Hypnosis & Applied Relaxation (AR) – January Research Snippet

Hypnosis & Applied Relaxation (AR)

January Research Snippet by Donald Robertson, NCH Research Director

(Some of the material for this post is derived from the forthcoming book The Practice of Cognitive-Behavioural HypnotherapyCopyright (c) Donald Robertson, 2011.  All rights reserved.)

This month’s snippet is a bit of a change again: a slightly longer article providing the whole outline of a modern evidence-based behaviour therapy for anxiety, which is well-suited to be assimilated into hypnotherapy.  People often ask “Why isn’t there more research on hypnosis?”  In fact, the people who ask this, in my experience, never seem to have read (or even heard of) the main research journals in the field of hypnosis (IJCEH, AJCH, and Contemporary Hypnosis) and are unaware that there’s actually an awful lot of research on hypnosis, arguably more than on any other psychological therapy, apart from cognitive-behavioural therapy (CBT).  However, one of the problems facing hypnosis researchers is that methods of hypnotherapy are too messy, eclectic and complex to be well-suited to good research design.  It helps build an evidence base if a treatment is “manualised” and can be described in a guide so that other researchers can replicate it in independent studies.  Hypnotherapists tend to do lots of strange things with clients, making it difficult to isolate which “bits” are effective and which bits are redundant.  Modern research on psychological therapies is constantly evolving and improving in quality.  Protocols for therapies tend to have become simpler in order to facilitate the process of research. 

A well-known example is the “Applied Relaxation” protocol developed in Sweden by the psychologist Lars-Goran Öst, currently a professor at the University of Stockholm, and his colleagues (Applied Relaxation: Description of a Coping Technique and Review of Controlled Studies, 1987).  It developed out of Edmund Jacobson’s Progressive Muscle Relaxation, Wolpe’s Systematic Desensitisation, and a variety of “coping skills” approaches to anxiety management that evolved in the 1970s.  The following account is based on Öst’s original protocol and the self-help version published by Davis et al. (Davis, et al., 1995 pp. 65-74; Applied Relaxation: Description of a Coping Technique and Review of Controlled Studies, 1987).  Although essentially a form of modern behaviour therapy, Applied Relaxation has also been used in combination with cognitive restructuring as part of a cognitive-behavioural therapy (CBT) approach.

Applied Relaxation is of interest to hypnotherapists because it consists of a very simple treatment protocol employing relaxation coping skills, which has been adapted for use with a range of problems, and supported by a number of well-designed research studies.  It has met critical appraisal criteria for being classed as an Empirically-Supported Treatment (EST) for panic disorder and research has also supported its efficacy in the treatment of generalised anxiety disorder (GAD) and, to some extent, for specific phobias, headache, pain, epilepsy, tinnitus, and other conditions.  It’s also been recommended for general management of worry and stress, i.e., for subclinical problems.

I think this protocol would be of interest to hypnotherapists because the method closely resembles “hypnotic desensitisation” (Wolberg, 1948; Wolpe, 1958) and it provides a good example of how a simplified hypnotherapy treatment protocol could be developed for use in treatment outcome research.  When reading the description below, just consider replacing the Jacobson tension-release relaxation method with self-hypnosis training in suggested relaxation and (I hope) it should be easy for hypnotherapists to see how this coping skills framework can be directly modified and transformed into a simple behavioural hypnotherapy method for anxiety.

Overview of the Applied Relaxation (AR) Protocol

The full text of a journal original article by Prof. Öst describing the method in detail is currently available online at this link.

Components of Applied Relaxation

Components of Applied Relaxation

In brief, Applied Relaxation begins with training in Progressive Muscle Relaxation, which is gradually developed into a cue-controlled relaxation coping skill, and systematically applied during in vivo exposure to feared situations.  The original protocol takes about 10-12 sessions, following assessment, and the specific stages of treatment are as follows,

  1. Assessment, formulation, and self-monitoring, which Öst seems to imply takes 2-3 sessions prior to training
  2. Progressive Muscle Relaxation, lasting 2-3 weeks/sessions
  3. Release-only relaxation, lasting 1-2 weeks/sessions
  4. Cue-controlled relaxation, lasting 1-2 weeks/sessions
  5. Differential relaxation, lasting 1-2 weeks/sessions
  6. Rapid relaxation, lasting 1-2 weeks/sessions
  7. Applied relaxation (application training), lasting 2-3 weeks/sessions
  8. Maintenance

1. Assessment & Formulation Phase

The full protocol begins with behavioural analysis and self-monitoring, usually carried out over three weeks.  Clients are asked to begin during the first week by recording their experiences on a very simple self-monitoring form that contains the following three headings: Date, Situation, and Intensity (rated 0-10).  In the second week, a column is added headed “Reaction (What did you feel?)”, and finally, in the third week, a column is included headed “Action (What did you do?”).  The final self-monitoring form, therefore contains headings as follows,

Tension Self-Monitoring Record

Date/Time

Situation

Reaction

(What did you feel? 

Focus on the earliest signs.)

Intensity

(0-100%)

Action

(What did you do?)

         

Öst introduces clients to a three-system conceptualisation model of anxiety (or stress) that distinguishes between physiological sensations, behaviour, and cognitive (subjective) responses.  The emphasis of assessment and conceptualisation is on helping the client spot the signs of stress, especially the earliest stages of the response developing.  This tends to particularly involve identifying common physiological sensations, such as muscles tensing or heart rate increasing, and environmental antecedents such as typical events or situations that are associated with elevated stress.  Öst recommends presenting the treatment rationale to clients as follows,

One good way of breaking this development [of anxiety] is to focus on the physiological reactions and learn not to react so strongly.  The method we are going to use to achieve this is called applied relaxation.  The aim of this technique is to learn a skill of relaxation, which can be applied very rapidly and in practically any situation. This skill can be compared to any other skill, e.g. learning to swim, ride a bike, or drive a car, in that it takes time and practice to learn, but once you have mastered it you can use it anywhere.  You are not restricted to the calm and non-stressful situation in my office or your own home.  The goal is to be able to relax in 20-30 sec and to use this skill to counteract, and eventually get rid of, the physiological reactions you usually experience in phobic situations.  To achieve this we are going through a gradual process starting with tensing and relaxing different muscle groups.  This takes about 15 min, and you are to practice it twice a day.  Then we start to reduce it by taking the tension part away, just relaxing, which takes 5-7 min.  The next step teaches you to connect the self-instruction “Relax” to the bodily state of relaxation.  Then we teach you to do different things while still being relaxed in the rest of your body, and also relaxing while standing and walking.  After that it is time for the rapid relaxation, which you practice many times a day in non-stressful situations.  Finally, you reach the stage of applying the skill in phobic situations, and I will take you to different anxiety arousing situations coaching you how to apply the relaxation at the first signs of anxiety in these situations.  Applied relaxation is thus a skill that most people can acquire with the right instructions and a lot of practice.  It is a “portable” skill that can be used in almost any situation and is not restricted to phobias, but can be used in other situations, e.g. when having problems in falling asleep. (Applied Relaxation: Description of a Coping Technique and Review of Controlled Studies, 1987)

2. Coping Skills Training Phase

2.1 Progressive Muscle Relaxation

The first phase of actual Applied Relaxation training consists of Jacobson’s Progressive Muscle Relaxation technique, which Öst derives directly from the abbreviated approach introduced by Wolpe and Lazarus as part of Systematic Desensitisation (Wolpe, et al., 1966; Jacobson, 1938).  This training is divided across the first 2-3 sessions, the first of which focuses on relaxing the head and arms (hands, arms, face, neck, and shoulders), to which are added, in the second session, relaxation of the torso and lower body (back, chest, stomach, breathing, hips, legs, and feet).  In Öst’s version, each muscle group is tensed for only five seconds, much abbreviated from Jacobson’s original method, followed by 10-15 seconds of relaxation.  In Jacobson’s original approach, the aim is to learn to keep relaxing the rest of the body while tensing individual muscle groups, i.e., to only tense the muscles you’re deliberately using, which helps create a bridge to the “differential relaxation” stage (Jacobson, 1938).  At the end of the procedure, the client rates their level of tension on scale (0-100%), similar to a traditional SUD scale, where zero means absolute relaxation and 100% means maximum tension – the same self-rating scale used during homework.  Although people do normally find it easier to relax when lying down, training begins in a seated upright position, as the purpose is to develop a coping skill that will generalise to situations where the client is physically active.  The same relaxation routine is to be practised twice daily for homework, sessions typically lasting about 15-20 minutes, with each recorded on a homework form for review during sessions.

Relaxation Homework Record
Date/Time Component(Technique) Tension Before(0-100%) Tension After(0-100%) Duration(Minutes) Comments(Any difficulties?)
           

2.2 Release-only Relaxation

The next phase of Applied Relaxation, like the original Progressive Muscle Relaxation approach, focuses on “release-only relaxation” training for an additional 1-2 weeks.  In this phase, the initial tensing of muscles is omitted, some basic skill having been acquired in closely studying the contrasting sensations of tension and relaxation.  This also means a reduction in the time taken to induce relaxation from 15-20 minutes to 5-7 minutes.  The therapist verbally prompts the client to “Breathe with calm, regular breaths and feel how you relax more and more for every breath… Just let go… Relax your forehead… eyebrows… eyelids… jaws… tongue and throat… lips… your entire face…”, etc. (Applied Relaxation: Description of a Coping Technique and Review of Controlled Studies, 1987).  The client then scans their body for any remaining tension and tries to relax completely.  However, if the client does find tension creeping back into a muscle group during release-only relaxation they are to revert to the original tension-release technique, for that part of the body alone.            

2.3 Cue-controlled Relaxation

The next phase, cue-controlled relaxation, involves training in a “verbal cue” or “self-instruction” to induce relaxation more quickly, usually in around 2-3 minutes, by using the word “RELAX”, which is practised for another 1-2 weeks.  This is apparently conceptualised by Öst as a process of conditioning the relaxation response to the verbal stimulus (“RELAX”).  During the session the client relaxes as deeply as possible using the release-only approach, signalling when they have done so by raising a finger.  The client then focuses on their breathing, while the therapist repeatedly says the words “INHALE”, just before each inhalation, and “EXHALE”, before each exhalation, five times in a row.  The therapist then fades this verbal prompt and the client takes over using her own self-instruction by saying “INHALE” and “RELAX” internally (covertly), in a similar manner.  After about a minute, the therapist begins repeating the words again, about five times, and the client takes over again, repeating the process above, and once more after a break of about fifteen minutes.  The therapist should ask the client to estimate how long it took them to relax completely, and feedback the correct answer, because, as Öst points out, clients typically over-estimate the duration.  This routine should also be practised about twice per day, to help condition an association between the verbal cue “RELAX” and rapid release-only relaxation.           

2.4 Differential Relaxation

The next phase involves “differential relaxation, again derived from Jacobson’s approach, which consists of learning to relax while using some muscles.  The client is asked to induce cue-controlled relaxation while seated in a hard chair or standing, and to remain relaxed while moving their head or arms, or legs, etc., and finally while walking.  Emphasis is placed on further reducing the time taken to induce relaxation, which typically comes down to 60-90 seconds, according to Öst.           

2.5. Rapid Relaxation

This is followed by a “rapid relaxation” training phase, which aims to help the client relax in vivo, in naturally stressful situations, while further reducing the time taken for relaxation to 20-30 seconds.  The client is asked to relax 15-20 times each day for homework.  Obviously, this means the technique is used very frequently throughout the day, and so cues are identified to act as reminders, such as each time the client checks the time on a watch or clock, or opens a door, etc.  Sticky notes or other reminders can be used in the work or home environment to act as additional reminders.  The rapid form of cue-controlled relaxation consists in taking three deep breaths, saying “RELAX” internally after each one, before exhaling slowly.  The body is then scanned for any remaining tension, and the client tries to maintain maximum relaxation in the real-world situation.           

3. Application & Maintanence Phase

3.1 Application

The “application” phase usually begins after roughly 8-10 sessions of preceding training, and involves brief exposure to a wide variety of anxiety-provoking stimuli and situations.  The client is encouraged to use their cue-controlled relaxation coping skill immediately prior to exposure, and to continue to use the technique during exposure, in response to any initial signs of escalating tension.  Exposure using Applied Relaxation typically takes 10-15 minutes, much briefer than normal prolonged exposure sessions, which can last 1-2 hours.  However, the aim is not to extinguish anxiety completely but rather to learn to cope with it by using cue-controlled relaxation as a coping strategy.  The client may be exposed in vivo to feared objects or events, or through interoceptive exposure to panic sensations, or using imaginal exposure, especially for feared catastrophes in worry and GAD.          

3.2 Maintanence

Training is followed by a “maintenance” programme to help ensure that the coping skill further generalises to different situations in the future and is not simply forgotten.  To help maintain the skill, clients are asked to scan their body at least once each day and use their rapid relaxation method to dispel any tension identified, and to practice either differential or rapid relaxation at least twice per week.  The client may also keep the therapist updated by posting them records of their progress, e.g., for a period of six months after treatment.

Hypnosis & Applied Relaxation

Very little in Öst’s original protocol needs to be changed in order, I think, to legitimately transform it into a hypnotherapy technique.  As cognitive-behavioural approaches to hypnotherapy typically conceptualise hypnosis mainly as a form of self-hypnosis, and emphasise specific evidence-based skills training procedures (such as Nicholas Spanos‘ CSTP), cognitive-behavioural hypnotherapy in particular lends itself well to a “coping skills” approach, like Öst’s Applied Relaxation.  There’s not much reason to believe that the tension-release (Jacobson) method has significant advantages in relation to treating common problems over suggestive methods like Autogenic Training, which can easily be used instead as part of a hypnotic version of Applied Relaxation.

Christmas Research Snippet: Hypnotism & Babies

Christmas Research Snippet: Hypnotism & Babies

Donald Robertson, NCH Research Director

For personal reasons, I’ve been delving into the research relating to hypnotism and childbirth recently, an area that, I confess, I’ve largely overlooked before.  Throughout its entire history, hypnotherapy has been used in relation to childbirth.  Even James Braid, the founder of hypnotherapy, reports a case where hypnotic suggestion was used to induce childbirth early for medical reasons.  However, the largest and most systematic use of hypnosis for issues relating to childbirth occurred in the Soviet Union at the start of the 20th century, based on the Pavlovian approach to hypnosis and psychotherapy.  Tens of thousands of women received hypnosis and a surprising amount of data was collected on its use.  In order to make it accessible to  a wider audience, by being conducted in a group setting, the hypnotic method was replaced by a psycho-educational method termed “psychoprophylaxis”, meaning “psychological prevention” of pain and anxiety during childbirth.  The French obstetrician Dr. Fernand Lamaze visited Moscow in the 1940s to study the Pavlovian psychoprophylactic method from which he developed the well-known Lamaze method of natural childbirth that continues in popularity today.  The Pavlovian hypnotic approach, psychoprophylaxis and the Lamaze methods competed with Dr. Grantly Dick-Read’s “Childbirth without Fear” approach, and all of these co-existed alongside numerous other uses of hypnosis in obstetrics, e.g., in the work of William S. Kroger, one of the best-known authors in clinical hypnosis, who wrote Psychosomatic Gynecology (1951) and the self-help book Childbirth with Hypnosis (1961).

Perhaps the most important recent review in this area was published by Donald C. Brown and D. Corydon Hammond in 2007 in a Special Issue of The International Journal for Clinical & Experimental Hypnosis dedicated to reviewing evidence-based practice in clinical hypnosis.  Professor Hammond is a clinical psychologist at the University of Utah School of Medicine and former president of the American Society of Clinical Hypnosis.  He’s well-known in the field of hypnosis for his many publications and as the editor of The Handbook of Hypnotic Suggestions & Metaphors (1990), a resource most experienced hypnotherapists possess and will be familiar with.

Brown & Hammond reviewed the evidence concerning the benefits of hypnosis in obstetrics, labor, and delivery, in relation to a range of issues, including,

  1. Reduction in use of analgesics and anaesthetics, i.e., reducing pain in labor
  2. Increasing enjoyment of labor
  3. Reducing the duration of labor
  4. Preventing preterm labor (PTL)

The review is quite wide-ranging and takes in many other benefits and applications of hypnosis, with reference to studies of varying age and quality.

The authors begin by reporting a previous review by Hoffman & Kipenhaur (1969) that found studies reported that hypnosis eliminated or substantially reduced the pain of childbirth for 50% (median) of women, with individual studies reporting success rates ranging from 35% to 90% of cases.  That suggests that the chances of having a painless childbirth with hypnosis varies enormously, depending upon the specific characteristics of the study, i.e., the way hypnotherapy is conducted and the characteristics of the women participating, including their level of motivation, expectations, etc.  Roughly half the women typically experienced substantial freedom from pain in these old studies.  There’s no mention of control comparisons, so it’s impossible to tell what percentage of these women would have reported painless childbirth without the use of hypnosis, i.e., their attitude and motivation to give birth naturally may explain their success to some extent. 

This ambiguity is addressed to some extent by a recent meta-analysis, identified by Brown and Hammond as the most comprehensive study to date on hypnosis for analgesia in childbirth.  The meta-analysis identified three randomised controlled trials (RCTs) where hypnotised and non-hypnotised women were compared (Cyana et al., 2004).  Across three studies, involving 142 women in total, they found that the hypnotised group were about half as likely to require pharmaceutical pain relief (analgesia) during childbirth compared to women giving birth without hypnosis.  More specifically, 62% of hypnotised women (mean) did not require analgesia compared to only 26% of non-hypnotised women (see chart).  This suggests, again, that more than half the women having hypnosis had relatively painless childbirths, although a large part of their success must be attributed to non-hypnotic factors.  (This is not a surprising finding and broadly consistent with research on other uses of hypnotherapy, and indeed psychological therapies in general.)

Although use of chemical analgesics, etc., is a more objective measurement, it does not necessarily reflect an accurate picture of the amount of subjective pain reported.  This has seldom been adequately reported in the literature, however, Brown and Hammond report a study by Mairs (1995) in which 28 hypnotised women subjectively rated their pain and anxiety levels, before (expected level) and after childbirth (actual level) , which were compared to ratings from 27 women in a non-hypnotised (control) group.  No differences were found between the hypnotised and non-hypnotised women in their anticipated levels of pain or anxiety before childbirth, however, after the birth the hypnotised women rated their pain as 5.41 on average compared to 7.58 in the non-hypnotised group, excluding those (n=7) who required caesarean sections.  By my calculations, that suggests that the women giving birth without hypnosis reported their feelings of pain as being about 40% higher during labour, on average, than the hypnotised group did.

In addition to these data, Brown & Hammond focus at length on the limited evidence regarding the potential of hypnosis in the prevention of preterm labour.  I’d suggest that anyone interested in the whole area of evidence-based practice in relation to hypnosis for obstetrics and childbirth, etc., consult this article for the wealth of information and useful references it contains.  Indeed, over fifty books and articles specifically relating to the use of hypnosis in childbirth were referenced by the authors.

Graph of Childbirth without Chemical Analgesia

Graph of Childbirth without Chemical Analgesia

 

Reference

Brown, DC; Hammond, DC    (2007).  ‘Evidence-based clinical hypnosis for obstetrics, labor and delivery, and preterm labour’, IJCEH, 55(3), pp. 355-371

Cyna, A.M.;McAuliffe, G.L.;Andrew, M.I.  (2004).  ‘Hypnosis for pain relief in labour and childbirth’, British Journal of Anaesthesia, 93(4), 505-511.

Blood & Tension: November Research Snippet

Blood & Tension

Applied Tension in Treating Blood Phobia

Donald Robertson, NCH Research Director

This month’s research snippet deviates once again from the usual format.  This is an issue I’ve been talking to some hypnotherapists about recently and it’s of interest because it highlights the possible limitations of relaxation-based therapies in treating certain common anxieties. 

Virtually all contemporary researchers have rejected the idea that hypnosis can be equated with any form of relaxation, or that relaxation is a necessary component of hypnotherapy.  However, the notion that hypnosis involves mental or physical relaxation is still very popular, even among many hypnotherapists.  It is also widely-assumed that relaxation serves well as a method of managing anxiety, including in most phobias.  However, the value of relaxation in treating certain forms of anxiety has been questioned over recent decades for a number of reasons.

In particular, the treatment of choice for blood-injection-injury (BII) type phobias is currently the “Applied Tension” method developed by Lars-Göran Öst and his colleagues at the University of Uppsala in Sweden.  Basically, Öst has produced a series of research studies which provide evidence that training in a special tension “coping skill” combined with exposure to feared situations or events appears to be more effective than exposure alone or accompanied by relaxation training (termed “Applied Relaxation”).  The rationale for Applied Tension is that BII phobia, unlike most other forms of anxiety, is often accompanied by actual fainting or feelings of faintness caused by the vasovagal response.  The response to blood among phobics has been found to be unusual in that it consists of a “biphasic” reaction during which blood pressure and heart rate first rise (as in normal anxiety) and then rapidly drop, leading to fainting.  

The tension coping skill learned in Applied Tension involves tensing one’s arms, chest, and legs until a feeling of warmth occurs in the face, usually taking about 10-20 seconds.  This is repeated five times in a row, with 20-30 second pauses between.  Relaxation more than normal is deliberately avoided.  Doing so has been found to increase blood pressure and, in particular, cerebral blood flow, and to do so sufficiently to prevent the drop in blood pressure associated with fainting and the associated sensations of faintness.  This coping skill is then repeated for sessions of five repetitions, five times per day, over the space of five weeks.  It is combined with systematic exposure to the feared situations, which in the research conducted by Öst, includes a visit to the blood donor clinic, where the phobic provides a blood sample, and ultimately to an operating theatre to observe thoracic surgery taking place in person.  90% of blood phobics have been found to have improved to a clinically-significant degree following this brief intensive treatment, compared to only 60% of those trained in relaxation methods.

Most of the (highly-regarded) research on Applied Tension for blood phobia comes from the same research group and has, unfortunately, tended to employ relatively small sample sizes.  Recently, the findings have been questioned somewhat by one team of reviewers (Ayala, Meuret & Ritz, 2009).  On the other hand, a recent large-scale study of 614 blood donors found that those who expressed fears of fainting were more likely to continue donating blood if trained in Applied Tension (Ditto, France & Holly, 2010).

So if tension may be more beneficial than relaxation in the treatment of blood phobia, how can this be incorporated into hypnotherapy?  Well hypnotherapy certainly doesn’t seem to require relaxation and so “active alert” approaches to hypnotic induction might be better indicated for this client group.  James Braid, the founder of hypnotherapy, definitely used to induce either tense (“cataleptic”) or relaxed states depending on the individual needs of his clients.  Modern active-alert hypnotic procedures can be combined with suggestions for confidence-building (or ego-strength) which seems important with this client group, and used in conjunction with Applied Tension training.  Let us know what you think, though, by posting your comments below.

References

Öst, Fellenius & Sterner   (1991).  ‘Applied tension, exposure in vivo, and tension-only in the treatment of blood phobia’, Behav. Res. Ther., vol. 29, no. 6, pp. 561-574.

Öst, Sterner & Fellenius  (1989).  ‘Applied tension, appplied relaxation, and the combination in the treatment of blood phobia’, Behav. Res. Ther., 27, 109-121.

Öst & Sterner (1986).  ‘A specific behavioral method for treatment of blood phobia’, Behav. Res. Ther., vol. 25, no. 1, pp. 25-29.

Ditto B.;  France CR.;  Holly C. (2010).  ‘Applied tension may help retain donors who are ambivalent about needles’, Vox Sanguinis.  98(3 Pt 1):e225-30

Ayala ES.;  Meuret AE.;  Ritz T.  (2009).  ‘Treatments for blood-injury-injection phobia: a critical review of current evidence’, Journal of Psychiatric Research.  43(15):1235-42

Hypnotherapy versus CBT: October Research Snippet

Hypnotherapy versus CBT: October Research Snippet

Donald Robertson, NCH Research Director

This month’s research snippet is about a very important treatment outcome study on public-speaking anxiety, a clinical trial comparing an established (evidence-based) CBT protocol for social phobia (social anxiety disorder) against the same protocol augmented by hypnosis, and a third (waiting list) control group.  The study was published in 1997 and has been frequently-cited since as providing evidence of the “additive” value of hypnosis as an adjunct to CBT and potentially other evidence-based treatments.  I’ve decided to summarise it this month because it’s probably one of the most important treatment outcome studies available in relation to hypnotherapy, and so NCH members should be familiar with its findings, and because the study was based on the doctoral dissertation of Nancy Schoenberger, the main author, who was supervised by Prof. Irving Kirsch, one of the speakers at this year’s NCH Extravaganza.  So if you’re lucky you may have the opportunity to ask Prof. Kirsch about this study yourselves!  In a nutshell, the authors conclude: “the addition of hypnosis to cognitive behavioural treatment enhanced the effects of treatment.”

The study involved 62 participants with severe public-speaking anxiety.  They were divided into three groups,

  1. Standard CBT (based on Heimberg’s protocol for social phobia)
  2. CBT+Hypnosis (Cognitive-behavioural hypnotherapy, CBH)
  3. Waiting list control, i.e., a group who received no treatment to control for the effect of spontaneous remission, etc.

The researchers emphasise the established finding that relaxation is not a necessary component of hypnosis (hypnosis is not a “state of relaxation”), although it featured as a treatment component in this study.  (This key misconception is virtually extinct among modern researchers but is still fairly widespread among hypnotherapists.) 

In sum, the hypnotic treatment included all components of the cognitive behavioural treatment.  It differed from the nonhypnotic treatment only in the following ways: (a) relaxation training was termed “hypnosis” and contained reference to entering hypnosis, (b) relaxation practice at home was termed “self-hypnosis”, (c) automatic thoughts were termed self-suggestions, and (d) suggestions for improvement were given following the hypnotic induction.

Participants in both treatment groups received five sessions, two-hours long, of CBT or CBH, based on Heimberg’s established protocol for the generalised subtype of social phobia.  This has already been applied to public-speaking, the most common fear among social phobics, and the authors adapted it to include relaxation skills training and tailored it for application to a specific fear (public speaking).

42 of the 62 participants completed the whole programme of treatment and assessment (= 68% completers).  Essentially, the study found that CBH subjects improved to a greater extent, because of the apparent additive value of hypnosis, across a battery of outcome measures, although the initial credibility rating of both treatments was virtually identical.  The mean effect size across all measures, calculated using a standard formula called Cohen’s d, was 0.80 for CBT, which increased to 1.25 in the group where hypnosis as incorporated.  This shows a substantial increase on average, apparently due to the inclusion of hypnosis in the standard CBT protocol.

The researchers also attempted to identify “moderators” of treatment, i.e., other factors which determined the response to therapy.  They measured hypnotic susceptibility and attitudes toward hypnosis for this purpose.  Suggestibility did not seem to correlate well with outcome measures except for pulse rate (which may have been problematic in this study anyway).  Positive attitudes to hypnosis appear to have moderated the benefits of hypnosis, and correlated with greater reduction in anxious behaviours.

Kirsch’s cognitive “response set” theory holds that the effects of hypnosis are largely mediated by changes in the client’s expectations of improvement.  (It’s generally been found by researchers that treatment expectations correlate with outcome, across the board.)  Although some hypnotists seem to dispute this, it was also central to Braid’s definition of hypnotism that it worked partly by means of expectation.  Statistical analysis in this study showed that hypnosis generated greated expectation for improvement in symptoms of public speaking anxiety than did CBT alone.

In sum, the addition of hypnosis to a cognitive behavioural treatment of anxiety enhances clients’ therapeutic outcome expectancies.  It also appears to promote greater improvement in both expected and experienced anxiety.  Behavioural improvement in hypnotic treatment is associated with positive initial attitudes toward hypnosis, and change in anxiety expectancy appears to be the central unifying characteristic among otherwise uncorrelated measures of change.  These data are consistent with [Kirsch’s] hypothesis that the benefits of adding hypnosis to treatment are mediated by expectancy.

This study followed on from an important meta-analysis by Kirsch and his colleagues which pooled data from different studies comparing different forms of CBT for different problems to the same treatment plus hypnosis and found that for between 70-90% of subjects, on average, hypnosis added to the effects of CBT.  This type of evidence is of particular importance to hypnotherapists as the future of hypnosis and hypnotherapy are likely to be bound up with the integration of hypnosis as a method with other empirically-supported treatments (ESTs).  Dr. Assen Alladin’s recent book Cognitive Hypnotherapy contains numerous integrative protocols which are carefully designed to enhance the effects of established evidence-based treatments for a range of conditions by the incorporation of hypnosis and we should hope that developments like this will continue to add to our understanding of how hypnosis interacts with other nonhypnotic treatments, as this will surely continue to define its role in the future. 

Reference

Schoenberger, N. E., Kirsch, I., Gearan, P., Montgomery, G., & Pastyrnak, S. L. (1997). Hypnotic Enhancement of a Cognitive Behavioral Treatment for Public Speaking Anxiety. Behavior Therapy (28), 127-140.

Important: Your AGM Vote Counts

Special Notice for NCH Members

The 2010 Annual General Meeting (AGM) of the NCH will take place at the Royal Society of Medicine at 2pm on Saturday 2nd October 2010. 

If you’re a voting member of NCH, which you probably are, then visit the secure link below to read more and indicate your voting intentions online.  If you’re not able to attend the AGM in person then you should consider allocating your vote to someone else (a proxy) to vote on your behalf.

Link to the AGM page with voting options for NCH members:

https://www.hypnotherapists.org.uk/agm/

Link to election addresses and AGM notices can be found in the members area here.

https://www.hypnotherapists.org.uk/1596/agm-2010-notices-motions-and-election-candidates/

If you need more advice please email NCH for information.

Mindfulness, Metacognition and Hypnosis: August Research Snippet

Mindfulness, Metacognition and Hypnosis

August Research Snippet

Donald Robertson, NCH Research Director

Apologies for the absence of a July Snippet but here’s August’s a bit early as compensation.  Following our previous snippets on meta-analyses, finding research online, and treatment outcome studies, etc., we’ve recently looked at attempts to combine mindfulness research and hypnosis in the treatment of depression.  This is a popular area so I thought I’d continue in the same theme by looking at, arguably, the most important recent article on this subject.  In 2006, Steven Jay Lynn collaborated with the Buddhist teacher Lama Surya Das, and two other researchers, in an attempt to explore the possibility of combining elements of Buddhist mindfulness meditation practice, cognitive therapy, and hypnosis, drawing on recent research in cognitive psychology.

Mindfulness versus Thought Suppression

Over the past couple of decades, enthusiasm for mindfulness meditation techniques derived from Buddhism has flourished among cognitive-behavioural therapists, inspired by the early success of Jon Kabat-Zinn’s meditation programme for stress management.  Meditation and acceptance strategies have been used to counteract the tendency of many clients to try to suppress, control, or “fight” distressing thoughts.  Lynn et al. refer to the recent study by Wegner and his colleagues, which found that when people tried to deliberately suppress a thought there was evidence of a “rebound effect” in which they subsequently experienced more intrusions of the thought than a control group who were simply asked to think freely about the same thing.  Other studies have found evidence that emotional suppression can inhibit memory and problem-solving and increase physiological signs of nervous arousal.  Lynn and his colleagues report that of nearly a hundred subjects who were asked to keep their minds blank while listening to hypnotic suggestions, only one reported any success. 

Where thought-control strategies backfire, mindfulness and acceptance have been seen as offering an alternative way of responding to distressing experiences.  Lynn et al. follow other contemporary cognitive-behavioural therapists in contrasting non-judgemental mindfulness and acceptance with the unhealthy suppression of thoughts and feelings.  (However, they fail to mention that experimental studies on this “rebound” effect in thought suppression have produced some mixed results – q.v. Clark & Beck, 2010, for a more detailed review.)  Lynn et al. also cite a 2003 meta-analysis of mindfulness-based cognitive therapy and stress reduction approaches by Baer, which found a mean effect size of 0.59 (a medium-sized treatment effect) for this approach across various emotional problems and medical conditions.  In other words, it probably works, but the effects are comparable to those of other therapies and not dramatically superior to them.

Mindfulness & Metacognition

Lynn et al. appeal to a cognitive model combining elements of Adrian Wells’ influential metacognitive theory and Lynn and Kirsch’s own “response set” theory to explain the mechanism underlying mindfulness meditation and its relationship with hypnosis.  Contrary to Beck’s earlier cognitive therapy model, Wells introduced a focus on the notion of “metacognition”, thinking about thinking, or beliefs about beliefs.  According to this model, negative automatic thoughts aren’t particularly unhealthy in themselves, but rather they become so because of our attitude toward them.  In plain English, whereas Beck’s original cognitive therapy assumed that negative thoughts play a central role in the development of emotional disturbance, Wells points to the fact that many people experience lots of negative thoughts without becoming upset by them, whereas patients with severe emotional disorders appear to be unusually disturbed by individual negative thoughts and worries.  Mindfulness meditation, likewise, can be seen as an attempt to adopt a more detached attitude toward our stream of consciousness, and thereby to modify our thinking about thinking, i.e., to see automatic (spontaneous) thoughts as relatively transient and harmless, rather than important and dangerous.  Indeed, Beck has recently assimilated many aspects of Wells’ metacognitive approach into his revised cognitive therapy for anxiety (Clark & Beck, 2010).

Curiously, Lynn et al. don’t mention the fact that Wells’ metacognitive model raises serious problems for hypnotherapy because it suggests that the assumptions often made by hypnotherapists about the “power of thought” risk reinforcing maladaptive (metacognitive) assumptions held by many clients, i.e., the assumption that thoughts (including suggestions) are inherently powerful, whereas Wells teaches his clients that ideas are only as powerful as we believe them to be and we can learn to dismiss them as “mere thoughts”, lacking any real power or significance.  Likewise, Lynn et al. cite the recent research by Twohig (2004), which found that by repeating a negative thought to oneself one hundred times, like a mantra or autosuggestion, subjects made it seem less believable rather than more so, as some hypnotists might assume.  To borrow Wells’ terminology, hypnotism itself can be seen as a set of metacognitive beliefs rather than an altered state of consciousness or “hypnotic trance”.  The belief that autosuggestions are powerful when phrased in certain ways and the strategy of attending to their meaning for a prolonged period, to the exclusion of distractions, are ways of “thinking about thinking” (metacognition), which it’s the aim of most “hypnotic inductions” to instantiate.  In a sense, mindfulness meditation can be seen as a kind of “de-hypnosis” or “counter-hypnosis”, which aims to develop a metacognitive mind-set that weakens the hold of certain thoughts or suggestions, e.g., “Imagine that you are transparent, and disturbing thoughts and emotions cannot penetrate you or have any power to control your actions” (Lynn et al.), which contrasts sharply with typical preliminary hypnotic suggestions to experience certain ideas (suggestions) as powerful, controlling, and deeply penetrating into the mind, etc. 

Combining Hypnosis & Meditation

Lynn et al. summarise the relevance of hypnosis to mindfulness training as follows,

  1. Suggestions can be used to motivate clients to persevere with meditation practice on a regular basis.
  2. Suggestions can be used to generate a patient mind-set, so that when the attention naturally wanders this is seen as normal and accepted.
  3. Suggestions can be given about acceptance of things that cannot be changed.
  4. Hypnosis can be used to help people avoid identification with thoughts and feelings.
  5. Hypnosis can help clients to become more tolerant of unpleasant feelings.
  6. Clients can be hypnotised to perceive negative thoughts as transient and unimportant.

They specifically recommend the use of the following hypnotherapy techniques in conjunction with mindfulness meditation, which generally involves exposure to aversive feelings and events in CBT,

  1. Mental (“covert behavioural”) rehearsal of previously avoided situations.
  2. Cue-controlled relaxation to help facilitate exposure to feared situations.
  3. The use of hypnotic desensitisation to facilitate mental (“imaginal”) exposure .
  4. The use of hypnotic regression or reliving as a form of imaginal exposure to traumatic memories (as in PTSD treatment).
  5. The use of suggestion to help clients tolerate the discomfort and repetition of exposure therapy.

They add that the most basic use of hypnosis in combination with mindfulness-based CBT would be in the use of suggestion to directly develop an ongoing state of mindfulness.  As Lynn et al. emphasise, virtually all modern researchers now take it for granted (following several well-known studies) that hypnosis does not necessarily entail any form of relaxation, although it is frequently accompanied by it.  The same applies to meditation and Lynn et al. refer to a recent EEG brain imaging study in which subjects trained in relaxation showed markedly different brain activity from those trained in mindfulness meditation.

Negative Reactions

As an aside, Lynn et al. also note that a considerable body of research demonstrates the existence of transient, relatively superficial, negative reactions following standard hypnosis, i.e., things like headaches, feelings of nausea, anxiety, etc., in up to 29% of subjects.  This is comparable to the rates of negative responses reported by control groups who are simply asked to sit with their eyes shut, without being hypnotised, for the same amount of time.  However, similar negative reactions are also reported following meditation training, and may even be more frequent, being reported in up to 63% of subjects.  Hence, we might say that although negative reactions can occur following hypnosis it may be as harmless (generally speaking) as common meditation or relaxation techniques.

 

References

Lynn, Steven Jay; Das, Lama Surya; Hallquist, Michael N.; Williams John C.             (2006).  Mindfulness, acceptance and hypnosis: cognitive and clinical perspectives.  IJCEH, 54(2), 143-166.

Clark, David A.; Beck, Aaron T.    (2010).  Cognitive Therapy of Anxiety Disorders: Science and Practice.

Hypnosis, Meditation, Problem-Solving, Depression (June Research Snippet)

June’s Enhanced Research Snippet

Hypnosis, Meditation, Problem-Solving, & Depression

Donald Robertson, NCH Research Director

For a bit of a change, this snippet is about a proposed protocol for treatment of clinical depression, based on existing evidence-based interventions.  I reckoned the subject needed a bit of background explanation so apologies if it’s a bit longer than usual!  It’s difficult to avoid jargon when talking about state-of-the-art stuff but I’ve tried to explain briefly what some of it means.  Email me with any questions, though.

research@hypnotherapists.org.uk

There’s been growing interest recently in the relationship between cutting-edge, “third wave”, approaches to cognitive-behavioural therapy (CBT) and hypnotism.  Some of these new approaches place particular emphasis on cultivating particular states or attitudes of mind, such as acceptance or mindfulness, rather than the disputation emphasised in early cognitive therapy.  There’s also increasing emphasis on the role of attention in psychopathology and psychotherapy.  These are both, obviously, factors which can be related to hypnotherapy, which specialises in inducing particular states of mind and shifting the allocation of attention.

A June 2010 special edition of the International Journal for Clinical and Experimental Hypnosis (IJCEH) was dedicated to the subject of clinical depression, edited by Michael Yapko, who is well-known as a specialist in this particular area.  This follows on the success of Assen Alladin’s recent randomised controlled trial (RCT), which provided evidence that cognitive hypnotherapy could compete with standard cognitive therapy in the treatment of depression, and may be superior on some measures.  (The treatment of clinical depression by ordinary hypnotherapists is considered inappropriate by many experts but this research can probably be applied, to some extent, to the treatment of subclinical symptoms of depression of the sort more commonly encountered in hypnotherapy.)  The article by Lynn et al. (see below) was of particular interest because it outlined proposals for a third-wave cognitive-behavioural approach to hypnotherapy for depression, with scripted examples. 

Lynn et al. focus in particular on the central role now ascribed to morbid “rumination” in the maintenance of depressive symptoms.  They provide proposals for combining thee specialised treatments with modern hypnotherapy.

  1. Rumination-Focused Cognitive-Behavioural Therapy (RFCBT)
  2. Cognitive Control Training (CCT)
  3. Mindfulness-Based Cognitive Therapy (MBCT)

Full details of the hybrid protocol can be found in the article referenced below.  However, to illustrate their approach, I’d like to elaborate briefly on one small aspect of this multi-component treatment approach.

Lynn et al. refer briefly to the use of problem-solving methods which are near-universal in CBT.  However, they could have also mentioned the fact that Problem-Solving Therapy (PST), an approach originating in the 1970s, has received growing support recently from treatment outcome studies as a stand-alone intervention for clinical depression.  (This is an area of special interest to me at present.)  Now, as far back as the 1940s, Lewis Wolberg had discussed the use of problem-solving methods within hypnotherapy, from a cognitive-behavioural perspective.  Wolberg, an eclectic psychotherapist, combined elements of behavioural psychology with rational persuasion psychotherapy, an early precursor of cognitive therapy, in his Medical Hypnotism, one of the best-known clinical hypnosis textbooks of the period. 

Problem-Solving Therapy (PST), in its modern form, has the merit of being a very brief and simple approach, with a well-rounded evidence-base.  It’s simple enough to combine well with hypnotherapy to form a brief hybrid treatment.  Lynn et al. go for a more complex mixture, as mentioned above, but their modified problem-solving plus hypnosis, might be viable as another stand-alone intervention.  I’d strongly recommend that you check out the third edition of the core text, Problem-Solving Therapy: A Positive Approach to Clinical Intervention, by D’Zurilla and Nezu, for a thorough description of PST methodology.  Problem-Solving methodology is derived from experimental studies on problem-solving, decision-making, and related skills, and focuses on helping clients to become more skilled and confident at identifying and solving their own problems of living, of whatever kind.  It’s based on the observation that clients, especially depressed clients, tend to complain of feeling overwhelmed by various problems of living and helpeless to start tackling them.  Essentially, the method is divided into five basic components,

  1. Problem Orientation.  The client is trained to adopt and maintain a positive attitude toward solving their problems, and the key components of this mind-set are explored with them.
  2. Problem Definition.  The client is trained to identify relevant problems and define them objectively with reference to appropriate goals and key obstacles.
  3. Brainstorming Alternatives.  Osborn’s principles of brainstorming are employed to systematically develop a wide variety of alternative solutions.
  4. Decision Making.  Cost-benefit analysis and other methods are used to evaluate proposed solutions and rank them in order of suitability.
  5. Solution Implementation.  An action plan is developed and tested out in practice, followed by systematic reflection on the observed consequences, and possibly re-iteration of the process above.

That’s it in a nutshell, but read the manual above for a proper description.  PST seems to benefit a wide range of clients but it’s been especially linked to the treatment of clinical depression where there is clear evidence of a correlation between depression and problem-solving deficits, in the first place, and evidence from treatment outcome studies that PST can be broadly equivalent to standard cognitive therapy or antidepressants, although delivered in a very brief format, over about six 30-minute sessions. 

Anyway, Lynn et al., propose the following ways in which problem-solving can be facilitated by hypnosis, and I would suggest that these can be integrated with standard problem-solving methodology to form brief hypno-PST for depression, or related issues,

  1. Age regression is used to regress subjects to times in the past when problem-solving was done better and prevented morbid rumination happening.
  2. Suggestions can be given for increased perception of the key features of problems to be solved.
  3. Imaginal rehearsal in hypnosis can be used to test out different proposed solutions and evaluate their consequences.
  4. Imaginal rehearsal can also be used to develop skill and confidence in implementing the chosen solution.
  5. Self-talk (autosuggestions such as “I can do this!”) can be rehearsed during hypnosis, to enhance coping skills in relation to solution implementation.
  6. Hypnotic age progression can be used to have clients envision a future time when they have already solved their problems and to retrospectively identify steps they might have taken to do so.

They also mention that brooding can be overcome by use of direct suggestions (which could be recorded on a CD) to develop a positive problem-orientation or problem-solving mind-set.  I would observe that there’s some reason to believe that problem-orientation is the most important part of the whole methodology and that hypnotic suggestion could serve well as a simple way of helping clients to feel more positive and confident about tackling their problems of living, and to see them more objectively, from a realistic perspective, rather than being threatened or overwhelmed by problems.

Lynn et al., as I have done, are merely commenting on existing evidence-based methods and speculating about protocols which could combine them within a hypnotherapy framework but we can probably look forward to other treatment outcome studies, like Assen Alladin’s, which attempt to provide direct evidence for the efficacy of such multi-component hypnotic approaches. 

Reference

Lynn, S., Barnes, S., Deming, A. & Accardi, M. (2010). Hypnosis, Rumination, and Depression: Catalyzing Attention and Mindfulness-Based Treatments. International Journal of Clinical and Experimental Hypnosis, 58(2), 202-221.

Review of Evidence-Based Hypnotherapy: May 2010 Mega-Research-Snippet

Which Forms of Hypnotherapy are Evidence-Based?

Hypnotherapy as Empirically-Supported Treatment (EST)

Ratings using Chambless & Hollon (1998) criteria reviewed by David M. Wark (2008)

Copyright © Donald Robertson, 2009  Reprinted from The Hypnotherapy Journal Spring 2009

I beg farther to remark, if my theory and pretensions, as to the nature, cause, and extent of the phenomena of [hypnotism] have none of the fascinations of the transcendental to captivate the lovers of the marvellous, the credulous and enthusiastic, which the pretensions and alleged occult agency of the mesmerists have, still I hope my views will not be the less acceptable to honest and sober-minded men, because they are all level to our comprehension, and reconcilable with well-known physiological and psychological principles.  – James Braid, Hypnotic Therapeutics, 1853

One of the most useful articles to be published recently was arguably Wark’s review of those studies on hypnotherapy that were rated as meeting the Chambless & Hollon (1998) criteria for “empirically-supported treatments” in the field of psychology, known as ESTs for short.  It may not surprise many NCH members to know that when the research literature on psychotherapy was previously reviewed by a task force of nineteen psychologists led by Prof. Dianne Chambless most of the psychological therapies identified as “empirically-supported” (formerly termed “empirically-validated”) tended to be specific forms of cognitive and/or behaviour therapy (CBT).  Most forms of psychotherapy, ranging from the more controversial and pseudoscientific ones to some of the more “respectable” and mainstream approaches, do not meet these strict criteria for empirical support.  However, one study was identified which demonstrated that cognitive-behavioural hypnotherapy (CBH) was “probably efficacious” for weight loss in obese clients.  In this respect, hypnotherapy might (tentatively) be said to have garnered more compelling evidence for its efficacy than many other modalities of psychological therapy, apart from the cognitive and/or behavioural treatments and some brief psychodynamic approaches. 

            However, over the past decade, many additional studies of a high quality have been published which provide support for the efficacy of hypnotherapy, including meta-analyses and systematic reviews which collate data from multiple studies to form a more general picture of the research findings in this area.  David Wark’s review entitled ‘What we can do with hypnosis: a brief note’ identifies  over thirty additional studies on hypnotherapy which he rates using the revised Chambless & Hollon (1998) criteria for either “possible”, “probable”, or “specific” empirically-supported treatments, depending upon the nature of the evidence available (see the explanations below).  I have compiled this information into a new table which you will find underneath.  Of course, these are not all the possible applications of hypnotherapy, simply the ones which currently have the strongest empirical support, based on Wark’s rating using established criteria for research quality.  More studies are published every year which potentially meet these criteria and might be included on a future list.

            I think it might be observed that certain hypnotherapy treatments for certain types of pain, anxiety, and weight loss are supported by the strongest evidence at present, by this standard.  In total, three studies (anxiety due to asthma, public speaking, and taking a test) provide good evidence for the efficacy of hypnotherapy as a treatment for anxiety.  Assen Alladin’s recent study which provides support for the use of hypnosis in the treatment of depression is rated as meeting the “possibly” efficacious criteria.  Most of the other studies provide evidence relating to the treatment of acute or chronic pain, and certain stress-related or psychosomatic medical conditions such as insomnia, migraine and IBS.  Wark even finds one study on hypnotherapy for smoking cessation which meets the criteria for “possibly efficacious”, an area where well-designed research has previously been lacking. 

            This overview is consistent with a general trend in the literature, since the Victorian era, which tends to point toward hypnotherapy showing most promise in the treatment of anxiety, insomnia, pain management, and several stress-related medical conditions, with mixed findings in relation to its use for the treatment of habits and addictions such as over-eating, smoking, and alcohol abuse.  For example, a committee of experts commissioned by the British Medical Association concluded in 1892 that,

The Committee are of opinion that as a therapeutic agent hypnotism is frequently effective in relieving pain, procuring sleep, and alleviating many functional [i.e., psycho-somatic] ailments.

However, we can now go beyond those early clinical observations and primitive experiments and provide an overview of the therapeutic usefulness of hypnotherapy based on modern research design meeting the highest standards of quality. 

 “Specific” empirically supported treatments
1. Anxiety about asthma attack   Brown, 2007
2. Headaches and migraine Relaxation + image modification > wait list control Hammond, 2007
 
“Effective” empirically-supported treatments
3. Cancer pain   Syrjala et al., 1992
4. Distress during surgery Hypnosis reduces distress and pain > controls Lang et al., 2006
5. Surgery pain (adult) Self-hypnosis reduces drug use > attention control Lang et al., 1996
6. Surgery pain (child) Hypnosis reduces pain + hospital time > control Lambert, 1996
7. Weight reduction Hypnosis + CBT > CBT, differences increase over time Kirsch, 1996
 
“Possible” empirically-supported treatments
8. Acute pain (adult)   Patterson & Jensen, 2003
9. Acute pain (children) Hypnosis > distraction for bone marrow aspiration Zeltzer & LaBaron, 1982
10. Anorexia Staged treatment with hypnosis > same without hypnosis Baker & Nash, 1987
11. Anxiety about public speaking Hypnosis > CBT Schoenberger et al., 1997
12. Anxiety about taking a test Self-hypnosis>discussion control Stanton, 1994
13. Asthma Hypnosis>attention control Ewer & Stewart, 1986
14. Bed wetting Suggestion with or without hypnosis > wait list control Edwards & Van der Spuy, 1986
15. Bulimia Hypnosis = CBT > wait list Griffiths et al., 1996
16. Chemotherapy distress Hypnosis>conversation + antiemetic medication Jacknow et al., 1994
17. Cystic fibrosis Self-hypnosis>wait list control Belsky & Khanna, 1994
18. Depression Hypnosis enhances CBT Alladin & Alibhai, 2007
19. Duodenal ulcer relapse Hypnosis + medication > medication only Colgan et al., 1988
20. Fibromyalgia Hypnosis > physical therapy for subjective symptoms Haanen et al., 1991
21. Haemorrhage Preoperative suggestion reduces blood flow Enqvist et al., 1995
22. High blood-pressure Hypnosis > wait list in reducing BP long-term Gay, 2007
23. Hip or knee osteoarthritis pain Hypnosis = relaxation > wait list control Gay et al., 2002
24. Insomnia (primary) Hypnosis + CBT > medication long-term Graci & Hardie, 2007
25. Irritable bowel syndrome (IBS) Hypnosis > psychotherapy Whorwell et al., 1984
26. Nausea & hyperemesis Hypnotic-like relaxation > control Lyles et al., 1982
27. Obstetrics Apgar score Hypnosis associated with higher Apgar score Harmon et al., 1990
28. Obstetrics pain Hypnosis shortens labour and reduces analgesic use Jenkins & Prichard, 1983
29. Smoking cessation Hypnosis or relaxation > wait list controls for good subjects Schubert, 1983
30. Trauma recovery Desensitisation = hypnosis = psychodynamic therapy > control Brom et al., 1989
31. Wart removal Suggestion with or without hypnosis > control or medication Spanos et al., 1990

These ratings are derived from the review published by Wark (2008), in which the references and criteria are given in full.  In brief, the main criteria for the ratings are those set by Chambless & Hollon (1998), which they define roughly as follows but see their article for a more specific and detailed account of the criteria.

Possible

A treatment is “possibly” empirically-supported if peer-reviewed studies meet the following minimum criteria.  Studies should normally contain samples of at least 25 subjects who are randomly assigned to treatment and control groups, i.e., the study is a randomised control trial (RCT).  There is a treatment manual or equivalent (such as a hypnosis script) so that the treatment can be replicated in other studies.  Treatment must be conducted upon a specific condition which has been adequately assessed, and adequate outcome measures must be used which are subject to suitable statistical analysis.  The outcome must essentially show the treatment to be significantly more effective than a placebo or no-treatment control group, or equivalent to another empirically-supported treatment.

Effective

A treatment is termed empirically-supported as being “effective” if statistically significant superiority to control group measures have been replicated with completely independent samples or by independent research teams, and data supporting the treatment in question must be shown to predominate if there are conflicting data from other studies.

Specific

A treatment can be considered empirically-supported as “specific” (i.e., better than “non-specific” treatment) if it has shown statistically significant superiority to a placebo (“sham”) therapy or another psychological therapy in at least two independent studies.

References

Bolocofsky, D.N., Spinler, D., & Coulthard-Morris, L. (1985).  ‘Effectiveness of hypnosis as an adjunct to behavioral weight management’,  Journal of Clinical Psychology, 41.

Chambless, D.L., & Hollon, S.  ‘Defining empirically supported therapies’, Journal of Consulting and Clinical Psychology, 66.

Task Force on Promotion and Dissemination of Psychological Procedures. ‘Training in and dissemination of empirically validated psychologist treatments: report and recommendations.’ Clin Psychol 1995;48:3–23.

Chambless DL, Sanderson WC, Shoham V, Bennett Johnson S, Pope KS, Crits-Christoph P, et al. ‘An update on empirically validated therapies.’ Clin Psychol 1996;49:5–18.

Chambless DL, Baker MJ, Baucom DH, Beutler LE, Calhoun KS, Crits-Christoph P, et al. ‘Update on empirically validated therapies, II.’ Clin Psychol 1998;51:3–16.

Wark, David M.  (2008). ‘What we can do with hypnosis: a brief note’, American Journal of Clinical Hypnosis, July 2008

Proposed HPD Version 2 Revisions

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.

August Research Snippet: Hypnosis, Pain, Expectation & Placebo

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.