It has been argued that the risk of suicide makes the use of hypnosis dangerous in the management of depression. Crasilneck & Hall (1985) argue that hypnosis is inappropriately used in an outpatient setting for this reason. The potential for increased suicide risk has been explained in a number of ways. Burrows (1980) argues that hypnosis may inappropriately relieve anxiety before depressive affect has significantly lifted, allowing the depressed individual sufficient energy and anxiety reduction to act on suicidal impulses. Crasilneck & Hall (1985) observe that this phenomenon is not confined to hypnosis but has also been described for the range of treatment methods including psychotherapy, antidepressant medication and electroconvulsive therapy (p. 323). The evidence to support this proposal is primarily in the form of clinical case material, making it difficult to counter the criticism that, given the significant rate of suicide in patients with major depression, such case material represents a chance correlation.
Spiegel & Spiegel (1978) suggest that the potential for suicide lies in the possibility that the depressed individual will place unrealistic hopes in the trance experience as a way of ending their depression. These unmet expectations may result in a suicide attempt. Meares (1979) argues a similar viewpoint when he expresses his concern that: 'A trial of hypnotherapy usually leads to disappointment and may involve the patient in an unnecessary risk of suicide' (p. 293) Yapko (1992) is critical of the Spiegels and other workers in the field who emphasize the formal assessment of suggestibility, arguing that this promotes a sense of success or failure which may enhance suicide potential. He argues that negative expecta tions are a core component of depression and rather than being seen as a risk factor, they need to be addressed in treatment using hypnosis.
The conclusion from this literature is that relief of anxiety without associated improvement in depression and unmet treatment expectations are potential predictors of suicide risk. In fact, prediction of suicide risk has been well researched and there appears to be good agreement about the primary factors involved. Beck and coworkers (Beck, Rush et al., 1979; Beck, Brown et al., 1990), reporting two large-scale prospective studies of suicide, found that hopelessness, as measured by the Beck Hopelessness Scale (1988), was a powerful predictor of eventual suicide. Fawcett, Schefter, Clark et al. (1987), again utilizing a predictive design, also found that hopelessness was a significant predictor, as was loss of pleasure or interest and 'mood cycling during the index episode'. Fawcett et al. (1987) also refer to the predictive value of a variable they describe as 'depressive turmoil'. It is not clear whether this is related to anxiety but certainly the findings are in the opposite direction to that suggested in the clinical literature, that is, increased turmoil was associated with increased suicidal risk while the clinical hypothesis predicts that decreased anxiety is associated with increased risk.
Given our understanding that hopelessness is the best predictor of suicide risk, the decision for the clinician becomes whether to avoid the use of hypnosis with patients high on this variable, or to utilize hypnosis as a tool for the modification of hopelessness. The cognitive-behavioural literature provides some data relevant to the field of hypnosis. For example, a study by Rush, Beck, Kovacs et al. (1982), showed that depressed patients treated with cognitive therapy showed a more rapid reduction in hopelessness scores than a comparison group of depressed patients treated with an antidepressant drug.
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