Proposals for HPD Revision & Improvement

Reproduced from The Hypnotherapy Journal, Issue 3 Vol. 9, Autumn 2009

Donald Robertson & John Harrington

[Addendum: I understand the Open University have now confirmed that the proposed changes would not affect the OU credits assigned to the HPD. - DR]

In accord with NCFE’s guidance, now that it’s been in use for several years, NCH have been reviewing the existing Hypnotherapy Practitioner Diploma (HPD) award in an attempt to make necessary updates and improvements.  We have already developed a draft document which clearly shows how the existing HPD learning outcomes might be merged into a smaller set of more generic outcomes.  NCFE have changed their standard format for the specification of learning outcomes since the original HPD was designed and they have advised us that a qualification of this kind would typically be comprised of 20-30 outcomes, whereas the existing HPD has about 86 individual outcomes.  Some of the Version 1 HPD outcomes were quite “high-level” and generic, whereas others become much more concrete and specific.  This created some inconsistency in the award which seemed to complicate the assessment process, e.g., one learning outcome seems to be trying to cover the whole history of hypnosis theory, and could be evidenced by a long essay-type answer. 

3.3 How the models and concepts in your area of practice have evolved and developed, how these tend to change with time and the similarities and differences between different versions.

Whereas others focus down upon very specific areas of practical concern which require a small amount of very specific evidence, e.g., 

15.4      When to touch the client and when not

For the sake of consistency, we’ve tried to subsume more specific issues under a simpler set of broader headings and set the learning outcomes at similar levels of abstraction.  We’ve also tried to minimise jargon, and to substitute theoretically-biased terminology with more generic language.  The “range” (explanation) of each outcome can then be used to provide further specification where needed.  Organising the HPD in a more structured way makes it much easier to read the document and work with the outcomes.  We can now outline the learning outcomes more simply in a single-page document, which provides a clear outline of what must be covered on an HPD training.

            There were also some typographical errors and minor corrections made, and some proposals for additional outcomes which seem to have been missing from the original HPD.  Version 2 of the HPD will be quality-assured by NCFE as meeting the same standard of competence, but easier to read and implement and hopefully as generic and “streamlined” as possible, to make it easier for different training schools to implement.  (To be clear, the number of outcomes has no bearing on the volume or level of work required for the award, which will remain the same.)  Below is the current draft, which is very much under discussion, and has been developed with advice from NCFE on the wording, etc.  The whole award pack provided for students and trainers will be much more comprehensive, hopefully, this is just the list of learning outcomes. 

            We are publishing these proposals at an early stage for the sake of transparency and to encourage NCH members to consider them and comment, especially trainers, who may have to implement them in relation to their existing courses.  We promise to acknowledge any feedback received and will be happy to discuss any comments or suggestions.  This is not a “final draft” until we’re satisfied everyone has had a reasonable and bona fide chance to comment.  According to NCFE, the original HPD was not formally mapped against the National Occupational Standards for Hypnotherapy published by Skills for Health, although it was very closely based upon them.  However, the Version 2 will be systematically mapped against the NOS, we hope, in a manner approved by NCFE.  There is some indication that the National Occupational Standards for Hypnotherapy will be revised themselves next year, in accord with recent revisions which have made other CAM NOS more generic.  The plus sign (+) Indicates an outcome which was previously absent from the HPD, or not clearly stated, but has been proposed for inclusion in version 2. 

UNIT 1: ASSESS & PREPARE CLIENT (INITIAL CONSULTATION)

1.         Assess the suitability of clients for treatment.  (Contra-indications, motivation, circumstances, nature of problem, etc.)

2.         Interview the client to assess their needs.

3.         Build rapport and a sound working alliance.

4.         Assess hypnotic susceptibility.

5.         Provide a rationale and explanation for hypnotherapy treatment.

UNIT 2: PLAN & DELIVER HYPNOTHERAPY TREATMENT

6.         Design a treatment plan and agree it with the client.

7.         Employ hypnotic inductions and related techniques.  (Deepeners, tests, emerging, etc.)

8.         Deliver hypnotherapy treatment.

9.         Teach and assign homework techniques.  (Self-hypnosis, CDs, etc.)

UNIT 3: EXPLAIN HYPNOTHERAPY THEORY

10.       Explain the main therapeutic approaches used in modern hypnotherapy.

11.       Evaluate the elements of psychopathology relevant to the practice of hypnotherapy.

12.       Evaluate the factors which might help or hinder the working alliance.

13.       + Explain and evaluate the nature of hypnosis.

14.       + Explain and evaluate the principles of effective hypnotic suggestion.

UNIT 4: EXPLAIN ETHICAL & PROFESSIONAL ISSUES

15.       Evaluate the key elements of the NCH or UKCHO codes of ethics and practice.

16.       Explain the scope and limits of your sphere of competence as a hypnotherapist.

17.       Explain the role of CPD and reflective practice in maintaining professional standards.

18.       + Evaluate the benefits of different forms of clinical supervision.

19.       Evaluate the role of confidentiality in hypnotherapy

20.       Evaluate the legal issues relating the practice of hypnotherapy.  (Criminal and civil law.)

21.       Evaluate the risks attached to hypnotherapy treatment in general and specific interventions.

22.       Evaluate common ethical dilemmas in the practice of hypnotherapy.

The Role of Expectation in Hypnosis:
Hypnosis, Imagination & Placebo Pain Relief

James Braid defined hypnotism as focused attention upon an “expectant dominant idea”, to the temporary exclusion (”abstraction”) of other thoughts.  Since that time, researchers have pondered the role of expectation in hypnotic responses.  Most therapists, and even more so stage hypnotists, probably share the common impression that the expectations of clients/subjects are an important factor, shaping how they respond to hypnotic suggestions.  However, human beings have a notable tendency toward “reductionism” and so debates like this tend to involve back-and-forth between all-or-nothing viewpoints, e.g., “hypnotism is all just expectation” versus “expectation doesn’t matter.”  An alternative, middle-way, would be the position that hypnotism is partially determined (”mediated”) by expectation, but not 100% so.  As one of the most prolific researchers in our field Professor Irving Kirsch has famously pointed out in his “response expectancy” theory of hypnosis, this would suggest that hypnotism is fundamentally related to the mechanism underlying the placebo effect, i.e., that hypnosis is a “non-deceptive mega-placebo”.  Again, that is very different from the notion that hypnotism is “just” a placebo, or the naive view that placebo effects are somehow “not real”.  People experience measurable physiological change and symptom remission after being given placebos and the process can be compared to the (anachronistic) concept of “waking suggestion” in the field of hypnotherapy.  Indeed, Braid introduced the concept of “hypnotism” (as opposed to Mesmerism) precisely on the basis of his observations of Victorian quack (”nostrum”) remedies, which modern researchers would consider examples of deceptive placebo remedies.  In other words, Braid saw people physically responding to treatments, such as animal magnetism or wearing “galvanic rings”, whose effects he and other sceptics attributed to expectation and suggestion, and subsequently developed hypnotism as a means of more honestly employing suggestion as an explicit technique in medicine.

In an important new experimental study ‘Response Expectancies: A Psychological Mechanism of Suggested and Placebo Analgesia”, Leonard S. Milling has carried out a very thorough and careful statistical analysis of the extent to which expectation appears to mediate the effect of hypnosis, imagination, and placebo, in the reduction of experimentally-induced pain among a sample of 172 college students (Contemporary Hypnosis, 26(2): 93-110, 2009).  All three interventions reduced pain substantially.  Traditional hypnotism and instructions to “imagine” were nearly equivalent, and both were almost twice as effective as the placebo.  This, and Milling’s other findings, lend additional support to the view that instructions to imagine may often be substituted for a traditional hypnotic induction, a central premise of Barber’s nonstate (”cognitive-behavioural”) theory of hypnosis.

Milling also found strong evidence supporting the role of expectation in mediating pain reduction.  However, the importance of expectation varied depending upon the techniques employed, calculated as follows,

• Traditional hypnotic induction plus suggestion.  25%
• Instructions to “imagine” plus suggestion.  29%
• Placebo (an inert topical lotion).  41%

As Milling concludes, this appears to show that about 25% of the effectiveness of traditional pain-reduction hypnotherapy is due to expectation.  Expectation is an important factor but there may be one or two other factors involved which contribute more to the response, e.g., attention, motivation, imagination, or a trait of hypnotisability, etc.  By comparison, expectation contributed more substantially to the placebo effect, but still less than fifty percent, supporting the view that a cluster of factors contribute to the placebo response and it is not simply reducible to expectation alone, although this may turn out to be the single most important manageable factor involved.  Motivation, role-perception, attention, and other factors may be involved in the placebo response as well and Milling also points to the Pavlovian theory of classical conditioning which has been cited as providing another mechanism by which placebos (and hypnotism) may function.  For instance, a person who has previously received a real medication and experienced its effects may be more likely to respond to a similar-looking placebo because it acts as a reminder (conditioned stimulus) for the associated sense of pain relief (a conditioned response) – independently of the effect of expectation.  So previous experience of a real drug combined with high levels of expectation would probably produce a strong placebo response.  Likewise, tapping into remembered sensations (”sensory recall”) may combine well with expectation in eliciting certain hypnotic responses.

As expectation is a “cognitive” factor, these findings can be interpreted as supporting the view that the effect of hypnotherapy for pain reduction is “cognitively-mediated” in a manner overlapping with CBT interventions, which also stress the role of cognition in shaping the perception of pain.  In other words, although superficially different, hypnotherapy and CBT probably work, to some extent, in a similar manner, at least to some extent. 

As Milling points out, the usual cautions apply insofar as this was experimental pain induced with college students, etc., and therefore only provides an analogy (indirect evidence) for the mechanisms underlying pain relief among genuine therapy clients with genuine medical problems.  (Although, I think most researchers would consider it likely similar factors operate in the clinical setting as well.)

“In sum, this study substantiates that response expectancies are an important mechanism of hypnotic, imaginative and placebo analgesia.  The findings corroborated the view that the effect of hypnosis on pain is partially mediated by response expectancies.  The results also showed that the effect of a placebo on pain was largely, but not completely, mediated by response expectancies.  [...] Thus, although the results of this study do not suggest that response expectancies are the final common pathway [as Kirsch has suggested] to pain relief, they do indicate that response expectancies are one of the major psychological mechanisms of suggested and placebo analgesia.”

So, as other studies have shown, the traditional hypnotic induction is probably not essential to hypnotic pain reduction, and client expectation is probably one of the most important factors which we should make use of.  Moreover, Barber, Spanos, Kirsch, and other cognitive-behavioural researchers have already discussed in some detail the possible means by which factors such as expectation may be systematically enhanced in hypnotherapy through methods tested in experimental settings such as role-modelling, manipulation of activating sensations, task-motivational instructions, etc.

The Conditioning & Inhibition Theory of Hypnosis

In previous snippets, we’ve looked at factors in the typology of suggestion, some clinical outcome studies, etc., this month I’d like to draw attention to some research attempting to support a comprehensive theory of hypnosis.  As the psychologist Kurt Lewin famously remarked: “Nothing is as practical as a good theory.”  That phrase came to mind when reading Alfred Barrios’ recent series of articles which concisely and systematically outline a relatively simple “conditioning and inhibition” theory of hypnosis (Barrios, 2001), which recently led to an exchange with Steven Jay Lynn relating to the similarities and differences between Barrios’ theory and the influential “socio-cognitive” theory of hypnosis. 

            Barrios’ theory ultimately derives, I think, from the “cortical inhibition” theory of hypnosis which crowned Pavlov’s physiological research on animals at the turn of last century – a theory further developed by Platonov and other Soviet hypnotherapists.  Anyway, Barrios does an admirable job of carefully spelling out his modern variation, with intermittent references to supporting research data.  In a nutshell, Barrios draws on a revised form of conditioning theory to describe hypnosis as a method for reinforcing the subject’s tendency to progressively fade out (”inhibit”) intrusive thoughts and sensations in a way that heightens their sensitivity to learned associations between words, such as hypnotic suggestions, and physiological responses such as emotions.  From this point of view, words, such as verbal suggestions, function as stimuli which in turn evoke “cognitive stimuli” (ideas and images) in a way that triggers hypnotic responses.  Barrios’ use of behavioural learning theory obviously has the potential to highlight certain overlaps between the theory and practice of hypnosis and behaviour therapy. 

Barrios’ theory consists of the following seven hypotheses, divided into three groups,

A. Hypnotic induction

1. “Hypnotic induction is a conditioning process.”

2. “The response conditioned during hypnotic induction is an inhibitory set, a set which tends to inhibit stimuli incompatible with the response suggested by the hypnotist.”

3. “A positive response to a suggestion will induce within the responding person a more or less generalised increase in the normally existent tendency to respond to succeeding suggestions.”

B. Explanation of hypnotic phenomena

4. “A suggestion produces the desired response by first evoking a cognitive stimulus which is associated with that process.”

5. “The inhibitory set facilitates the suggested response by inhibiting stimuli competing with the cognitive stimulus.”

C. Post-hypnotic suggestion

6. “Suggestion leads to behaviour change by a form of higher-order conditioning called C-C [cognitive-cognitive] conditioning.”

7. “Hypnosis facilitates the C-C conditioning produced by suggestion.”

Barrios published two subsequent articles, the first of which explores the relationship between his “conditioning and inhibition” theory and four other modern theories of hypnosis: sociocognitive theory (Spanos/Lynn), Neo-dissociation (Hilgard), response expectancy (Kirsch), and Milton Erickson’s approach (Barrios, 2007).  The second reviews the possible benefits and applications of the theory to understanding phenomena such as the placebo effect, improving the effectiveness of hypnotic induction, improving post-hypnotic suggestions, and the development of Barrios’ therapeutic technique called Self-Programmed Control (Barrios, 2007b).

Comparison Between Theories

In the current edition of Contemporary Hypnosis, Steven Jay Lynn and Sean O’Hagen have responded in some detail to Barrios’ comparison between the conditioning and inhibition and sociocognitive theories of hypnosis.  

Sociocognitive theories reject the traditional view that hypnotic experiences require the presence of an altered state of consciousness.  Rather, the same social and cognitive variables that determine mundane complex social behaviours are said to determine hypnotic responses and experiences. (Lynn & O’Hagan, 2009)

They praise Barrios for providing a systematic and comprehensive account of his theory and its practical implications.  Indeed, contrary to Barrios’, they conclude that his theory is itself one of several falling under the broad “sociocognitive” umbrella term.  However, while endorsing some of his points, they disagree with others, citing several research studies in support of their own position.  In particular,

1. Barrios emphasises the power of hypnotist prestige but sociocognitive researchers have generally found the qualities of the hypnotist to be of less importance than the qualities of the subject, e.g., their level of motivation, expectations, and imaginative capacity.
2. Following Spanos, Barrios emphasises the power of “goal directed fantasies”, or mental imagery, in evoking hypnotic responses but, according to Lynn, research has failed to show that imagery alone can account for hypnotic responses without the aid of factors such as motivation and expectation.
3. Barrios, like many hypnotists, naturally assumes that hypnotic suggestions are more effective when presented in order of difficulty, giving the subject an increasing confidence in their ability to respond. However, Lynn cites evidence from experimental studies showing that this is not the case and subjects respond just as well when suggestions are given in descending order of difficulty.
4. They do, however, find support for Barrios’ contention that subjects increase in responsiveness to genuine suggestion tests after first being duped into believing they are hypnotised, e.g., by surreptitiously playing quiet music in the background while suggesting that they will hallucinate the sound of music, etc.
5. They raise doubts over Barrios’ claim that some induction techniques induce hypnosis more “deeply” than others. Research has consistently failed to demonstrate much difference between different induction techniques.
6. Moreover, the increase in suggestibility following hypnotic induction techniques is around 20% on average, which seems to show that the presence of a hypnotic state (”trance”), even if such a thing did exist, would be far less important to hypnotism than other factors such as the personality of the subject, their attitudes, and the type of suggestions given.

It’s truly fascinating to observe these debates between researchers from different theoretical traditions because they highlight the pros and cons of their respective points of view.  This is research in action; the competition between contrasting hypotheses, appealing to their respective supporting evidence.  It’s through this kind of dialogue that genuine progress is achieved in hypnotic research and we work our way gradually closer to an accurate and comprehensive theory of hypnosis and hypnotherapy. 

Bibliography

Barrios, A. A. (2001). A Theory of Hypnosis based on Principles of Conditioning & Inhibition. Contemporary Hypnosis , 18 (4), 163-203.

Barrios, A. A. (2007). Commentary on a Theory of Hypnosis based on Principles of Conditioning & Inhibition, Part I: Contrasts with Other Perspectives & Supporting Evidence. Contemporary Hypnosis , 24 (3), 109-122.

Barrios, A. A. (2007b). Commentary on a Theory of Hypnosis based on Principles of Conditioning & Inhibition, Part II: Benefits of the Theory. Contemporary Hypnosis , 24 (3), 123-138.

Lynn, S. J., & O’Hagan, S. (2009). The Sociocognitive and Conditioning and Inhibition Theories of Hypnosis. Contemporary Hypnosis , 26 (2), 121-125.

The Discovery of Hypnosis

The Discovery of Hypnosis: The Complete Writings of James Braid, the Father of Hypnotherapy.
Donald Robertson (editor)

This book has been published,

• To help inform and educate hypnotherapists about the origins of their field.

• To provide a resource to raise the credibility of modern hypnotherapy by drawing attention to its empirical roots.
 

Visit the link below to purchase a copy or review the book at Amazon. We hope to shortly make available a browsable online PDF version through Amazon and Google books.

The Discovery of Hypnosis: The Complete Writings of James Braid the Father of Hypnotherapy

Several excerpts from this book have been published in the Hypnotherapy Journal of NCH, and a recent article has been published in the International Journal of Clinical & Experimental Hypnosis (IJCEH). Click the link below to view the IJCEH abstract, or order a PDF of the article online.

Braid’s Lost Manuscript, “On Hypnotism” (1860)