© Aile Trumm, 2019
Considering how long hypnotherapy research has been on-going, starting with the father of scientific hypnotherapy Dr. James Braid (1795-1860) up until modern age, it is still surprising that hypnosis has remained a mystery to most laypersons and medical professionals. Professionals in the field of psychology and medicine still quote the ‘lack of scientific evidence’ when asked to consider hypnotherapy (1). Consequently, hypnotherapy has been virtually ignored despite the long–standing evidence of its therapeutic value (1). The current article attempts to explore some reasons behind these misconceptions and ways for the community of hypnotherapists themselves to contribute in changing that perception.
An interesting development has occurred from 1995. Some states in US have started to legislate against the use of hypnosis except by doctors, psychiatrists and psychologists (20). Powell and Forde suggested in 1995 that this is due to the involvement and power of drug companies in influencing policies and making sure that the growth of hypnotherapy is suppressed by legislating that only prescribing medical professionals may conduct hypnotherapy (20).
Interestingly, the current check of legislation reveals that in many US States hypnotherapy can only be used for ‘vocational or avocational self-improvement as long as hypnotherapists do not treat emotional or mental disorders’ (21).
Furthermore, ‘nothing in this Act shall be construed to prevent a person from practicing hypnosis without a license issued under this Act provided that the person (1) does not otherwise engage in the practice of clinical psychology including, but not limited to, the independent evaluation, classification, and treatment of mental, emotional, behavioral, or nervous disorders or conditions, developmental disabilities, alcoholism and substance abuse, disorders of habit or conduct, the psychological aspects of physical illness, (2) does not otherwise engage in the practice of medicine including, but not limited to, the diagnosis or treatment of physical or mental ailments or conditions, and (3) does not hold himself or herself out to the public by a title or description stating or implying that the individual is a clinical psychologist or is licensed to practice clinical psychology.’ (225 Illinois Compiled Statutes 15/3(h). (21)
Hypnosis and National Health Service (NHS)
When investigating further what has been written about hypnotherapists on the NHS website, NHS Choices (18) seem to disregard or discourage hypnotherapy as an alternative (standalone) treatment by definition:
Hypnotherapy is defined as: ‘a type of complementary therapy that uses hypnosis, which is an altered state of consciousness’ (NHS Choices, 2017).
Furthermore, there is some additional information on their website about choosing a hypnotherapist:
‘In the UK, hypnotherapists don’t have to have any specific training by law.
This means hypnotherapy can be offered by people with little training who aren’t health professionals.
When looking for a private hypnotherapist:
- choose someone with a healthcare background – such as a doctor, psychologist or counsellor’ (NHS Choices, 2017).
There is no further information about well-qualified hypnotherapists abiding by trademarks, good quality training, experience and being part of a reputable professional body. There are no links or mention about the research progress or lack of side-effects of hypnotherapy treatments.
The following example will illustrate a few realities in evidence-based medicine in UK. Recently, there was a 3-piece documentary on BBC One Mental Health Season, starting with Nadiya Hussain’s ‘Anxiety and Me’ (8). When Nadiya explored options of treatment on the NHS website (18), in fact the only options available seemed to be medication and CBT (or a combination of both).
On the discourse of medication, hypnotherapy may potentially also be a valuable alternative to medication in the treatment of anxiety, as hypnosis has no side effects, whereas there are known problems and side effects associated with some prescribed anxiety medications. Patients have reported feeling dazed and unfocused, even when being prescribed low doses. People who are prescribed medication often experience medication hangovers as some of the tranquillisers are highly addictive. Taking commonly prescribed anxiety medication (benzodiazepines, beta blockers, SSRI antidepressants, Buspirone) may disrupt work, school and everyday functioning of the patient due to side effects and may cause problems further down the line due to withdrawal (9). Not all of the information or available options were provided to the protagonist of the documentary.
The general acceptance and also the protagonists who wish to utilise medication may be due to the acceptance of the theory of chemical imbalance in the brain. This theory, although heavily advertised by pharmaceutical companies and taken as common knowledge, has been heavily criticised (10-17).The chemical imbalance theory was formulated in 1960’s based on the observed effect of substances alerting mood, reversing the cause and effect sequence. The theory took off in the world of advertisement for medication. Money and resources have been invested to confirm the chemical imbalance theory and advertise that whatever the problems might be- ranging from anxiety, depression, and attention deficit to shyness, the cause is imbalance in the brain instead of imbalance resulting from psychological stress (15, 16, 17).
In fact, The National Institute of Healthcare Excellence (NICE) decision in 2011 to include hypnotherapy as a complementary intervention for the treatment of anxiety disorders was based on one paper by Zhao et al. (19). In the aforementioned paper, benzodiazepine treatment was compared to application of hypnotherapy and no significant difference was found, possibly suggesting an alternative to the medication (19). Currently, this inclusion has been removed (18).
In fact, when looking at the NHS website (18), the recommendations for the treatment of anxiety disorders include:
- psychological therapies – you can receive psychological therapies such as cognitive behavioural therapy (CBT) through the NHS; you don’t need a referral from your GP and you can refer yourself: find a psychological therapies service in your area
- medication – such as a type of antidepressant called selective serotonin reuptake inhibitors (SSRIs)
- As part of this plan, you may be offered a treatment you haven’t tried before, which might be one of the psychological treatments or medications mentioned above.
- Alternatively, you may be offered a combination of a psychological treatment with a medication, or a combination of 2 different medications.
Experts to consult:
- psychiatric nurses
- clinical psychologists
- occupational therapists
- social workers
Hypnotherapists or alternative therapists are not mentioned.
Research in Hypnotherapy
Hypnotherapy research continues to be labelled ‘unscientific’ in the broader research community despite research progress starting from 1960’s, when a comprehensive study indicated that the following average number of sessions needed for various therapies and success rates were as follows: 600 (38%) for psychoanalysis; 22 (72%) for behavior therapy; and 6 (93%) for hypnotherapy (5). In 2013 an article was published on the British Psychological Society website called ‘Neuroscience gets serious about hypnosis’, where it was stated that ‘many neurological symptoms are medically unexplained with no apparent organic cause and it is here that hypnosis is proving especially useful as a new way to model, explore and treat people’s symptoms’ (6)
It is felt that the major reason behind the rejection of hypnosis has been that for most people it is still virtually unknown. It is odd that hypnosis is unknown as there is so much research conducted on the topic, not even considering the vast amount of anecdotal evidence, case studies and service evaluations. Case studies and research methodologies that are not randomised controlled trials (RCT’s) are not considered. This may be because there is still a misconception in research community that RCTs are the most scientific, most reliable methods of research (22).
So what is an RCT? ‘An RCT is a type of study in which participants are randomly assigned to one of two or more clinical interventions. A sample of the population of interest is randomly allocated to one or another intervention and the two groups are followed up for a specified period of time. Apart from the interventions being compared, the two groups are treated and observed in an identical manner. At the end of the study, the groups are analysed in terms of outcomes defined at the outset. The results from, say, the treatment A group are compared with results from the treatment B group. As the groups are treated identically apart from the intervention received, any differences in outcomes are attributed to the trial therapy’ (22).
Why is that so important to consider? Mainly, because often it is unethical to randomise groups (you can’t make half of the participants smoke and other half not, for example). Also, it does not matter how randomly you randomise these groups and how equally you try to treat them, some bias is always experienced. Furthermore, the main criticism about hypnotherapy RCT’s is the lack of control condition- a lack of ‘mock hypnotherapy’. The model of RCT lends itself beautifully to drug trials- one pill vs sugar pill vs no intervention. When you deal with therapy, the process of the therapy (lack of side-effects, especially when treating children and adults with various co-morbidities) and the experience of the therapy is as important as the result. RCT has no way of measuring the journey, just the final outcome.
Bias towards clinical hypnotherapy? Clinical hypnotherapy appears to be the most popular due to its meshing with psychology (7). As clinicians are more likely to be trained in research methodology than hypnotherapists and conduct research and publish articles, there might be an additional bias towards the type of hypnotherapy that has been researched. To overcome these biases, it may be useful to utilise hypnotherapists from different types of hypnotherapy interventions to administer treatment. Additional insight may include the effectiveness of different types of hypnotherapy. Furthermore, it may reduce the reporting bias and benefit research methodologically. It would appear that the experience or level of hypnotherapy training of a person/people conducting hypnotherapy is rarely mentioned in the research papers and it appears to be acceptable that a qualified psychologist or psychiatrist may practice hypnotherapy without mentioning any formal training in hypnotherapy. It would be beneficial to integrate interdisciplinary collaboration in this research area, having well-designed studies, experienced researchers and experienced hypnotherapists working together (26).
Healthcare is changing
According to Andrew and Halcomb (23), healthcare is in a pre-paradigm period. More modern research methodologies have been developed (as mixed methods research that involves both qualitative and quantitative research) which may finally show what hypnotherapy can do, the journey and result included. Bloom (24) emphasises this as a holistic revolution, the world where unanswered questions about consciousness find answers and the concept of the unconscious is going to be integrated into scientific thinking. This claim can be evidenced by the rise in popularity of people seeking alternative treatments. Health disciplines need to realise that more daring alternatives or investigation is needed (23).
‘The psychological disposition to modify and generate experiences following targeted suggestion remains one of the most remarkable but under-researched human cognitive abilities given its striking causal influence on behaviour and consciousness,’ said Oakley and Halligan (25). Therefore us as hypnotherapists may contribute to it by continuing the amazing job of treating patients so the critical mass of awareness will rise; by educating ourselves about how to read and access research; by collecting data and making it available to researchers and by participating in research.
(1) Barrios, Alfred A. Understanding Hypnosis: Theory, Scope and Potential, Nova Science Publishers, Incorporated; 2009. ProQuest Ebook Central. Available from: https://ebookcentral.proquest.com/lib/bham/detail.action?docID=3018516.
(2) Jensen, M., Jamieson, G., Lutz, A., et al. New directions in hypnosis research: strategies for advancing the cognitive and clinical neuroscience of hypnosis. Neuroscience of Consciousness. Available from: https://doi.org/10.1093/nc/nix004.
(3) Milton V. Kline. Freud and hypnosis: A reevaluation, International Journal of Clinical and Experimental Hypnosis, 20:4, 252-263. Available from: DOI: 10.1080/00207147208409296; 1972
(4) Freud, S. The Standard Edition of the Complete Psychological Works of Sigmund Freud Volume XX (1925-26): An Autobiographical Stud; Inhibitions, Symptoms, and Anxiety ; The Question of Lay Analysis and Other Works. Hogarth Press; 1959
(5) Barrios, A. In: Hypnosis: Theories, Research and Applications Editors: G. D. Koester and P. R. Delisle ISBN 978-1-60456© 2009 Nova Science Publishers, Inc. Chapter 1 A New Theory For Understanding and Appreciating The Power of Hypnosis: Comparing This Theory to Previous Theories and Noting its Many Benefits. SPC Center, Culver City, CA, USA
(6) Jarrett, C. Neuroscience gets serious about hypnosis. BPS Research Digest; 2013. Available from: https://digest.bps.org.uk/2013/08/01/neuroscience-gets-serious-about-hypnosis/
(7) Jensen, M., Jamieson, G., Lutz, A., et al. New directions in hypnosis research: strategies for advancing the cognitive and clinical neuroscience of hypnosis. Neuroscience of Consciousness; 2017. Available from: https://doi.org/10.1093/nc/nix004
(8) BBC1, Mental Health Season; 2019. Available from: https://www.bing.com/videos/search?q=bbc+one+documentary+series+about+mental+health+nadiya+hussain&view=detail&mid=04965BEF3D37BF1592EC04965BEF3D37BF1592EC&FORM=VIRE
(9) Smith, M., Robinson, L. and Segal, J. Anxiety Medication. Helpguide.org; 2017 Available from: https://www.helpguide.org/articles/anxiety/anxiety-medication.htm
(10) Leo, J. & Lacasse, J.R. 45: 35 ; 2008. Available from: https://doi.org/10.1007/s12115-007-9047-3
(11) Pies, R.W. Debunking the Two Chemical Imbalance Myths, Again. Psychiatric Times; 2019. Available from: https://www.psychiatrictimes.com/depression/debunking-two-chemical-imbalance-myths-again
(12) Kelly Patricia O’Meara, Psyched Out: How Psychiatry Sells Mental Illness and Pushes Pills That Kill (Author
House, 2006), pp. 47-48, citing Jonathan Leo paper, ‘The Biology of Mental Illness,’; 2004.
(13) Valenstein, E.S., Blaming the Brain, The Free Press, New York; 1998
(14) Kaiser, D., Commentary: Against Biologic Psychiatry, Psychiatric Times, Dec; 1996.
(15) Vedantam, S. Drug Ads Hyping Anxiety Make Some Uneasy, The Washington Post, 16 July; 2001.
(16) Park, J.S. & Ahn, H.-Y.,) Direct-to-Consumer (DTC) Antidepressant Advertising and Consumer Misperceptions About the Chemical Imbalance Theory of Depression: The Moderating Role of Skepticism, Health Marketing Quarterly, 30:4, 362-378; 2013 Available from: DOI: 10.1080/07359683.2013.847337
(17) US Fed News Service. Study: Media Perpetuates Unsubstantiated Chemical Imbalance Theory of Depression. Including US State News. Mar 03; 2008Available from: https://search-proquest-com.ezproxye.bham.ac.uk/docview/469501705?accountid=8630
(18) NHS. Generalised anxiety disorder in adults; 2019 Available from: https://www.nhs.uk/conditions/generalised-anxiety-disorder/
(19) Zhao Y.-H., Shan Y., H., Ma L.-H., et al. Clinical Efficacy of Hypnotherapy in the Treatment of Generalized Anxiety Disorder. Chinese Mental Health Journal; 2005 http://en.cnki.com.cn/Article_en/CJFDTOTAL-ZXWS200508014.htm
(20) Powell, C & Forde, G. ‘The Self-Hypnosis Book’ Newleaf, Dublin; 1995
(21) Hypnosis Law & Regulations: State Laws Regarding Hypnosis, Hypnotherapy & Hypnotism; 2018 Available from: https://www.interpersonalhypnotherapy.com/us-state-hypnosis-laws
(22) Akobeng, A.K. Understanding Randomised Controlled Trials. Archives of Disease in Childhood;90:840-844; 2005. Available from: https://adc.bmj.com/content/90/8/840
(23) Andrew, S., & Halcomb, E.J. Mixed Methods Research for Nursing and the Health Sciences. John Wiley & Sons, Incorporated. ProQuest Ebook Central; 2009. Available from: http://ebookcentral.proquest.com/lib/bham/detail.action?docID=547079
(24) Bloom, W. ed. Holistic Revolution: The Essential New Age Reader. London: Penguin Books; 2000
(25) Oakley, D.A., & Halligan, P.W. Hypnotic suggestion: opportunities for cognitive neuroscience. Nature Reviews Neuroscience, 14 (8), 565-76; 2013
(26) Trumm, A. Hypnotherapy Research in anxiety disorders. Lesserian Curative Hypnotherapy Knowledge Base; 2018 Available from: http://kb.lesserian.co.uk/hypnotherapy-research-in-anxiety-disorders/