Training programs in using hypnosis differ from each other around the world. Each program strives for standards of training that enhance the learning, accreditation, and public trust in practitioners of hypnotic interventions in individuals seeking responsible health care. While many clinicians want to learn hypnosis in order to treat the more difficult cases which they encounter, true proficiency occurs over time and requires advanced workshops in subsequent months or years. Moreover, an important principle is that no one should treat those patients with hypnosis that one is not trained and comfortable treating without hypnosis. A final part of training is devoted to ethical principles, professional conduct, and certification. Joining national and international organizations ensures future personal and professional development.
Current controversies in hypnosis research and their applications to clinical practice raise major issues. Dr Bloom stresses the danger of accepting as literally true uncorroborated claims of perinatal and prenatal memories and recollections from past lives. The problems of accepting recovered memories of early childhood sexual abuse are of universal concern. While such abuse certainly does occur, there is the possibility that these memories may be due more to an artifact of the hypnosis than an indication that the abuse occurred. There are guidelines to aid the clinician in using hypnosis in uncovering memories of sexual abuse (Bloom, 1994), but in the final analysis, it is the clinician's own judgment with a particular case on how to proceed.
Dr Linden's chapter outlines a four-step process for establishing the hypnotic relationship with a client: evaluation, education of client, assessment of hypno-tizability, and the teaching of self-hypnosis phase, during which time positive expectancies about hypnosis and motivation of the client are enhanced. As the author points out, the public is more open to and more educated about hypnosis than in the past. Moreover, the criteria for patient selection have altered with increased understanding of the interactive nature of the treatment process and its relation to the doctor-patient partnership. Case histories reveal that often the client wants help not with the presenting problem but with an entirely different concern. Therefore diagnostic skills are no less important than hypnotic skills.
Several important but widely differing issues for concern may be mentioned here. Before initiating hypnotic intervention, the nonmedical clinician is advised to inquire of clients as to whether any medical evaluation of their condition has been performed. Many common presentations to the hypnotherapist may have organic etiologies which require surgical or pharmaceutical treatment. In obtaining the trauma history the clinician must be capable of dealing with abreactive material which may surface as normal psychological defenses are evaded. And when inquiry into childhood physical and/or sexual abuse is being made, it is crucial to avoid suggestive or leading questions which may compromise the validity of activated memories.
Some clinical presentations which are poorly suited to hypnotic intervention are listed. Forensic subjects also can pose a particular challenge to clinicians. Finally, when a client's presenting problem is outside the clinician's field of expertise the client should be referred elsewhere.
Chapter 4, on memory in hypnosis, is especially important in view of controversies about repressed memories. The author attempts to give unbiased consideration to the complexity of memory itself, as well as complications introduced by the interaction between client and therapist. The use of hypnosis provides no guarantee to assessing veracity; a degree of confidence (both in hypnosis and in the waking state) should in no way be taken as a reliable indicator of accurate memory. This chapter examines the association between hypnosis and memory by first exploring briefly the nature of both hypnosis and memory, and then looking specifically at two relevant memory phenomena: pseudomemory, and the recovery of repressed memories of sexual abuse.
As Professor Sheehan points out, while hypnosis may increase the volume of material recalled, there is no dependable enhancement in the accuracy (vs inaccuracy) of the information retrieved. Demonstrations of increases in the accuracy of remembered material are, in fact, relatively rare. Moreover, it is probably very rare in the clinical or forensic setting to find any participant who can lay claim to be emotionally neutral.
The data to be collected must always be gathered in a way that shows respect for general clinical considerations affecting the welfare of those involved. The future welfare of the client concerned and those of others accused of the act of abusing, for example, depends on the strict enforcement of ethical guidelines which are now in place relating to the reporting of recovered memories (Bloom, 1994).
There are general clinical considerations that must be respected in the conduct of hypnosis. And these considerations can only be met if the appropriate guidelines are followed.
We have at last an opportunity to explore activity in the brain during hypnosis with neuroimaging techniques such as regional cerebral blood flow (rCBF), positron emission tomography (PET), single photon emission computer tomography (SPECT), and functional Magnetic Resonance Imaging (fMRI).
Dr Crawford reports how these techniques are addressing questions about psychological and physiological phenomena. There is evidence that hypnotic phenomena selectively involve cortical and subcortical processing. At a neurophy-siological level, highly hypnotizable subjects often demonstrate greater EEG hemispheric asymmetries in hypnotic and nonhypnotic conditions. Cerebral metabolism studies have reported increases in certain brain regions during hypnosis (see Chapter 5 for references). Given that increased blood flow and metabolism may be associated with increased mental effort, these data suggest hypnosis may involve enhanced cognitive effort.
This chapter also reports on preliminary neurophysiological research in the role of opioid and nonopioid neurotransmitters and modulators which may be involved in hypnoanalgesia. Recent fMRI research by the author (Crawford, Knebel & Vendemia, 1998) has certainly found shifts in thalamic, insular and other brain structure activity. Future neuroimaging and neurochemical studies will greatly contribute to our expanded knowledge of how hypnotic analgesia is so effective as a behavioural intervention for acute and chronic pain.
Despite the theoretical title, the chapter by Dr Zeig has a very practical touch, as befits one by a disciple of Milton Erickson. Erickson used multilevel communication, both within and outside trance, to stimulate the patient's own initiative in generating more desirable behaviour. As a first step, the therapist should make sure that the patient is responding. Therapeutic change is then promoted by the patient's ability to hear and respond to what the therapist has said indirectly. Moreover, since the change has appeared through the patient's own initiative, it will be more complete and lasting. Table 6.1 gives a very clear exposition of how Erickson developed his strategy.
To obtain the best response, the therapist must understand that individuals may be working together in any of the following positions: one-up, one-down or equal. Zeig has given accounts of these different situations. These accounts are not only clear but entertaining, especially the metacomplementary relationships leading to secondary gain.
Erickson worked at modifying his technique where necessary to promote that responsiveness. Similarly, during induction, the therapist may need to experiment somewhat, before success is obtained in conveying covert messages to which the patient will respond and initiate self-change.
The first chapter of specific clinical applications of hypnosis is concerned with the currently relevant and controversial one of recovered memory in trauma victims. Clinicians must recognize that clients' remembrance of a previously forgotten trauma has clinical relevance; but recovered memories of abuse cannot be accepted as self-validating. Using hypnosis, it has been demonstrated that memory can be reconstructed (e.g. Barnier & McConkey, 1992).
Clinicians working with individuals who report recovered memories of childhood abuse must display the sensitivity appropriate for dealing with any possibility of childhood abuse (McConkey, 1997). In doing so, however, they need to maintain and use justifiable methods of diagnosis and treatment. Because of its long history of misuse, clinicians when using hypnosis must be scrupulous in applying scientifically based and clinically sound therapeutic intervention.
Hypnosis is particularly suited to use as an adjunct in treatment of anxiety disorders; 95% of practitioners of hypnosis use it to assist in the treatment of anxiety. Hypnosis can be a powerful adjunct to desensitization and to coping rehearsal, since it attributes realism to imagined events. Arousal reduction and relaxation may be enhanced using hypnotic procedures. Self-hypnosis techniques or hypnotic interventions have proved useful in simple phobias, for panic patients and in the treatment of agoraphobia. As Frankel and Orne (1976) have noted, phobic patients tend to be more hypnotizable than other patients or the general population. Apart from general anxiety reduction, hypnotic techniques may be applied to re-establish a sense of self-worth and self-esteem.
Contrasted with the treatment of anxiety, there appears to be a widespread assumption that hypnosis is inappropriate for the management of depression because of the risk of suicide. Given our understanding that hopelessness is the best predictor of suicide risk, the clinician needs to decide whether to avoid the use of hypnosis with patients high on this variable, or to utilize hypnosis as a tool for its reduction.
Major depression remains a challenge to all treatment modalities, including pharmacotherapy, cognitive-behaviour therapy, and psychotherapy. The traditional prejudice against its use in depression has prevented a serious assessment of whether hypnosis has anything significant to contribute to this widespread disabling problem. The authors of Chapter 9 present a series of arguments in favour of a trial of hypnotherapy augmenting cognitive-behavioural management of depression.
To complete the anxiety-depression spectrum, Spiegel's lucid and comprehensive presentation of PTSD symptoms and treatment approaches in Chapter 10 begins with an account of the vicissitudes undergone in developing the concept of post-traumatic stress disorder. It provides a cautionary tale that however confident we feel in the accuracy of our knowledge we can never know all the answers, and therefore should retain an open mind for opposing views.
Dr Spiegel notes the growing interest in the overlap between hypnotic and dissociative states and post-traumatic stress disorder, in particular a clear analogy between the three main components of hypnosis: absorption, dissociation, and suggestibility (Spiegel, 1994), and the categories of PTSD symptoms.
Like PTSD, conversion disorders are particularly suited for treatment using hypnosis. In 1986 Trillat made the hasty conclusion that hysteria was an illness that would no longer be seen, but conversion disorders still present neurologists, psychiatrists and psychotherapists with a considerable problem. Chapter 11 by Dr Hoogduin and Dr Roelofs views the relationship between conversion disorders and dissociative disorders from a modern cognitive psychological standpoint. Hyp-notherapeutic strategies are described and illustrated by case histories. Finally, it is emphasized that in an appreciable percentage of patients misdiagnosed as having a (psychological) conversion disorder, there may be an organic cause for the complaint.
A further note for caution is sounded. Is hypnosis an essential element in all the cases where treatment involving it leads to a favourable result? There is great need for controlled research in this area. On the other hand, there has been no controlled research relating to other treatment strategies, although some well-documented case descriptions indicate that behaviour therapy and physiotherapy achieve very positive results with conversion disorders.
As Dr Murray-Jobsis notes in Chapter 12, it is over a century and a half since hypnotic methods have been applied to the treatment of the extremely difficult conditions of psychosis and personality disorder. Most experimental work supports the conclusion that psychotic and personality disordered patients possess hypnotic capacity which can be used productively and safely.
The clinician dealing with the severely disturbed patient must have experience with this type of population, and also requires sensitivity. Moreover empathy in pacing is an essential in hypnotherapy of these psychologically fragile patients.
The conceptual framework of hypnotherapy in dealing with psychotic patients and personality disorder has a psychoanalytic framework. The aim is to redo life experiences and allow the disturbed patient to redevelop potential for healthy growth and development. Virtually all traditional psychotherapy techniques can be adapted for use with hypnosis in the treatment of these patients.
The use of hypnosis for dissociative trance disorder is also presented from a strongly psychoanalytical viewpoint. Treatment involves interrupting pathological trance states and restructuring the dissociative experiences, often with the use of autohypnotic techniques, so that the patient can retain control over his or her proclivity for slipping into trance.
In considering the use of hypnosis with the dissociative disorders, we come again to current concerns about the contribution of hypnosis to pseudomemory formation. Firstly, can hypnosis contribute to the worsening of dissociative identity disorder? Secondly, it has been argued that trauma may not be at the root of many of these disorders, so that hypnotic searching for memories of childhood traumatizations may generate confabulations with far-reaching consequences.
Dr Kluft maintains in Chapter 13 that all perspectives have contributions to make to this complex area of study, and that a rational view of the subject precludes the complete or peremptory discounting of either perspective. Although there is concern about confabulations with this use of hypnosis, it is also possible for patients to recover well-being by working through a confabulated trauma. Since the recovery of the patient rather than the recovery of historical truth is the goal, this should not be a major concern in most instances.
Dissociation is a commonplace reaction to trauma in psychiatric patients and in nonpatient populations This chapter offers a detailed review of methods of treatment and clinical techniques are presented for hypnotic interventions in the dissociative disorders. In the absence of contraindications Dr Kluft considers most traumatized persons with major dissociative manifestations to be excellent candidates for the use of therapeutic hypnosis.
Both Dr Torem and Dr Vanderlinden comment that with anorexia nervosa and bulimia there has been remarkably little utilization of hypnosis as a therapeutic tool, whereas hypnotherapists have been intensively engaged in the treatment of obesity. Nevertheless, the effectiveness of hypnotic interventions in patients with eating disorders has been recorded in the literature over and over again since the time of Pierre Janet.
The clinical literature identifies a variety of psychodynamics attributed to the psychopathology of eating disorders. Many patients with these disorders feel helpless, hopeless, and ashamed of having to seek psychological help. Ego-strengthening suggestions are therefore an important part of most hypnotherapy interventions. Assignments which they are asked to complete are designed so that the patient will metaphorically and concretely experience a feeling of success, as well as a sense of gaining mastery, control, and exercising new choices and options. Ego State Therapy has become a frequent focus in the hypnosis literature.
While only psychological bases are at present considered to be operational in anorexia nervosa and bulimia, the picture is different for obesity. It is assumed nowadays that biological and psychological factors can function in combination as pathogenic factors in the development of obesity, therefore it is noted that hypnosis should always be part of a multidimensional approach.
Dr Vanderlinden offers a very practical commonsense overview of the problem. Thus, for a considerable group of patients, weight reduction is either not a realistic goal, or the aim of treatment should be adapted; for instance they must learn to accept themselves as overweight, instead of pursuing weight reduction. The author's own approach (Vanderlinden, Norré & Vandereycken, 1992) contains, among others, behavioural, cognitive, and interactional components.
Most treatments are exclusively aimed at quick weight reduction and ignore the crucial goal, namely weight stabilization and prevention of relapse. A follow-up lasting 1 to 2 years is absolutely indicated to prevent possible relapse, with regular encouragement of the patient.
The treatment of sexual dysfunction can take a psychodynamic psychotherapy approach, a brief focused eclectic psychotherapy approach, or a cognitive-behavioural approach, and hypnotic assistance to each of these is advantageous. There is a surprisingly low degree of usage of hypnosis in sexual dysfunction. And yet, the involvement of thought, image and symbolism in sexual interest, arousal and behaviour cannot be overemphasized. Changing the information, associations, symbols and images that contribute to dysfunction is a primary goal of therapy. Hypnosis provides a powerful means of influencing all these cognitive levels in treatment.
The several chapters dealing with painful conditions highlight the differences between acute and chronic pain, and therefore the need for different strategies in their management.
Whereas acute pain is best managed by anxiety-reducing strategies, chronic pain requires strategies that deal with effective handling of one's psychological environment. In many cases chronic pain may have no clear organic basis, but secondary gain issues typically exist with the chronic pain patient and hypnotic strategies need to be developed which will not initially threaten these issues. Hypnotic intervention based on anxiety reduction will only frustrate the patient and the therapist, and will usually be unsuccessful.
As Dr Evans points out in Chapter 17, the clinical criterion of successful treatment outcome for chronic pain patients is far more complex than mere pain reduction. 'Multiple outcome measures need to consider decreased depression and medication and opioid use; improved sleep, social and family relations and quality of life; increase in range of motion and activity level; and return to work' (p. 249).
Dr Rose notes in Chapter 18 that, in keeping with modern approaches to patient care and autonomy, pain patients are encouraged to become more involved in their own management, both by selecting their own fantasies and maintaining a two-way communication with a hypnosis practitioner. Cues to the appropriate utilization of hypnotic approaches to treat pain are often given in the very terminology patients use to describe their pain. At a later stage, training in self-hypnosis gives patients a sense of mastery and control over their pain and they can become independent of the therapist. A case study reported by Dr Rose repeats the caution by Dr Vanderlinden that patients coming to hypnotherapists for alleviation of chronic conditions may have an organic etiology for the condition. In this case investigations prior to hypnosis had been unsuccessful in finding the organic cause.
The seriously burned patient needs psychiatric help from the time of injury to full recovery (Chapter 19). Opioids are the treatment of choice for pain relief, even though relief is seldom complete. Hypnosis can be a helpful adjunct, and should not be withheld even in patients who test low in hypnotizability.
In the first 2 to 4 hours postburn, hypnosis diminishes the inflammatory response. Later, it is helpful for resting pain, and especially effective for control of pain in those patients with the most excruciating procedural pain. Infection is minimized, suppressed appetite can be restored, and body image and active participation in rehabilitation are enhanced. A burned patient who has accepted the suggestion that his wounded area is 'cool and comfortable' is easy to treat, optimistic, and heals rapidly.
Commonly, the patient who enters the dentist's room is at some level of trance and the dentist has the opportunity to manipulate this hypnotic state to enhance patient comfort in the dental situation. The hypnotic interaction has begun before the first word is uttered.
Another area in which hypnotic strategies are utilized, but the concepts of hypnosis are not mentioned, is in the 3-minute smoking cessation interaction. This can take place at the conclusion of the oral examination and cancer screening, if there is an indication by the patient that there is a desire to 'quit.'
With the advent of stereophonic headphones, the dentist can offer positive hypnotic suggestions while taking care of the mouth. When preparing the patient tapes, it is recommended that the form of speech be primarily in the passive voice and the text be devoid of personal pronouns. For the listener, hearing just the ideas and suggestions is empowering. Note that Dr Glazer, in Chapter 20, in this way is using Ericksonian injunctive communication, as recommended by Dr Zeig. It should be noted that the words pain, hurt and discomfort are never introduced. Because the brain does not easily compute 'no' in the hypnotic state, it is more effective to offer positive suggestions.
Fear of dentists is commonly listed in the top five commonly held fears and is among the ten most frequent intense fears. There are strong indications that a significant portion of the dental phobic population is hypnotizable and that the same high hypnotizability that allows them to develop a phobia is also a useful tool to help them overcome the phobia.
Implicit in these findings is a caution for dentists that they should be aware that a significant portion of the population is highly responsive to suggestion. Attention should therefore be given not to deliver suggestions to patients that may be counter-productive to treatment. Otherwise treatment difficulties and enduring problems may be created inadvertently.
During the 1970s research began to report both the clinical efficacy and psychophysiologic changes associated with self-hypnosis in children. At the same time the benefits of hypnosis training were recognized for children with chronic illnesses such as cancer, haemophilia, and asthma. Successful applications of self-regulation include a focus on personal control and decision-making by the child, and specific attention to the child's preferences in using personal imagery skills.
For behavioural problems indirect approaches are used. These might include improved coping, allaying of anxiety, and facilitating improved self-esteem with the aid of self-hypnosis, rather than expecting problem resolution as one might reasonably expect in the treatment of habits. The biobehavioural disorders such as asthma, migraine, encopresis, Tourette's Syndrome, and inflammatory bowel disease, are all known to be exacerbated by psychological stress. Teaching self-hypnosis promotes a sense of self-control as well as providing a strategy for reducing symptoms. Clinicians should obtain appropriate training in paediatric clinical hypnosis to apply and integrate it within general or specialty paediatric care.
Since we know that hypnosis used properly by appropriately trained clinicians is safe and effective and has no adverse side effects (Kohen & Olness, 1993), it can become an important potential tool in managing a wide variety of clinical issues in child health care.
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