁸ Task-based and trait studies converge on increased coupling between executive control hubs and the salience system, particularly between the left dorsolateral PFC and SN nodes (ie, anterior cingulate, insula), suggesting a redirection of executive control that highlights suggested content as “salient” and downweighs competing percepts.⁹ During hypnotic analgesia, for instance, connectivity between the anterior cingulate cortex (ACC)/insula and prefrontal regions increases, while coupling between pain-modulatory hubs and primary somatosensory areas decreases, which aligns with reported pain relief.¹⁰ Similarly, high hypnotizability is associated with greater recruitment of the right inferior frontal gyrus and reduced recruitment of the ACC and intraparietal sulcus during incongruent trials of selective attention tasks.¹¹ Taken together, these findings depict hypnosis as a targeted reconfiguration rather than a wholesale breakdown of brain organization. The SN assumes a gatekeeping role that amplifies suggestions; executive resources are engaged but retuned, and the DMN’s contributions to self-referential processing can be attenuated or modulated depending on the task at hand. Because entry into this state is volitional and the exit is rapid, willful dissociation harnesses network plasticity for therapeutic ends, supporting analgesia, anxiety reduction, and habit change, while largely preserving agency.

Current functional magnetic resonance imaging evidence confirms that meditation, mindfulness, guided imagery, and hypnosis are neurobiologically distinct states, each defined by a unique functional connectivity fingerprint. Key studies by Brewer et al,¹² Tang et al,¹³ Dijkstra et al,¹⁴ and Landry et al¹⁵ provide a validated foundation for this understanding. DMN modulation is a common, though not universal, theme: It is consistently reduced in meditation, mindfulness, and hypnosis but variably engaged in guided imagery. The functional partners of this DMN change are markedly different. Meditation and mindfulness couple DMN reduction with strengthened SN and frontoparietal network (FPN) connectivity for self-regulation. Hypnosis couples it with enhanced DAN and altered executive control network connectivity for perceptual suggestibility. Guided imagery largely bypasses this attentional control framework, instead recruiting sensory and limbic networks for simulation. The profiles have clinical implications: SN/FPN strengthening in meditation and mindfulness supports their use in disorders of dysregulated attention and emotion, such as anxiety and depression. The top-down control architecture of hypnosis may explain its efficacy in pain management and habit modification. The sensory-limbic engagement in guided imagery underpins its utility in stress reduction, pain modulation, and psychotherapeutic techniques like rescripting. Maldonado and Spiegel¹⁶ have summarized the neurophysiological underpinnings of hypnosis, which might serve as a resource for those interested in learning more.

How Does Dissociation Contribute to Symptoms of PTSD?

Dissociation in PTSD occupies a different clinical terrain. Rather than being chosen or contextually harnessed, it tends to emerge involuntarily, often in response to trauma cues, and it includes depersonalization (ie, feeling detached from oneself) and derealization (ie, feeling as though the world is unreal). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, recognizes a dissociative subtype of PTSD, underscoring its clinical significance.¹⁷ Neurobiologically, PTSD involves disruptions in the integrity and coordination of large-scale networks that regulate emotion, memory, and self-processes. Resting-state studies have identified abnormalities in DMN connectivity in PTSD, particularly involving the posterior cingulate and the medial prefrontal nodes that anchor self-referential processing.¹⁸ A broader body of work suggests that PTSD oscillates between states of undermodulation (eg, with hyperarousal, intrusive reexperiencing, and insufficient “top-down” control) and overmodulation (eg, with emotional numbing, detachment, and dissociation), with excessive top-down suppression of limbic responses. The latter pattern aligns with increased involvement of the medial prefrontal/ACC regions in dampening limbic signals, which may confer immediate protection from overwhelming affect at the cost of disengagement from one’s internal state and context.^19,20

From a network perspective, dissociative PTSD reflects a maladaptive SN that may misassign salience (ie, either overtagging threat and driving hypervigilance or undertagging emotionally relevant interoceptive cues during detachment). Meanwhile, alterations in the DMN impair the integration of autobiographical memory and a coherent sense of self over time. Clinically, the goal is to restore flexible switching and reintegration with therapies that emphasize titrated exposure, interoceptive grounding, and narrative reconstruction to rebuild healthy DMN integrity and SN-mediated regulation.

How Do Psychedelics Induce Dissociation?

Classic psychedelics, such as psilocybin and lysergic acid diethylamide, primarily stimulate 5-hydroxytryptamine receptor 2A receptors and induce profound changes in perception and self-experience. Multimodal neuroimaging has repeatedly demonstrated a disintegration of the DMN under the influence of these agents, with diminished coupling between the posterior cingulate and the medial PFC. This breakdown of the network that scaffolds the narrative self correlates with “ego dissolution,” a transient loss of the sense of a bounded, separate self.^21,22 Concomitantly, psychedelics increase global functional connectivity and reduce the brain’s usual modular segregation, allowing atypical crosstalk among networks that are normally more insulated.²³ Additional evidence points to loosened thalamocortical gating and widespread cortical desynchronization, consistent with the sensory flooding, synesthesia, and temporal distortions that are often reported following use of psychedelics.^21,22 Carhart-Harris and colleagues²² have framed these changes within the “entropic brain” hypothesis: Psychedelics acutely raise the entropy, or variability, of brain activity, transiently relaxing rigid priors and enabling flexible reconfiguration. Therapeutically, when these states are embedded within careful preparation, supportive “set and setting,” and structured integration, patients may leverage this increased plasticity to revise maladaptive beliefs and patterns, with emerging evidence for their utility in depression, anxiety, and addictions. In contrast to hypnosis, psychedelic-induced dissociation is largely involuntary and dose-dependent, with a broader, brain-wide reorganization rather than a targeted, suggestion-driven retuning.

Efforts to enhance measured hypnotizability through behavioral training sometimes result in an increase in scores, but trait hypnotizability still accounts for 3 times the variance in performance.²⁴ Other techniques that have been used to enhance hypnotic susceptibility include sensory deprivation,²⁵ acupuncture,^26,27 and certain pharmacologic agents including stimulant psychotomimetics²⁸ and oxytocin.^29,30 Similarly, hypnosis can be used to enhance the effect of other therapeutic techniques such as cognitive-behavioral therapy, biofeedback, acupuncture, relaxation techniques, and meditation-based techniques.¹⁶ Other medications (eg, sodium amytal, amobarbital) have been administered as an intravenous infusion to induce a state of light narcosis during the assessment of catatonia and conversion disorder and to differentiate functional from organic disorders. ³¹

Does Dissociation Have 1 Mechanism With Many Expressions?

Looking at the 4 states discussed above through the lens of network dynamics enables the viewing of shared threads and crucial differences. Each involves a perturbation of the usual DMN-CEN antagonism and SN coordination; however, what changes is the direction and scope of the reconfiguration, as well as the degree of agency involved. Daydreaming gently strengthens DMN coherence and softens the anticorrelation with executive systems, enabling internally oriented thought while preserving metacognitive oversight. Willful dissociation (hypnosis) recruits the SN to prioritize suggested content, and it retunes executive control to enact it; DMN dynamics flex in a task-dependent manner, and sensory networks can be downregulated (eg, to produce analgesia) without globally disorganizing the brain. PTSD-related dissociation, by contrast, reflects a maladaptive, often rigid pattern: DMN alterations impair autobiographical integration, SN signaling can be miscalibrated, and prefrontal-limbic interactions tilt toward either undermodulation or overmodulation, the latter underpinning detachment and derealization. Psychedelics push the system into a high-entropy state. The DMN disintegrates, boundaries among networks loosen, and global connectivity surges, and these conditions are ripe for ego dissolution and novel associative processing.

Agency tracks this gradient. It is highest in daydreaming and hypnosis (the latter being explicitly willful) and lowest in PTSD dissociation (involuntary, context-triggered) and psychedelic states (pharmacologically induced and driven). Clinical valence also differs. Daydreaming and hypnosis are adaptive when appropriately harnessed; psychedelic states can be therapeutically valuable in structured care; PTSD-related dissociation is typically impairing, demanding interventions that restore a flexible and balanced network. Across settings, a unifying therapeutic aim is to reestablish healthy SN-mediated switching and a resilient, context-appropriate interplay between the DMN and the CEN.

What Are the Clinical Implications of Understanding the Underpinnings of Dissociation?

Given our understanding of dissociation, 3 practical strategies can be formulated:

1. Assess dissociation in context: transient mind wandering is normative; trauma-linked depersonalization signals risk; hypnotic responsiveness can be therapeutically leveraged; psychedelic experiences, if encountered, warrant careful screening and integration.
2. Map symptoms onto plausible network-level changes to guide psychoeducation: eg, explain ego changes via DMN disruption or attentional narrowing via SN-driven prioritization.
3. Align interventions with mechanisms: hypnosis for analgesia or procedure-related anxiety; trauma-focused therapies to rebuild self-continuity and interoceptive grounding; and, where legal and appropriate, psychedelic-assisted therapy within regulated protocols that emphasize preparation and integration. Hypnosis creates a modifiable cognitive state, but its neural effects depend on the content of the suggestions. Suggestions to reduce pain engage affective networks (eg, ACC and limbic regions) and dampen sensory processing, whereas suggestions that alter emotions recruit language/working-memory circuits in the left PFC to modulate sensory inputs in a top-down fashion.^32–34

What Percentage of the Population Is Readily Hypnotizable?

Hypnosis is a natural state of attentive, focused concentration. As such, most individuals can experience trance-like states in their daily lives. The classic literature on hypnotizability suggests that most individuals possess some degree of hypnotic capacity. Indeed, most adults fall in the middle of the hypnotic range (ie, roughly 60%–70% are moderately hypnotizable), with an additional 10%–15% of adults falling in the highly hypnotizable range, indicating that only a small minority of adults are considered to have low hypnotizability (ie, 15%–25%).^35–37

Hypnosis is a natural psychophysiological state of attentive, receptive concentration, during which individuals experience a relative suspension of peripheral awareness. Hypnotic phenomena occur spontaneously, but they can also be elicited at will. In the context of a therapeutic relationship, the alteration of consciousness that hypnotized individuals experience may have a variety of therapeutic applications. The hypnotic experience may be understood as involving 3 main factors: absorption, dissociation, and cognitive flexibility (or suggestibility).^38,39

Depending on the degree of one’s natural ability to enter a trance state (hypnotic capacity or hypnotizability), a given subject will require more or less help to enter and to use his or her hypnotic capacity. That is, highly hypnotizable individuals enter trance states with ease, on many occasions even without being fully aware of it. Conversely, individuals with low hypnotizability require more direction or help from the therapist who facilitates the trance experience.¹⁶ Even when there is no intent to use hypnosis formally, the ability to enter a trance state is widely and naturally distributed throughout the normal population.

How Can You Tell If a Patient Will Be a “Good Subject” for Using This Technique?

Hypnosis is a stable and measurable trait. Given that not everyone is equally hypnotizable, it helps to perform a clinical assessment of a patient’s hypnotizability level before embarking on hypnosis as a therapeutic technique. Most of the hypnotizability scales developed in the early part of the twentieth century were designed for use in research settings, eg, the Stanford Hypnotic Susceptibility Scale³⁶ and the Harvard Group Scale of Hypnotic Susceptibility.⁴⁰ These scales involve a structured hypnotic induction and an assessment of the subject’s response to a variety of instructions, including alterations in one’s control over movement, sensation, temporal orientation, and perception, such as hallucinatory experiences. Research scales are accurate and useful in research settings, but they are time-consuming and impractical in clinical settings.

Briefer and more practical hypnotizability scales were developed for clinical use, eg, the Hypnotic Induction Profile.^41–43 Clinical hypnotizability scales require only about 5–10 minutes and are designed for use with patients in any clinical setting (within hospitals or in the therapist’s office). Clinical hypnotizability scales are readily accepted by patients, and their use helps to overcome performance anxiety by shifting the focus from one in which the therapist tries to make the patient have a hypnotic experience (ie, the patient’s performance) to one in which the therapist assesses the patient’s response to a set of instructions (ie, therapeutic intervention). Thus, the focus is on the evaluation of the patient’s ability to enter the hypnotic state rather than on “hypnotizing the patient,” and this approach also serves a therapeutic function, demonstrating to the patient that “all hypnosis is self-hypnosis.” This approach removes a sense of dependency on the therapist and demonstrates to patients that they are in control. These scales all involve a structured hypnotic induction and an assessment of the subject’s response to a variety of instructions, such as alterations in the sense of control over body movements, physical sensations, orientation to time and space, and perception. The intense concentration and increased receptivity that are characteristic of the trance phenomenon help to predict the patient’s responsivity to psychological treatment. Indeed, research has found a high correlation between high hypnotizability scores and responsivity to a variety of medical and psychosomatic conditions, eg, pain, smoking cessation, dental procedures, dermatologic conditions, gastrointestinal disorders, functional neurological disorders, anxiety, acute and PTSD, and dissociative disorders.^16,44 A recently published retrospective observational study that reported on the experience of app-delivered hypnosis in 84,395 users across 282,893 stress-reduction sessions demonstrated significant improvement in stress management.⁴⁵ In the study, greater stress reduction was observed with interactive and regular-length sessions, higher hypnotizability, older age groups, and paying members. These findings demonstrated that disseminable digital formulations of hypnosis can contribute to stress reduction.

What Kinds of Problems Can Be Managed With Use of Willful Dissociation/Hypnosis?

A myriad of affective (eg, anxiety, fear), behavioral (eg, cigarette smoking, compulsive behaviors), and cognitive (eg, inattention) symptoms and problems (eg, pain) can be altered by use of willful dissociation. Many of these issues arise in the context of receiving care for medical conditions. Not uncommonly, the reluctance to embark on pharmacologic solutions for symptoms leads to a willingness to consider more holistic approaches (eg, guided imagery, willful dissociation, and hypnosis). Although some patients and health care providers are reluctant to broach the subject of hypnosis (given its checkered history as a technique used in vaudeville and the media’s portrayal of hypnosis as a tool to control others), many more are willing to consider using mindful meditation and progressive muscular relaxation to achieve calm and control distress.

Patients are reassured by learning that they cannot be made to do something that they do not want to do and that the approach is collaborative and under their control. Once individuals experience heightened relaxation, they become more willing to expand their thinking with suggestions to target distressing symptoms and problems.

What Other Techniques Can I Use Without Being Formally Certified in the Practice of Hypnosis?

The use of guided imagery, voluntary breath practices, and meditation also relies upon a patient’s ability to allow themselves to engage in these techniques. While formal training is not required, practitioners can gain experience during residency training or by attending courses on these techniques once they are established in clinical practice.

A recent publication demonstrated that app-delivered self-hypnosis is very effective in stress management.⁴⁵ These findings provide evidence that disseminable digital formulations of hypnosis can meaningfully contribute to stress reduction and potentially manage other psychological conditions, even if you are not a certified provider.

How Can Willful Dissociation Be Learned and Taught to Patients?

Most clinicians learn how to perform the technique by watching others use the technique (and listening to how they decide to move from one phase of gentle breathing and guided relaxation to the delivery of suggestions that target a patient’s symptoms) with patients or during demonstrations of the technique in teaching sessions. Then, clinicians gain comfort and expertise in the use of this technique through practice. While some clinicians rely on standardized scripts, others improvise and tailor their suggestions to the images and sensations revealed by the patient. Once a patient uses this technique, they can follow the same steps taken by the clinician who performed the technique with them, listening to their own voice or to a tape-recorded session with a clinician.

What Are the Risks of Performing Willful Dissociation (Hypnosis)?

Part of the evaluation of suitability for hypnosis includes the evaluation of potential risks. Patients may consciously or unconsciously find the induction into trance and the trance state to be a frightening loss of control. While this is the exact reverse of the actuality of hypnosis (ie, the patient is in more control), caution should be taken with patients who have a history of paranoid thinking, who are behaving in disinhibited ways (“I just lost control of myself”), or are providing overtly stated concerns, such as “What are you going to do to me?” For such patients, engaging them in guided imagery or voluntary breath practices provides an alternative to the formal use of a hypnotic trance induction and experience.

Why Is Willful Dissociation (Hypnosis) Not Taught to, and Used by, Clinicians More Widely?

Hypnosis is often stigmatized; moreover, it is frequently portrayed as a means of controlling others (eg, for recreational or nefarious purposes). When “stage hypnosis” is performed in front of large audiences, the hypnotist often has a subject perform comical (or humiliating) acts seemingly without the subject’s awareness or control. When hypnosis is portrayed on television and in the movies, it is often depicted as a means of exerting manipulative control, so that the subject is rendered unconscious, amnestic, or controlled by others. This view of hypnosis espoused by the media shapes the views of practicing physicians and their patients about hypnosis.

Unfortunately, these portrayals, while often entertaining, lead to misunderstandings about hypnotherapy, which uses the technique for therapeutic purposes (eg, retrieving affectively charged memories). Those who undergo hypnotherapy dissociate willfully and allow the therapist to guide their experience and memories, based on a trusting relationship and shared goals. Patients who undergo hypnotherapy maintain the ability to stop the process at any point; therefore, the fear of losing control that scares many individuals is not based on reality. Other factors that limit the use of hypnotherapy include a decreased emphasis on the nature and practice of the technique in psychiatric training, inadequate reimbursement for the procedure, and the ability of nonphysician psychotherapists to provide similar psychotherapeutic interventions as psychiatrists (using psychotherapies that fit well within research paradigms).

Will I Need to Be Certified to Perform Willful Dissociation (Hypnosis) or Guided Imagery?

In general, psychiatrists do not require formal certification or registration to perform hypnotherapy or related techniques, as these may be considered akin to other psychotherapies. As with other psychotherapy modalities, practitioners should receive training regarding the indications for, the administration of, and the complications of hypnosis prior to its use. In clinical practice, hypnotherapy and related modalities are often used in concert with other psychotherapeutic approaches, depending on the provider’s experience and style and the patient’s problems.

In the United States, several states (eg, Connecticut, Colorado, Washington) are reported to have regulations or requirements for registering to perform hypnosis, and several others have statutes or case law that clarifies a hypnotist’s definition and roles.⁴⁶ However, many of these regulations were created to prevent nonmedical hypnotherapists from claiming to be medical practitioners; therefore, their applicability to psychiatrists or other licensed psychotherapists is unclear. Those who are considering using hypnosis in their practice should speak to fellow practitioners or legal counsel in their area to clarify applicable regulations or limitations regarding hypnosis.

At some institutions, hypnotherapy may be subject to hospital credentialing, involving a request for privileges and documentation of training in, or competence with, hypnotherapy. Competence in this technique can be substantiated in myriad ways (eg, providing case logs of past use of the technique, receiving supporting letters from supervisors, or obtaining formal certification of training in hypnotherapy). Nonpsychiatrist psychotherapists (eg, psychologists, social workers) may be subject to different standards and requirements for certification and the documentation of competence. These policies are generally determined by hospital systems and by state licensing boards. Similarly, physicians other than psychiatrists may also be interested in using hypnosis in their clinical practice. Since hypnosis is not a common part of any other specialty’s scope of practice or training, these physicians will generally need to seek external training to attain competence. As with most interventions, patients can be billed for the service if there is documentation of medical necessity and the practitioner’s competence in that modality, but reimbursement practices may vary depending on payer policies.

Where Can You Learn How to Perform Willful Dissociation and Hypnosis?

When a health care professional is interested in receiving formal training in hypnotherapy, several training options are available. Colleagues who are knowledgeable about hypnotherapy and websites of professional organizations whose members perform hypnosis are valuable resources for information about how to attain competency in this modality. For example, the American Psychological Association’s Division 30: Society of Psychological Hypnosis is a body designed to promote and educate practitioners and the public about the role of hypnosis in research and patient care.⁴⁷

In addition, numerous formal certification programs are available through various professional organizations, most notably the American Society of Clinical Hypnosis (https://asch.net) and the Society for Clinical and Experimental Hypnosis (http://www.sech.us), among others. Certification programs may consist of didactic learning, case-based learning, and formal supervision. As an intervention that requires specific skills, longitudinal training programs that include practical and supervised components will generally be most effective at ensuring competence in this domain.

For psychotherapists considering training in hypnotherapy, having a theoretical framework to conceptualize the training is useful. Understanding hypnotherapy and its evidence base is important for educating patients and colleagues about hypnosis and its role in specific clinical contexts. Subsequent skills that hypnotherapists will need for effective practice include how to select patients, induce relaxation (or trance), deliver hypnosis (including specific scripts or suggestions), and teach patients how to hypnotize themselves. Textbooks and instructional videos can supplement hypnotherapy education, but direct observation and feedback from other professionals who are competent in this modality are helpful to put theory into practice.

What Happened to Mr A?

Mr A recovered uneventfully from his myocardial infarction. Grateful for his exposure to willful dissociation in the MICU, he wondered how this technique could help him in other ways. The psychiatrist suggested that it might help him stop smoking cigarettes. After gathering more information about when, why, how much, and where Mr A smokes, as well as when and why he would not smoke (eg, if it smelled awful, if it made him acutely ill), the same guided imagery used in the MICU was recreated, and several suggestions were added (eg, “Whenever you smoke a cigarette and inhale the cigarette smoke, you will feel as if you are about to retch; this will remind you to take the cigarette out of your mouth and extinguish it. Then, the fresh, clean smell of pine that you recall from being on the mountain top will fill your lungs and that smell will relax you.”). Before opening his eyes, Mr A was asked to imagine smoking a cigarette. As he imagined inhaling the cigarette smoke, he felt nauseated and then imagined extinguishing the cigarette and smelling pine. Although Mr A had smoked 2 packs per day for 25 years, he stopped smoking cigarettes following this session.

CONCLUSION

Dissociation exists along a continuum from common and adaptive shifts of mental focus (daydreaming) to deliberately cultivated states that are used in therapy (hypnosis), to maladaptive experiences that accompany trauma-related psychopathology (PTSD), to pharmacologically induced alterations (eg, by psychedelics). Hypnosis is marked by a narrowed scope of attention and an increased responsiveness to suggestions. Because entry into this state is volitional and the exit is rapid, willful dissociation harnesses network plasticity for therapeutic ends (eg, supporting analgesia, anxiety reduction, and habit change) while largely preserving agency. Although some patients and health care providers are reluctant to try hypnosis (given its portrayal in the media as a tool to control others), many more are willing to use mindful meditation and progressive muscular relaxation to achieve calm and to control distress. Most clinicians learn how to perform the technique by watching others use the technique with patients or during demonstrations of the technique in teaching sessions. Once a patient uses this technique, he or she can follow the same steps taken by the clinician who performed the technique with them, now listening to their own voice or to a session recorded by the clinician on the patient’s phone, a recording sent to them via email or on a CD mailed to them.

Article Information

Published Online: September 3, 2026. https://doi.org/10.4088/PCC.26f04222
© 2026 Physicians Postgraduate Press, Inc.
Submitted: March 3, 2026; accepted May 1, 2026.
To Cite: Muskin PR, Maldonado JR, Dragonetti JD, et al. Relaxation, guided imagery, willful dissociation, and hypnosis: practical strategies for primary care providers. Prim Care Companion CNS Disord. 2026;28(5):26f04222.
Author Affiliations: Department of Psychiatry, Columbia University Irving Medical Center and Columbia University Vagelos College of Physicians and Surgeons, New York, New York (Muskin); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Maldonado); Department of Psychiatry, Wake Forest University School of Medicine, Winston-Salem, North Carolina (Dragonetti); Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts.
Drs Muskin, Maldonado, and Dragonetti are co-first authors; Dr Stern is the senior author.
Corresponding Author: Theodore A. Stern, MD, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts ([email protected]).
Financial Disclosure: Dr Stern has received royalties from Elsevier for editing textbooks on psychiatry. Drs Muskin, Maldonado, and Dragonetti have no disclosures to report.
Funding/Support: None.

Clinical Points

• Willful dissociation refers to hypnosis (ie, a state voluntarily entered through focused attention and suggestion).
• The context of dissociation is important: Transient mind wandering is normative, trauma-linked depersonalization signals risk, and hypnotic responsiveness can be therapeutically leveraged.
• A myriad of affective, behavioral, and cognitive symptoms and problems (eg, pain) can be altered by use of willful dissociation in the context of receiving medical care.
• Patients are reassured by learning that they cannot be made to do something that they do not want to do and that the approach is collaborative and under their control.